Inspection Reports for
Shady Nook Care Center
36 VILLAGE DRIVE, LAWRENCEBURG, IN, 47025
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
17.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
314% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
100% occupied
Based on a February 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 23, 2026
Visit Reason
The inspection was conducted due to a complaint investigation related to resident-to-resident abuse and the adequacy of dementia care at the facility.
Complaint Details
The investigation was related to Intake 2714547 concerning resident-to-resident abuse and inadequate dementia care. The complaint was substantiated with findings of abuse and insufficient behavioral management.
Findings
The facility failed to prevent resident-to-resident abuse involving two residents, one of whom sustained bruising and broken glasses. The facility also failed to provide appropriate supervision and interventions for a resident with dementia exhibiting aggressive behaviors, resulting in inadequate psychosocial well-being.
Deficiencies (2)
F 0600: The facility failed to protect a resident from resident-to-resident abuse, resulting in bruising and broken glasses. Staff witnessed the incident and intervened, but the aggressive resident was not easily redirected.
F 0744: The facility failed to provide appropriate treatment and supervision to a resident with dementia who exhibited verbal and physical aggression towards others. Behavior documentation was incomplete and interventions were insufficient to manage the resident's behaviors.
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for dementia care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 3 | Unit Manager on the Dementia Unit | Provided information about resident behaviors and documentation practices |
| Social Services Director | Provided information about Resident C's aggressive behaviors and facility policies |
Inspection Report
Routine
Deficiencies: 3
Date: Jan 6, 2026
Visit Reason
The inspection was conducted to evaluate compliance with quality of care, medication administration, and medical record documentation standards at Shady Nook Care Center.
Findings
The facility failed to monitor and document a resident's skin conditions related to bruising and scratches, failed to administer medication per physician orders for hypotension, and failed to document an incident and monitor skin conditions for two residents. Video footage and interviews revealed lack of timely and adequate documentation and assessment.
Deficiencies (3)
F 0684: The facility failed to monitor and document Resident 30's skin conditions related to bruising and scratches in a timely manner after an incident on 12/29/2025.
F 0755: The facility failed to administer Resident 30's medication for hypotension as prescribed by the physician on multiple occasions when vital signs were within parameters.
F 0842: The facility failed to document an incident involving Residents 25 and 30 and failed to monitor and document skin conditions for both residents in accordance with professional standards.
Report Facts
Residents reviewed: 19
Dates medication not administered: 8
Dates missing progress notes: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 3 | Unit Manager | Interviewed regarding Resident 30's bruising and documentation |
| Director of Nursing | Director of Nursing | Interviewed and reviewed video footage related to Resident 30's injuries and documentation |
| Certified Nurse Aide 6 | Certified Nurse Aide | Interviewed about awareness of incidents and bruises on dementia unit |
| QMA 5 | Qualified Medication Aide | Interviewed about medication passing and observations on dementia unit |
| LPN 4 | Licensed Practical Nurse | Observed assessing and cleaning Resident 30's left hand and head |
| RN 2 | Registered Nurse | Interviewed about medication administration per physician orders |
| Psych Nurse Practitioner | Nurse Practitioner | Interviewed about reporting of aggressive behaviors and resident observations |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about video camera footage availability |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation related to a significant medication error where a resident received another resident's medications, resulting in hospitalization.
Complaint Details
This citation relates to Intake 2661017. The complaint was substantiated as the medication error was confirmed and resulted in actual harm to the resident.
Findings
The facility failed to ensure a resident was free from significant medication errors when Resident C received Resident L's medications, causing actual harm including hospitalization and administration of Narcan. The facility implemented staff education and medication administration audits to correct the deficient practice.
Deficiencies (1)
F 0760: The facility failed to ensure residents were free from significant medication errors when Resident C received Resident L's morning medications, resulting in hospitalization and administration of Narcan. The deficient practice affected 1 of 3 residents reviewed for medication errors.
Report Facts
Doses of Narcan administered: 2
Residents reviewed for medication errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Nurse who administered the wrong medications to Resident C. |
| Director of Nursing | Director of Nursing | Notified immediately after medication error and provided policy information. |
| NP 3 | Nurse Practitioner | Documented the medication error and ordered hospital evaluation. |
| Assistant Director of Nursing | Assistant Director of Nursing | Notified the NP and assisted in resident assessment after medication error. |
| NP 4 | Nurse Practitioner | Hospital NP who treated Resident C in ICU after medication error. |
| NP 5 | Nurse Practitioner | Facility NP who conducted follow-up visit after hospitalization. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00451861 completed on February 19, 2025.
Complaint Details
Complaint IN00451861 was investigated and found to be corrected.
Findings
Shady Nook Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 19, 2025
Visit Reason
The inspection was conducted in response to a complaint (IN00451861) regarding the facility's failure to provide timely urinary incontinence care and ensure scheduled urology appointments for a resident.
Complaint Details
This citation relates to Complaint IN00451861. The complaint was substantiated based on findings that the facility did not ensure timely urology care for Resident B and lacked documentation of follow-up on rescheduled appointments.
Findings
The facility failed to ensure that Resident B, who was incontinent and had urinary retention, received timely urology services. Multiple urology appointments were rescheduled or canceled without documented follow-up, and progress notes lacked evidence of contact with the urology office prior to the inspection date.
Deficiencies (1)
F 0690: The facility failed to provide appropriate care for residents with urinary incontinence and failed to ensure timely urology appointments for Resident B. Documentation showed multiple rescheduled or canceled appointments without timely follow-up.
Report Facts
Residents reviewed for urinary incontinence: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding rescheduling of Resident B's appointments and facility policies. | |
| LPN 2 | Interviewed regarding ensuring residents attend scheduled appointments and rescheduling canceled appointments. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 1
Date: Feb 18, 2025
Visit Reason
This visit was conducted for the investigation of four complaints (IN00453427, IN00451861, IN00450888, and IN00450653) regarding the facility's compliance with regulatory requirements.
Complaint Details
Complaint IN00451861 was substantiated with a federal/state deficiency cited at F690 related to failure to provide timely urinary incontinence services. Complaints IN00453427, IN00450888, and IN00450653 had no deficiencies related to the allegations.
Findings
The investigation found no deficiencies related to three of the complaints, but cited a federal/state deficiency related to urinary incontinence services for one complaint (IN00451861). The facility failed to ensure timely services to maintain continence for one resident with urinary incontinence.
Deficiencies (1)
Facility failed to ensure a resident with urinary incontinence received services to maintain continence in a timely manner.
Report Facts
Census: 85
Total Capacity: 85
Medicare Census: 7
Medicaid Census: 62
Other Payor Census: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Administrator | Named as facility representative and involved in interviews |
| Director of Nursing | Interviewed regarding the deficiency and appointment scheduling for Resident B | |
| LPN 2 | Interviewed about ensuring residents attend scheduled appointments |
Inspection Report
Re-Inspection
Census: 88
Capacity: 94
Deficiencies: 1
Date: Jan 23, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/05/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR Life Safety Code survey, Shady Nook Care Center was found in compliance with Medicare/Medicaid participation requirements and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinkled and had appropriate fire alarm and smoke detection systems. One deficiency related to HVAC compliance was noted with an annual waiver request.
Deficiencies (1)
HVAC heating, ventilation, and air conditioning shall comply with 9.2 and be installed per manufacturer's specifications. This requirement is not met as evidenced by an annual waiver request.
Report Facts
Facility capacity: 94
Census: 88
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
This visit was for the Investigation of Complaints IN00449162 and IN00448319 and was conducted in conjunction with a Post Survey Revisit to the Recertification and State Licensure survey completed on November 13, 2024.
Complaint Details
Complaint IN00449162 and Complaint IN00448319 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00449162 and IN00448319 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigations.
Report Facts
Census: 86
Total Capacity: 86
Medicare Census: 5
Medicaid Census: 65
Other Payor Census: 16
Inspection Report
Re-Inspection
Census: 86
Capacity: 86
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Recertification and State Licensure survey completed on November 13, 2024, and was conducted in conjunction with the Investigation of Complaints IN00449162 and IN00448319.
Complaint Details
Complaint IN00449162 and Complaint IN00448319 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in complaints IN00449162 and IN00448319 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to Recertification and State Licensure survey.
Report Facts
Census Bed Type: 86
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 16
Inspection Report
Annual Inspection
Census: 85
Capacity: 94
Deficiencies: 7
Date: Dec 5, 2024
Visit Reason
Annual Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and Emergency Preparedness Survey in accordance with 42 CFR 483.73.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies were identified related to means of egress obstructions, sprinkler system maintenance, portable fire extinguisher installation, HVAC return air system use of egress corridors, and improper storage of oxygen cylinders.
Deficiencies (7)
Failed to ensure 1 of 1 corridor means of egress on the Memory Care Hall was continuously maintained free of all obstructions or impediments to full instant use in case of emergency; a large reclining chair obstructed the exit.
Failed to ensure 1 of over 4 exit discharges had a level walking surface and was free of obstructions; large mats obstructed exit discharge near Hair Care.
Failed to maintain ceiling construction behind dryers causing potential sprinkler malfunction; hole in ceiling where sprinkler head may have been located.
Failed to ensure 1 of 1 sprinkler heads in laundry area were not loaded or covered with foreign material; sprinkler head covered in dust.
Failed to ensure 4 of 4 portable fire extinguishers in Maintenance Office were properly installed; extinguishers were unsecured and sitting on the floor.
Failed to ensure egress corridors were not used as a portion of a return air system serving adjoining rooms for 47 of 47 resident rooms.
Failed to ensure 1 of 1 cylinders of nonflammable gases such as oxygen were properly secured from falling; oxygen cylinder was standing upright and not properly chained or supported.
Report Facts
Certified beds: 94
Census: 85
Residents affected by corridor obstruction: 26
Residents affected by exit discharge obstruction: 15
Laundry staff affected: 3
Staff affected: 2
Resident rooms affected: 47
Staff affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Maintenance Director | Interviewed regarding multiple deficiencies including corridor obstruction, sprinkler system, fire extinguishers, HVAC, and oxygen cylinder storage. |
Inspection Report
Annual Inspection
Census: 82
Capacity: 82
Deficiencies: 6
Date: Nov 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00446976.
Complaint Details
Complaint IN00446976 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in several areas including accuracy of Minimum Data Set assessments, quality of care related to medication administration and vital signs, infection control for urinary catheters, medication storage, and food sanitation. No deficiencies were related to the complaint investigation.
Deficiencies (6)
Failed to ensure accuracy of Minimum Data Set assessments for 3 of 21 residents reviewed.
Failed to obtain physician ordered vital signs prior to medication administration for 1 of 21 residents reviewed.
Failed to follow appropriate infection control guidelines related to indwelling urinary catheters for 1 of 2 residents reviewed.
Failed to follow physician's orders related to hold parameters for a medication for 1 of 5 residents reviewed.
Failed to appropriately store medications for 3 of 4 medication carts reviewed.
Failed to prepare and store foods in a sanitary manner and maintain resident snack refrigerators in a sanitary manner.
Report Facts
Residents reviewed for MDS accuracy: 21
Residents reviewed for Quality of Care: 21
Residents reviewed for urinary catheters: 2
Residents reviewed for unnecessary drugs: 5
Medication carts reviewed: 4
Residents receiving food: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Administrator | Signed the inspection report |
| RN 4 | Interviewed regarding medication administration and documentation | |
| Director of Nursing | DON | Provided records, interviewed regarding deficiencies, and described corrective actions |
| Therapy Manager | Interviewed regarding resident discharge and ice pack storage | |
| Certified Nurse Aide 2 | CNA | Interviewed regarding catheter care |
| Unit Manager 7 | Observed medication cart deficiencies | |
| Assistant Director of Nursing | ADON | Interviewed regarding snack refrigerator contents and food service |
| Licensed Practical Nurse 6 | LPN | Interviewed regarding snack refrigerator contents |
| Medical Director | Reviewed medical records and vital signs with DON | |
| Dietary Manager | DM | Observed kitchen sanitation and cleaning schedules |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Nov 13, 2024
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments, failure to obtain vital signs prior to medication administration, improper infection control related to urinary catheters, medication administration errors, unsafe medication storage, and unsanitary food preparation and storage practices.
Deficiencies (6)
F0641: The facility failed to ensure the accuracy of Minimum Data Set assessments for 3 of 21 residents reviewed, including incorrect documentation of hospice care and feeding tube status.
F0684: The facility failed to obtain physician ordered vital signs prior to medication administration for 1 of 21 residents, resulting in undocumented vital signs on multiple dates.
F0690: The facility failed to follow infection control guidelines by allowing indwelling urinary catheter tubing to touch the floor for 1 of 2 residents reviewed.
F0757: The facility failed to follow physician's hold parameters for medication administration for 1 of 5 residents, administering medication when heart rate was below prescribed limits.
F0761: The facility failed to appropriately store medications, with loose pills found in three medication carts during observation.
F0812: The facility failed to prepare and store foods in a sanitary manner, with unsanitary conditions observed in the kitchen and resident snack refrigerators.
Report Facts
Residents reviewed: 21
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts reviewed: 4
Medication carts with deficiencies: 3
Residents affected: 82
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00441615 and IN00439979, and included a Covid-19 Infection Control Survey.
Complaint Details
Complaint IN00441615 and Complaint IN00439979 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00441615 and IN00439979 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 85
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 63
Census Payor Type - Other: 18
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
Annual inspection survey of Shady Nook Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 31, 2024
Visit Reason
Paper compliance review related to the Investigation of Complaints IN00433817 and IN00435973 completed on June 5, 2024.
Complaint Details
The visit was related to complaint investigations IN00433817 and IN00435973, with compliance found upon review.
Findings
Shady Nook Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigations.
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 1
Date: Jun 5, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00433817 and IN00435973 regarding pharmacy services and insulin administration.
Complaint Details
Complaint IN00433817 and IN00435973 were investigated and substantiated with deficiencies cited at F755 related to pharmacy services and insulin administration.
Findings
The facility failed to administer routine insulin in a timely manner for 1 of 3 residents reviewed (Resident B), with multiple instances of insulin given outside the prescribed time window. The facility policies on insulin and medication administration require timely delivery within one hour of the scheduled time. The facility submitted a plan of correction addressing the issue, including audits, staff education, and ongoing monitoring.
Deficiencies (1)
Facility failed to provide timely and routinely prescribed insulin administration services for 1 resident reviewed for Medication Administration.
Report Facts
Census: 84
Total Capacity: 84
Medicare Residents: 5
Medicaid Residents: 58
Other Residents: 21
Insulin doses given outside scheduled time: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey M. Boltz | Administrator | Signed report and provided facility policies |
| Licensed Practical Nurse 2 | Interviewed regarding insulin administration timing |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 5, 2024
Visit Reason
The inspection was conducted in response to complaints IN00433817 and IN00435973 regarding the timely administration of insulin to residents.
Complaint Details
This citation relates to complaints IN00433817 and IN00435973. The complaint was substantiated based on record review, resident interview, and staff interview confirming delayed insulin administration.
Findings
The facility failed to administer routine insulin in a timely manner for one of three residents reviewed for pharmacy services. The resident reported being woken up late at night to receive insulin, which was administered after the scheduled time.
Deficiencies (1)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of each resident by not administering routine insulin in a timely manner for one resident. Insulin doses were given outside the one-hour window specified by facility policy.
Report Facts
Residents reviewed for pharmacy services: 3
Insulin doses administered twice in 24 hours: 8
Units of insulin ordered: 30
Inspection Report
Complaint Investigation
Census: 89
Capacity: 89
Deficiencies: 0
Date: Apr 30, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00431060, IN00432184, and IN00432361 at Shady Nook Care Center.
Complaint Details
Complaints IN00431060, IN00432184, and IN00432361 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 89
Census Payor Type Medicare: 5
Census Payor Type Medicaid: 57
Census Payor Type Other: 27
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00429357.
Complaint Details
Complaint IN00429357 - No deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census Bed Type: 84
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 26
Inspection Report
Re-Inspection
Census: 75
Capacity: 94
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/11/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Shady Nook Care Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Inspection Report
Re-Inspection
Census: 80
Capacity: 80
Deficiencies: 0
Date: Oct 24, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and Complaint IN00416797 completed on September 25, 2023.
Complaint Details
Complaint IN00416797 - Corrected
Findings
Shady Nook Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and Complaint IN00416797.
Report Facts
Census SNF/NF beds: 80
Total census: 80
Medicare census: 5
Medicaid census: 60
Other payor census: 15
Inspection Report
Annual Inspection
Census: 83
Capacity: 94
Deficiencies: 12
Date: Oct 11, 2023
Visit Reason
Annual Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with several Life Safety Code requirements including fire wall maintenance, egress door accessibility, emergency lighting, hazardous area enclosures, fire alarm system maintenance, sprinkler system installation and maintenance, corridor door smoke resistance, HVAC return air system use, and elevator shunt trip device installation.
Deficiencies (12)
Failed to maintain building construction type for Type V(111) construction in 4 of 6 fire walls due to missing firestop foam with UL listing/documentation.
Failed to ensure means of egress doors were readily accessible; exit door keypad code not posted.
One battery powered emergency light failed to illuminate during testing.
Failed to separate hazardous areas (mechanical room) by smoke resistant partitions due to unsealed pipe penetration.
Fire alarm system did not display accurate time and date; missing inspection/testing documentation for elevator machine room initiating devices.
Sprinkler system had two sprinklers spaced less than 6 feet apart in oxygen storage room.
One sprinkler deflector not installed parallel to ceiling in oxygen storage room.
Missing escutcheon on ceiling mounted sprinkler in D Street shower room closet.
Corridor doors to resident rooms 24, 26, and 33 had gaps preventing resistance to smoke passage.
Egress corridors used as return air system for 47 resident rooms, not permitted by NFPA 90A.
Elevator machine room sprinkler system lacked shunt trip device to disconnect power upon sprinkler activation.
Failed to maintain automatic sprinkler system inspection/testing records; missing documentation for dry pendent sprinklers tested/replaced in 2019.
Report Facts
Certified beds: 94
Census: 83
Oxygen cylinders: 108
Sprinkler spacing: 4.5
Sprinkler spacing: 1.5
Sprinkler spacing: 1
Cost estimate: 29782
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Named in relation to multiple findings and interviews |
Inspection Report
Annual Inspection
Census: 81
Capacity: 81
Deficiencies: 6
Date: Sep 25, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00416797.
Complaint Details
Complaint IN00416797 was investigated during this visit. A Federal/State deficiency related to the allegation was cited at F689.
Findings
The facility was found deficient in multiple areas including failure to follow physician orders for insulin administration, inadequate fall interventions, lack of catheter care education and transmission-based precautions, failure to follow weight monitoring orders, lack of trauma-informed care interventions, and a significant medication error related to insulin administration.
Deficiencies (6)
Failure to follow physician orders related to insulin administration, notification, and hold parameters for 1 of 21 residents reviewed for quality of care (Resident 48).
Failure to ensure appropriate fall interventions were implemented for 1 of 4 residents reviewed for falls (Resident C).
Failure to ensure a resident who provided self-care with an indwelling urinary catheter was educated on catheter care and infection control guidelines related to transmission-based precautions for a urinary tract infection (Resident 77).
Failure to follow a physician's order related to weight monitoring for 2 of 21 residents reviewed for hydration status (Residents 29 and 71).
Failure to ensure resident specific interventions to provide trauma informed care were in place for 1 of 1 resident with a diagnosis of Post Traumatic Stress Disorder (Resident 11).
Failure to prevent a significant medication error related to insulin administration for 1 of 4 residents reviewed for medication administration (Resident 48).
Report Facts
Census: 81
Total Capacity: 81
Insulin administration errors: 9
Weight gain notifications missing: 11
Weight gain notifications missing: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Administrator | Signed the inspection report |
| LPN 3 | Licensed Practical Nurse | Named in insulin administration deficiency and medication error |
| RN 6 | Registered Nurse | Interviewed regarding medication administration documentation |
| CNA 2 | Certified Nurse Aide | Interviewed regarding fall incident and gait belt use |
| CNA 5 | Certified Nurse Aide | Interviewed regarding catheter care and gait belt use |
| QMA 4 | Qualified Medication Aide | Observed obtaining blood glucose level for Resident 48 |
| DON | Director of Nursing | Interviewed regarding insulin administration, catheter care, fall prevention, and weight monitoring |
| Social Services Director | Interviewed regarding trauma informed care for Resident 11 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 25, 2023
Visit Reason
The inspection was conducted in response to complaints regarding the facility's failure to follow physician orders related to insulin administration and failure to implement appropriate fall interventions for residents.
Complaint Details
This Federal tag relates to Complaint IN00416797.
Findings
The facility failed to follow physician orders for insulin administration, including administering insulin when blood glucose levels were below hold parameters and failing to notify the physician of critical blood glucose levels. Additionally, the facility failed to ensure appropriate fall interventions, including the use of gait belts, for a resident who sustained a fall resulting in serious injury.
Deficiencies (2)
F 0684: The facility failed to follow physician orders related to insulin administration, notification, and hold parameters for 1 of 21 residents reviewed. Insulin was administered when blood glucose was below 100, and the physician was not notified of blood glucose levels above 450 as required.
F 0689: The facility failed to ensure appropriate fall interventions were implemented for 1 of 4 residents reviewed for falls. A resident fell without the use of a gait belt, resulting in a traumatic subdural hematoma and a 3-part fracture of the surgical neck of the left humerus.
Report Facts
Residents reviewed for insulin administration: 21
Residents reviewed for falls: 4
Blood glucose levels above 450 without physician notification: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Interviewed regarding medication hold parameters and documentation. | |
| RN 6 | Interviewed regarding medication administration documentation. | |
| CNA 2 | Certified Nurse Aide | Witnessed resident fall and described circumstances of the fall. |
| CNA 5 | Certified Nurse Aide | Interviewed about gait belt use during resident transfers. |
| DON | Director of Nursing interviewed regarding documentation and fall prevention policies. | |
| Administrator | Provided facility policies and interviewed regarding documentation and fall prevention. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 25, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to multiple resident care concerns including fall interventions, urinary catheter care, weight monitoring, trauma-informed care, and medication administration.
Complaint Details
This Federal tag relates to Complaint IN00416797.
Findings
The facility failed to ensure appropriate fall interventions for one resident, failed to educate a resident on catheter care and implement transmission-based precautions, failed to follow physician orders for weight monitoring for two residents, lacked resident-specific interventions for trauma-informed care for one resident, and failed to prevent a significant medication error related to insulin administration for one resident.
Deficiencies (5)
F 0689: The facility failed to ensure appropriate fall interventions were implemented for 1 of 4 residents reviewed for falls. A resident fell while staff assisted with dressing and was not assisted with a gait belt as required.
F 0690: The facility failed to ensure a resident with an indwelling urinary catheter was educated on catheter care and infection control guidelines related to transmission-based precautions for 1 of 4 residents reviewed for urinary tract infections. The resident was not placed in contact isolation despite having MRSA and Pseudomonas Aeruginosa infections.
F 0692: The facility failed to follow physician orders related to weight monitoring for 2 of 21 residents. Multiple weights were undocumented or showed significant weight gain without physician notification.
F 0699: The facility failed to ensure resident-specific interventions to provide trauma-informed care were in place for 1 of 1 resident with PTSD. The care plan lacked specific interventions related to PTSD triggers and re-traumatization prevention.
F 0760: The facility failed to prevent a significant medication error related to insulin administration for 1 of 4 residents. Insulin was almost administered before the resident ate, contrary to the physician's order to give insulin after meals.
Report Facts
Deficiencies cited: 5
Weight gain: 7.8
Weight gain: 5.4
Weight gain: 6
Weight gain: 8.8
Weight gain: 5.2
Weight gain: 9
Weight gain: 9.4
Blood glucose reading: 255
Insulin dosage: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nurse Aide | Named in fall incident involving Resident C. |
| CNA 5 | Certified Nurse Aide | Provided information on gait belt use and catheter care practices. |
| DON | Director of Nursing | Provided clarifications on gait belt use, catheter care education, and insulin administration. |
| LPN 3 | Licensed Practical Nurse | Observed preparing to administer insulin to Resident 48. |
| QMA 4 | Qualified Medication Aide | Obtained blood glucose level for Resident 48. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: Aug 25, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00415405 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00415405 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations regarding the complaint.
Report Facts
Census Bed Type: 80
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 23
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 25, 2023
Visit Reason
Annual inspection survey of Shady Nook Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Date: Jul 17, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00412277 and IN00413012.
Complaint Details
Complaint IN00412277 and IN00413012 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00412277 and IN00413012 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 80
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 24
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410964.
Complaint Details
Complaint IN00410964 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 5
Medicaid census: 58
Other payor census: 18
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 23, 2023
Visit Reason
The visit was conducted as a paper compliance review related to the investigation of Complaint IN00406692.
Complaint Details
Complaint IN00406692 was investigated with a paper compliance review completed on May 11, 2023, and found to be in compliance.
Findings
Shady Nook Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 11, 2023
Visit Reason
The inspection was conducted in response to Complaint IN00406692 regarding medication administration timeliness at Shady Nook Care Center.
Complaint Details
This Federal tag relates to Complaint IN00406692 concerning late medication administration.
Findings
The facility failed to administer medications in a timely manner for 5 of 5 residents reviewed. Multiple medication administration audit reports showed consistent late medication administration beyond the facility's policy allowance of one hour before or after the scheduled time.
Deficiencies (1)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Medications for Residents B, C, D, E, and F were administered late on multiple occasions beyond the allowed one-hour window.
Report Facts
Residents reviewed for medication timeliness: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Provided Medication Administration Audit Reports and indicated medication administration timing policy. |
| QMA 2 | Qualified Medication Aide | Interviewed regarding medication administration documentation and timing. |
| RN 3 | Registered Nurse | Interviewed regarding medication administration documentation and timing. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 1
Date: May 10, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00407790 and IN00406692. Complaint IN00407790 had no deficiencies related to the allegations, while Complaint IN00406692 resulted in federal/state deficiencies cited related to medication administration timeliness.
Complaint Details
Complaint IN00406692 was substantiated with federal/state deficiencies cited at F755 related to medication administration timeliness. Complaint IN00407790 had no deficiencies related to the allegations.
Findings
The facility failed to administer medications in a timely manner for 5 of 5 residents reviewed (Residents B, C, D, E, and F). Multiple instances of late medication administration were documented, with delays ranging from minutes to several hours beyond scheduled times. The facility policy requires medications to be administered within one hour of the prescribed time.
Deficiencies (1)
Failure to administer medications in a timely manner for 5 of 5 residents reviewed.
Report Facts
Residents reviewed for medication timeliness: 5
Facility census: 78
Facility total capacity: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Boltz | Director of Nursing | Provided Medication Administration Audit Reports and participated in interviews regarding medication administration findings. |
| RN 3 | Registered Nurse | Interviewed regarding medication administration documentation and timing. |
| Qualified Medication Aide 2 | QMA | Interviewed regarding medication administration documentation and timing. |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Date: Jan 23, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00399064 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00399064 was unsubstantiated due to lack of evidence.
Findings
The complaint IN00399064 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and COVID-19 survey.
Report Facts
Census SNF/NF: 81
Total Capacity: 81
Census Payor Type Medicare: 8
Census Payor Type Medicaid: 58
Census Payor Type Other: 15
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Date: Dec 5, 2022
Visit Reason
This visit was for the investigation of complaints IN00389547 and IN00391378.
Complaint Details
Complaint IN00389547 - Unsubstantiated due to lack of evidence. Complaint IN00391378 - Unsubstantiated due to lack of evidence.
Findings
Both complaints IN00389547 and IN00391378 were found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Report Facts
Census: 81
Total Capacity: 81
Medicare Census: 10
Medicaid Census: 58
Other Payor Census: 13
Inspection Report
Re-Inspection
Census: 78
Capacity: 94
Deficiencies: 0
Date: Nov 9, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey originally conducted on 09/14/22.
Findings
At this Life Safety Code survey, Shady Nook Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety from Fire requirements. The facility was fully sprinkled with a fire alarm system and smoke detection in all resident areas.
Report Facts
Certified beds: 94
Census: 78
Inspection Report
Life Safety
Census: 80
Capacity: 94
Deficiencies: 25
Date: Sep 14, 2022
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency preparedness, means of egress, fire alarm system, sprinkler system, hazardous areas, and fire safety plan deficiencies.
Deficiencies (25)
Emergency preparedness policies lacked a system to track location of on-duty staff and sheltered residents during and after an emergency.
Emergency preparedness policies lacked procedures for use of volunteers and emergency staffing strategies.
Emergency preparedness communication plan lacked a method for sharing information with residents and families.
Three basement storage room egress doors, one resident room door, and one activities storage room door were not equipped with latches or locks that allow instant use from inside.
Basement/lower level egress corridor was obstructed by five chairs.
Facility emergency preparedness policies and procedures lacked complete compliance with tracking, volunteers, communication, and emergency staffing requirements.
Fire alarm delayed egress locking arrangements did not release locks within 15 seconds as required.
Dining room exit means of egress was not properly illuminated beyond porch overhang.
Exit signage was missing in courtyard to direct residents and staff to exit gate.
Facility failed to ensure combustible storage in basement/lower level was separated from egress corridor by smoke resisting partitions.
Activity room and maintenance room doors were not provided with self-closing devices.
Cooktop stove in Physical Therapy room was not shut off at switch when not in use and was functional.
Interior wall and ceiling finishes in basement/lower level storage room corridor wall were painted plywood without proper flame spread rating.
One of two fire alarm control annunciator panels was not protected by automatic smoke detection.
Documentation for sensitivity testing of smoke detectors was incomplete and inconsistent with inspection reports.
Facility fire watch policy was incomplete lacking IDOH contact web link, training documentation, and sole responsibility of fire watch personnel.
Two areas open to corridor in basement/lower level were not protected by electrically supervised automatic smoke detection system.
Sprinkler escutcheons in staff breakroom and resident room 20 were missing or hanging leaving gaps.
Facility failed to provide a complete written policy for sprinkler system impairment procedures and fire watch requirements.
Laundry chute door was not fully self-closing and positive latching; soiled linen chute lacked automatic sprinkler protection.
Wet locations including activity office, C Hall bathroom, and beauty salon lacked ground fault circuit interrupter (GFCI) protection.
Egress corridors were used as return air system for all resident rooms and corridors without proper waiver.
Fire safety plan was incomplete and did not address backup 9-1-1 call, staff response to battery smoke alarms, K-class extinguisher use, removal of wheeled equipment, and evacuation procedures.
Laundry chute door was not self-closing, positive latching, and gasketed; sprinkler not installed in soiled linen chute.
Facility failed to ensure fire drills were held at varied times for second shift during 3 of 4 quarters.
Report Facts
Certified beds: 94
Census: 80
Deficiency count: 36
Smoke detectors: 49
Smoke detectors tested: 36
Fire drills: 4
Fire drills second shift: 3
Sprinkler escutcheons inspected: 6
Sprinkler escutcheons deficient: 2
Wet locations without GFCI: 3
Inspection Report
Re-Inspection
Census: 77
Capacity: 77
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 4, 2022.
Findings
Shady Nook Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 15
Inspection Report
Annual Inspection
Census: 79
Capacity: 79
Deficiencies: 5
Date: Aug 4, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 31 to August 4, 2022.
Findings
The facility was found deficient in multiple areas including nutrition and hydration status maintenance, psychotropic medication monitoring, medication storage and labeling, food safety and storage, and infection control related to indwelling urinary catheters.
Deficiencies (5)
Failed to provide nutritional supplements for a resident with poor meal intake (Resident 61).
Failed to monitor residents who received psychotropic medications for adverse side effects (Residents 48, 15, and 46).
Failed to store medications appropriately related to labeling medications in medication carts (B Hall, C Hall, D Hall medication carts).
Failed to store foods in a sanitary manner related to unlabeled and outdated foods in the kitchen.
Failed to follow appropriate infection control guidelines related to indwelling urinary catheters for 2 residents (Residents 70 and 175).
Report Facts
Census: 79
Total Capacity: 79
Survey Dates: 5
Residents reviewed for nutrition: 2
Residents reviewed for psychotropic medication monitoring: 5
Medication carts reviewed: 6
Residents reviewed for infection control: 3
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