Shady Nook Care Center: Wrong Opioids Given to Resident - IN
The error happened on the morning of November 1, 2025. A nurse called the Director of Nursing to report she had accidentally given a resident the wrong medications. The resident was assessed and his vital signs were checked. The facility's nurse practitioner was notified and ordered him sent to the local hospital for evaluation.
He wasn't just observed and sent home. He was admitted to the ICU.
A note from a hospital nurse practitioner, written at 7:33 a.m. on November 2 from the intensive care unit, documented what the resident had received: oxycodone and Ultram, both opioid pain medications, neither of which he was prescribed. Hospital staff gave him intravenous fluids. They administered two doses of Narcan, 0.4 milligrams each, through his IV. Narcan is used to reverse the effects of a narcotic overdose. A urine drug screen confirmed opiates in his system.
The resident had no critical lab values before the error or during his first two days in the hospital. A follow-up note from the facility's own nurse practitioner, dated November 4, recorded that he appeared stable with no changes in diagnoses or medications.
Stable. After two doses of Narcan in the ICU.
The Director of Nursing told inspectors on November 20 that she received the call that morning and that the resident was assessed right away, the nurse practitioner was notified, and the resident was sent to the hospital, where he was admitted for observation. She said the facility educated all nursing staff after the incident and put an audit tool in place to monitor medication administration going forward.
The nurse who administered the medications, identified in the inspection report as RN 2, told inspectors she would normally verify a resident's first name, last name, and date of birth before giving medications. She did not explain why that verification did not happen on November 1.
The facility's own medication administration policy, last revised in January 2022, required staff to confirm the correct medication, the correct dose, the correct route, the correct rate, the correct time, and the correct resident every single time a medication was given. The policy existed. The nurse knew the protocol. The resident still ended up in the ICU with someone else's opioids in his bloodstream.
Federal inspectors cited the facility for causing actual harm to the resident, the second-most serious harm level in the citation system, one step below immediate jeopardy.
The facility told inspectors the deficient practice was corrected on November 2, the same day the resident was still in the hospital recovering, through staff education, medication administration audits, and monitoring.
What the inspection report does not say is how the mix-up happened in the first place. It does not identify which resident's medications were given, or how two opioids prescribed for one person ended up administered to another. It does not say whether the nurse was managing multiple patients at once, whether medications had been pre-pulled from their packaging, or whether labeling played any role. Those details were not part of what inspectors documented.
What the record does show is a man who went to bed in a nursing home and woke up, or didn't fully wake up, with narcotics flooding his system that his body had no tolerance for, followed by an ambulance ride, an ICU admission, and two rounds of a drug designed to pull people back from the edge of a narcotic overdose.
The follow-up note says he was stable. It does not say what the days between the ICU and that note looked like for him.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shady Nook Care Center from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SHADY NOOK CARE CENTER in LAWRENCEBURG, IN was cited for violations during a health inspection on November 20, 2025.
The error happened on the morning of November 1, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.