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Shady Lake Nursing Home: Quality Oversight Gaps - LA
When questioned about the missing records, the facility administrator acknowledged the oversight....
Latest reports, citations, and penalties from CMS data
When questioned about the missing records, the facility administrator acknowledged the oversight....
The resident remained on a regular diet with no nutritional modifications despite consuming only **26-75% of meals**....
However, the medication was never transcribed into the facility's medication administration system and was therefore never given to the resident....
According to inspection records, the facility experienced a period of non-compliance that was later resolved through corrective measures....
In June 2024, eight of 23 treatment opportunities for the heel wound were not completed, and six of 11 opportunities for the knee wound were missed....
Despite submitting plans of correction after each citation, the facility has been unable to maintain compliance with federal infection control regulations....
According to the inspection narrative, R136 was assessed as cognitively intact but completely dependent on staff for all activities of daily living....
When facilities receive F919 citations, it indicates inspectors identified areas where the facility's operations did not align with required standards....
Advanced age, multiple chronic conditions, and close living quarters create conditions where infectious diseases can spread rapidly and cause severe outcomes....
According to treatment records, when the resident's catheter became blocked on February 1, 2025, nursing staff replaced it—but used the wrong equipment....
The resident also had severe cognitive impairment, making self-advocacy regarding dietary restrictions difficult or impossible....
According to inspection records, facility staff failed to ensure the resident received pain medications as ordered by the physician....
According to the inspection report, the facility's infection control surveillance and data analysis activities ceased after May 27, 2024....
A second discharged resident's liquid Lorazepam was also discovered in the same location....
The DON indicated she had not been aware of these disposal practices until the inspection....
These protocols are specifically designed to prevent the transmission of multi-drug resistant organisms between vulnerable residents....
The same issue appeared in the November 2024 report....
The repeat citation indicated that corrective actions implemented after the initial violation proved ineffective....
The facility's treatment systems failed at multiple levels, creating serious risks for vulnerable residents requiring specialized wound management....
The one-star staffing designation reflects more than just numbers on a spreadsheet....