Shady Nook Care Center
Inspection Findings
F-Tag F0760
F 0760 Level of Harm - Actual harm Residents Affected - Few
assessed the resident and checked his vital signs, while the Assistant Director of Nursing (ADON) notified
the NP. The NP ordered the resident to be sent to the local hospital for evaluation. RN 2 indicated she would normally verify a resident's first and last name and date of birth before administering medications.
A hospital Nurse Practitioner (NP) 4 note from the Intensive Care Unit, dated 11/02/2025 at 7:33 A.M., was provided by the DON on 11/20/2025 at 12:43 P.M. The record indicated the resident was from this long-term care facility, had received someone else's medications, oxycodone, Ultram (both opioid pain medications), that the resident did not normally take. The resident received IV (Intravenous) fluids and two doses of Narcan, a medication that reverses the effects of a narcotic, 0.4 milligrams (mg) through his IV. A Urinary Drug Screen (UDS) test confirmed the resident had opiates in his system.
A follow-up visit Progress Note from facility NP 5, dated 11/04/2025, indicated the resident appeared stable with no changes in diagnoses or medications.
The resident had no critical lab values prior to the medication error or on day one and day two in the hospital.
During an interview, on 11/20/2025 at 10:02 A.M., the DON indicated she received a call on the morning of 11/01/2025 from the nurse that was on shift saying she accidentally gave a resident the wrong medications.
The resident was assessed right away, the NP was notified, and the resident was sent to the local hospital where he was admitted for observation. The facility educated all nursing staff and implemented an audit tool to monitor medication administration.
The current General Dose Preparation and Medication Administration policy, with a revision date of 01/01/2022, was provided by the DON on 11/20/2025 at 12:43 P.M. The policy indicated, .Facility staff should.Verify each time a medication is administered that it is the correct medication, at the correct dose, at
the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication schedule.
The deficient practice was corrected on 11/02/2025, after the facility implemented a systemic plan of staff education, medication administration audits, and monitoring to ensure implementation of the in-servicing was monitored related to medication administration.
This citation relates to Intake 2661017. 3.1-48(c)(2)
FORM CMS-2567 (02/99) Previous Versions Obsolete
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If continuation sheet
SHADY NOOK CARE CENTER in LAWRENCEBURG, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LAWRENCEBURG, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SHADY NOOK CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.