Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shady Nook Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and Alzheimer's disease sustained facial and arm bruising and broken glasses after being physically assaulted by another severely cognitively impaired resident with a known history of escalating aggressive behaviors. Documentation showed the aggressive resident had prior physical behaviors toward others and delusional beliefs that the setting was her home, with a care plan directing staff to intervene to protect others' safety. On the day of the incident, the aggressive resident was wandering and not redirectable, then began yelling at and grabbing the other resident in a hallway, resulting in the documented injuries, contrary to the facility’s abuse policy prohibiting abuse by other residents.
A resident with severe cognitive impairment and Alzheimer’s disease exhibited escalating verbal and physical aggression toward staff and other residents, including hitting, yelling, grabbing, and shoving, while ambulating around the unit. Although care plans and a dementia protocol called for calm approaches, redirection, and removal from situations, staff interviews showed that behaviors increased over time, staff attempts to keep the resident busy were often ineffective, and supervision relied on trying to watch the resident at all times. Documentation of behaviors was inconsistent, with confusion over whether CNAs could chart and whether behaviors belonged in progress notes or behavior notes, and no behavior sheets were completed, leaving key team members unaware of the full extent of the resident’s aggression and limiting timely adjustment of interventions.
A facility failed to provide timely services for a resident with urinary incontinence, resulting in a deficiency. The resident had a history of urinary retention and was scheduled for a urology appointment and an abdominal ultrasound, which were rescheduled multiple times without proper documentation. The initial appointment was canceled due to weather, and there was a lack of follow-up communication. The facility's policy required adherence to prescriber orders and timely treatment, which was not followed.
The facility failed to maintain sanitary conditions in the kitchen and resident snack refrigerators. Observations included debris and improper storage in the kitchen, with cleaning schedules not followed. Snack refrigerators contained non-food items and outdated foods, violating facility policies on food storage and labeling.
The facility failed to ensure accurate MDS assessments for three residents. A resident was incorrectly documented as having a feeding tube, another was wrongly noted as discharged to a hospital instead of another LTC facility, and a third was inaccurately reported as receiving Hospice care. These errors were confirmed by the MDS Coordinator.
A resident with hypertension, diabetes, and dementia did not have vital signs documented before receiving Lisinopril and Propranolol, as required by physician orders. The EMAR records for September and October 2024 showed missing documentation for blood pressure and heart rate, despite the medications being administered. The resident experienced falls, and interviews confirmed that staff were expected to record vital signs before medication administration, but this was not consistently done.
A facility failed to follow infection control guidelines for a resident with an indwelling urinary catheter, leading to the tubing being observed on the floor multiple times. The resident, who was cognitively intact and had a history of renal issues, was being treated for a UTI. Despite the facility's policy to keep catheter tubing off the floor, staff acknowledged the oversight.
A resident with Parkinson's disease and ventricular fibrillation was administered Metoprolol despite physician's orders to withhold it if the heart rate was below 60 bpm. The facility's staff failed to record vital signs before administering the medication, leading to multiple instances of non-compliance with the prescribed hold parameters.
The facility failed to store medications properly in three medication carts. Loose pills were found in C Street Medication Carts 1 and 2, and B Street Medication Cart 1. The DON acknowledged the issue and was unable to identify the residents to whom the medications belonged. The facility's policy requires medications to be stored securely and properly.
A resident with diabetes did not receive their routine insulin in a timely manner, as prescribed. The facility's records showed multiple instances where insulin was administered after the scheduled time, often after midnight. Interviews confirmed that the facility's policy of administering medications within a one-hour window was not followed.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when one cognitively impaired resident with known behavioral issues physically assaulted another cognitively impaired resident. Resident D, who had Alzheimer's disease and was severely cognitively impaired, was documented in a progress note as having been involved in an altercation in which another resident struck her, causing her glasses to break and resulting in bruising to her face and both arms. A weekly skin assessment the following day documented bruising on both antecubital areas of her arms, the left periorbital area, and the left side of her nose, and later observation showed a fading bruise on her left arm. Resident C, also severely cognitively impaired and ambulatory with supervision, had a documented history of physical behaviors toward others and delusional beliefs that the facility was her home and that others needed to leave. Her care plan included an intervention for staff to intervene as necessary to protect the rights and safety of others. On the date of the incident, progress notes indicated Resident C was wandering in the hallway and could not be redirected, and later became aggressive, yelling at and grabbing Resident D and not being easily redirected by staff. Staff interviews described Resident C as a "walking behavior" who had become more aggressive over the prior two and a half months, with recent physical aggression such as randomly hitting other residents or smacking them, while Resident D was described as non-aggressive and not bothersome to others. The facility’s abuse policy stated residents must not be subjected to abuse by anyone, including other residents.
Failure to Monitor and Manage Escalating Dementia-Related Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate supervision, documentation, and individualized interventions for a resident with severe cognitive impairment and Alzheimer’s disease with early onset, who exhibited escalating behavioral symptoms. The resident’s MDS showed severe cognitive impairment and diagnoses including Alzheimer’s disease and non-traumatic brain dysfunction, with the ability to ambulate with supervision and a history of physical behaviors toward others. Existing care plans documented verbal behaviors such as yelling and cursing, physical aggression toward staff and others related to delusional beliefs that others were in her home, and delusions and hallucinations, with interventions such as allowing the resident to calm, having other staff approach, offering snacks or beverages for redirection, speaking in a calm manner, and removing the resident from situations as needed. Progress notes documented specific incidents, including the resident striking a staff member and becoming aggressive with another resident, yelling and grabbing the other resident and being difficult to redirect. Staff interviews revealed that the resident’s aggression had increased over the prior months, with reports that she had become more physically aggressive with other residents, including randomly hitting or smacking them as she walked by, screaming in another resident’s face, and shoving a resident’s shoulder. Staff described trying to watch the resident at all times and attempting to keep her busy, but reported that these efforts were not consistently effective. There was confusion and inconsistency regarding behavior documentation, with some staff believing behaviors should be charted in progress notes and others in behavior notes, and the Unit Manager stating CNAs could not chart behaviors. The Social Services Director reported there were no behavior sheets completed for this resident and that she was only aware of behaviors documented by nurses in progress notes, despite additional staff reports of resident-to-resident aggression and an earlier altercation. This pattern of incomplete behavior monitoring and lack of systematic reporting and adjustment of interventions occurred despite a facility dementia protocol requiring progressive or persistent worsening of symptoms and increased need for staff support to be reported to the IDT so that interventions and the overall plan could be adjusted.
Failure to Ensure Timely Urology Services for Resident with Urinary Incontinence
Penalty
Summary
The facility failed to ensure timely services for a resident with urinary incontinence, leading to a deficiency in maintaining continence. The resident, who was cognitively intact, had a history of urinary retention and was scheduled for a urology appointment and an abdominal ultrasound following hospital discharge. However, the appointments were rescheduled multiple times, and there was a lack of documentation in the clinical record regarding the rescheduling process. The initial urology appointment was canceled due to weather, and the rescheduling was not documented until much later, indicating a lapse in communication and follow-up. Interviews with the Director of Nursing (DON) and the urology office revealed that the facility did not ensure the resident attended the scheduled appointments, and there was no evidence of additional contact with the urology office prior to the surveyor's inquiry. The facility's policy required adherence to prescriber orders and timely identification and treatment of urinary issues, which was not followed in this case. This deficiency was related to a complaint investigation and highlighted the facility's failure to provide necessary care for the resident's urinary incontinence.
Sanitation Deficiencies in Kitchen and Snack Refrigerators
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and resident snack refrigerators, as observed during two separate kitchen tours and inspections of snack refrigerators. During the initial kitchen tour, the dry storage room floor was found littered with various debris, including dry cereal, a package of crackers, and a line of white powder identified as food thickener. The thickener was improperly stored with a scoop left inside the bag. Additionally, silver bowls covering plates in the plate warmer had a sticky residue, and wheeled carts used for meal service were sticky and littered with crumbs. The cleaning schedule was not adhered to, with no cleaning completed since the day shift on a previous date. In a subsequent kitchen tour, similar unsanitary conditions were observed, including dust-covered mechanical apparatuses on a metal shelf unit and sticky spots on a wheeled cart used for meal service. The silver bowls still had residue, and a shelf under the steam table contained loose paper clips among the plastic lids. These observations indicate a failure to follow the facility's cleaning and sanitation policies, which require cleaning after each use and maintaining a comprehensive cleaning schedule. The inspection of resident snack refrigerators revealed improper storage of non-food items and outdated foods. One refrigerator contained an unidentified cold pack, while another had a plastic bag of ice cream cups leaning against a cold therapy ice pack. A third refrigerator contained a grocery bag with outdated coleslaw, onion rings, and a dirty spoon. The facility's policies require labeling and proper storage of food brought by family or visitors, with perishable items discarded after 48 hours. However, these policies were not followed, as evidenced by the presence of outdated and improperly stored items.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For Resident 8, the Quarterly MDS assessment inaccurately indicated that the resident was receiving parenteral/intravenous feeding and had a feeding tube, despite the absence of a physician's order for tube feeding and the resident's own statement that he never had a feeding tube. The MDS Coordinator confirmed the inaccuracy of the assessment. For Resident 91, the Discharge MDS assessment incorrectly documented that the resident was discharged to a short-term general hospital, while in reality, the resident was transferred to another long-term care facility. This was corroborated by the Therapy Manager and a nursing note. The MDS Coordinator acknowledged the error in the discharge destination. Similarly, Resident 27's Quarterly MDS assessment inaccurately reported that the resident was receiving Hospice care, which was not supported by the physician's orders. The MDS Coordinator confirmed that the resident did not receive Hospice care, indicating another error in the assessment.
Failure to Document Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to obtain physician-ordered vital signs prior to administering medications for a resident with diagnoses including hypertension, diabetes, and dementia. The resident was prescribed Lisinopril and Propranolol, both of which required staff to hold the medication if the resident's systolic blood pressure was less than 100 or if their heart rate was less than 60 beats per minute. However, the Electronic Medication Administration Records (EMAR) for September and October 2024 showed numerous instances where the required vital signs were not documented before medication administration. In September 2024, the EMAR records for the resident were left blank for blood pressure and heart rate documentation from September 3 through September 30, despite the medications being administered daily. The Vitals records indicated sporadic documentation of vital signs, with significant gaps on several days. A progress note from September 10, 2024, indicated that the medications were held due to a low heart rate, but there was no documentation of vital signs for other prescribed times. The resident experienced falls on September 3 and September 24, 2024, but the clinical record lacked vital signs documentation related to medication administration on multiple other dates. In October 2024, the EMAR records continued to show missing documentation for vital signs from October 1 through October 25, 2024. The Vitals records for October also showed limited documentation, with vital signs recorded only on a few dates. Interviews with RN 4 confirmed that there was a place on the EMAR for recording vital signs if required by medication parameters, and staff were expected to obtain these before administering medication. The facility's policy on administering medications emphasized the need for safe and timely administration, including verifying vital signs when necessary, but this was not consistently followed.
Inadequate Infection Control for Urinary Catheter
Penalty
Summary
The facility failed to adhere to appropriate infection control guidelines concerning the management of indwelling urinary catheters, as observed in the case of a resident who had a urinary tract infection. During multiple observations, it was noted that the resident's indwelling urinary catheter tubing was consistently found lying on the floor under their wheelchair. This occurred on several occasions, including when the resident was in the main dining room and while propelling themselves in their wheelchair. Both the Director of Nursing and a Certified Nurse Aide acknowledged that the catheter tubing should not be in contact with the floor, indicating a lapse in following the facility's infection control protocols. The resident involved was cognitively intact and had a medical history that included hypertension, renal insufficiency, obstructive uropathy, and diabetes. The resident was receiving antibiotic treatment for a urinary tract infection, as indicated in their Electronic Medication Administration Record. The facility's policy on urinary catheter care, revised in December 2007, explicitly stated that catheter tubing and drainage bags should be kept off the floor to prevent infection. Despite this policy, the observations revealed a failure to maintain the catheter tubing in a manner that would prevent contamination and potential infection.
Failure to Follow Medication Hold Parameters
Penalty
Summary
The facility failed to adhere to the physician's orders regarding medication administration for a resident diagnosed with Parkinson's disease and ventricular fibrillation. The resident was prescribed Metoprolol, with specific instructions to withhold the medication if the heart rate was below 60 beats per minute. However, the medication was administered on multiple occasions when the resident's heart rate was below the specified threshold, indicating a failure to follow the prescribed hold parameters. The clinical record review and interviews revealed that the facility's staff did not consistently record vital signs prior to administering the medication, as required by the facility's policy. The EMAR system had a provision for recording vital signs and noting reasons for holding medication, but this protocol was not followed. The facility's policy, which mandates checking vital signs before medication administration, was not adhered to, leading to the administration of Metoprolol outside the prescribed parameters.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to appropriately store medications in three out of four medication carts reviewed. On C Street Medication Cart 1, a small round yellow pill and a small oblong pale green pill were found loose in the bottom of the second drawer, and a small round white pill was found loose in the third drawer. On C Street Medication Cart 2, a small round white pill and half of another small round white pill were found loose in the bottom of the second drawer. Additionally, on B Street Medication Cart 1, a small round pink pill and a small round white pill were found loose in the bottom of the second drawer. These observations were made in the presence of RN 4 and Unit Manager 7. During an interview, the Director of Nursing (DON) acknowledged that loose pills should not be present in the medication carts and was unable to identify which residents the loose medications belonged to. The facility's current policy on medication storage, provided by the DON, states that medications and biologicals should be stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to administer routine insulin in a timely manner for Resident B, who was cognitively intact and had diagnoses including end stage renal disease, heart failure, hypertension, and diabetes. The resident was prescribed Tresiba, an insulin medication, to be administered at 9:00 P.M. every night. However, the Electronic Medication Administration Record (EMAR) and Electronic Treatment Administration Record (ETAR) for March, April, and May 2024 showed that the insulin was administered twice in 24 hours on multiple occasions, with the second dose often given after midnight, well beyond the prescribed time. Interviews with an LPN and Resident B revealed that the insulin was frequently administered outside the facility's policy, which allowed a one-hour window for medication administration. The LPN confirmed that insulin should be given within an hour of the scheduled time, yet Resident B reported being woken up after midnight to receive their insulin. The facility's policies on insulin administration and medication administration were not adhered to, leading to this deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lawrenceburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Envive Of Lawrenceburg | 0.3 mi | — | 15 | 0 |
| Ridgewood Health Campus | 0.6 mi | — | 0 | 0 |
| Shawneespring Health Care Center | 9.8 mi | — | 7 | 1 |
| Three Rivers Healthcare Center | 10.2 mi | — | 2 | 0 |
| Harrison Trail Health Campus | 11.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.