Shady Grove Nursing and Rehabilitation Center

Honor the resident’s right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Rule F0559. D: no actual harm, potential for more than minimal harm. From a complaint.

Ensure the transfer/discharge meets the resident’s needs/preferences and that the resident is prepared for a safe transfer/discharge.

Rule F0627. D: no actual harm, potential for more than minimal harm. From a complaint.

Assist a resident in gaining access to vision and hearing services.

Rule F0685. D: no actual harm, potential for more than minimal harm. From a complaint.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 31, 2026.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 31, 2026.

Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Rule F0550. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Allow residents to self-administer drugs if determined clinically appropriate.

Rule F0554. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Rule F0584. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Provide the required documentation or notification related to the resident’s needs, appeal rights, or bed-hold policies.

Rule F0628. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted

Rule F0655. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Rule F0694. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Provide safe, appropriate pain management for a resident who requires such services.

Rule F0697. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Ensure the resident’s doctor reviews the resident’s care, writes, signs and dates progress notes and orders, at each required visit.

Rule F0711. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Rule F0725. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Rule F0761. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Rule F0806. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Provide and implement an infection prevention and control program.

Rule F0880. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Have enough outside ventilation via a window or mechanical ventilation, or both.

Rule F0923. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Rule F0756. B: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Jun 24, 2026.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Rule F0755. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 24, 2026.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 19, 2026.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Rule F0690. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 27, 2026.

Provide and implement an infection prevention and control program.

Rule F0880. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 27, 2026.

Provide care by qualified persons according to each resident’s written plan of care.

Rule F0659. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 11, 2025.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. G: actual harm. From a complaint. Correction date, as CMS recorded it: Aug 14, 2025.

Allow residents to self-administer drugs if determined clinically appropriate.

Rule F0554. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 14, 2025.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 14, 2025.

Ensure medication error rates are not 5 percent or greater.

Rule F0759. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 14, 2025.

Reasonably accommodate the needs and preferences of each resident.

Rule F0558. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Rule F0561. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Honor the resident’s right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Rule F0578. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Rule F0582. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Rule F0584. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Rule F0622. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Rule F0623. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Prepare residents for a safe transfer or discharge from the nursing home.

Rule F0624. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Rule F0625. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

PASARR screening for Mental disorders or Intellectual Disabilities

Rule F0645. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Rule F0677. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Rule F0690. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Provide enough food/fluids to maintain a resident’s health.

Rule F0692. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Provide safe, appropriate pain management for a resident who requires such services.

Rule F0697. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Rule F0700. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Obtain a doctor’s order to admit a resident and ensure the resident is under a doctor’s care.

Rule F0710. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Rule F0755. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Ensure medication error rates are not 5 percent or greater.

Rule F0759. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Rule F0761. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Provide routine and 24-hour emergency dental care for each resident.

Rule F0790. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Provide and implement an infection prevention and control program.

Rule F0880. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Keep all essential equipment working safely.

Rule F0908. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Rule F0909. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 5, 2025.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. F: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 5, 2025.

Ensure services provided by the nursing facility meet professional standards of quality.

Rule F0658. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 5, 2025.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 5, 2025.

Ensure the resident’s doctor reviews the resident’s care, writes, signs and dates progress notes and orders, at each required visit.

Rule F0711. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 5, 2025.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 5, 2025.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Rule F0607. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 5, 2025.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 5, 2025.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 5, 2025.

Plan the resident’s discharge to meet the resident’s goals and needs.

Rule F0660. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 5, 2025.

Honor the resident’s right to receive visitors of his or her choosing, at the time of his or her choosing.

Rule F0563. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 29, 2024.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 29, 2024.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 29, 2024.

PASARR screening for Mental disorders or Intellectual Disabilities

Rule F0645. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 29, 2024.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 29, 2024.

Ensure services provided by the nursing facility meet professional standards of quality.

Rule F0658. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 29, 2024.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 29, 2024.

Provide safe, appropriate pain management for a resident who requires such services.

Rule F0697. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 29, 2024.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 29, 2024.

Have enough outside ventilation via a window or mechanical ventilation, or both.

Rule F0923. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 29, 2024.