Shadescrest Health Care Center

In the surveyor’s words

From the most serious findings on record at Shadescrest Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 9, 2024

  Based on observation, interviews, review of an undated facility policy titled, DIETARY POLICY SANITATION AND INFECTION CONTROL, and review of the 2022 Food Code from the United States (U.S.) Food and Drug Administration (FDA); the facility failed to ensure two pans of casserole in the freezer was labeled with a use by date. This was observed on 02/05/2024, and had the potential to affect 84 out of 88 residents who were receiving food from the facility's kitchen. Findings include: A review of an undated facility policy titled, DIETARY POLICY SANITATION AND INFECTION CONTROL revealed the following: . 10. Storage of Leftovers . b. Leftovers, cold foods etc., shall be kept on a tray and covered with a fitted lid, foil wrap or plastic wrap. […]

• No harm, potential for more than minimal, patternF578Feb 9, 2024

  Based on record review, interviews, review of a section in the facility's Privacy Notice (Admission Packet) titled, . RESIDENT'S RIGHTS AND INFORMATION ., and review of [NAME] and Perry's FUNDAMENTALS OF NURSING NINTH EDITION, the facility failed to ensure residents and/or their representatives had the opportunity to formulate an advance directive including providing a written description of the facility's policies to implement advance directive and applicable state law. This deficient practice affected RI #'s 7, 23, 31, 44, 52, 62, 63, 70, 77, 78, and 79, 11 of 18 residents reviewed for advance directives. Findings include: A review of the facility's Privacy Notice, with an effective date of 04/14/2003, contained the following information: . RESIDENT'S RIGHT AND INFORMATION . 13. […]

• No harm, potential for more than minimal, patternF689Feb 9, 2024

  Based on observations, interviews, record review, review of the facility's SMOKING CONSENT AND WAIVER, and review of a facility policy titled Resident Smoking, the facility failed to ensure: 1) smoking assessments were completed on Resident Identifier (RI) #'s 33, 35, 48, 56, 58, 65, 72 and 138 to assess the resident's ability to smoke safely, 2) the smoking materials were kept locked up on the weekend; and 3) RI #31's fall risk preventions were implemented. These deficient practices affected eight of eight residents who smoked at the facility; and RI #31, one of one resident sampled for falls. Findings include: 1) Review of the facility's undated SMOKING CONSENT AND WAIVER, revealed the following: . 4. I agree that . […]

• No harm, potential for more than minimal, isolatedF551Feb 9, 2024

  Based on staff interviews, record review, and review of a section contained within the facility's Privacy Notice (Admission Packet) titled, . RESIDENTS' RIGHTS AND RESPONSIBILITIES OF FACILITIES ., the facility failed to ensure Resident Identifier (RI) #40 and RI #44 had a choice in choosing their representative /responsible party. This deficient practice affected RI #'s 40 and 44, two of 41 sampled residents. Findings include: A review of the facility's Privacy Notice, with an effective date of 04/14/2003, contained the following information: . RESIDENTS' RIGHTS AND RESPONSIBILITIES OF FACILITIES . The management and staff of their center will make every effort to assist you in exercising your Residents' Rights. 8. […]

• No harm, potential for more than minimal, isolatedF552Feb 9, 2024

  Based on staff interviews, record review, and review of a section contained within the facility's Privacy Notice (Admission Packet) titled, . RESIDENTS' RIGHTS AND RESPONSIBILITIES OF FACILITIES ., the facility failed to ensure Resident Identifier (RI) #2's and RI 40's listed responsible parties signed the consent for the residents to received the COVID-19 vaccination. This deficient practice affect RI #2 and RI #40, two of 41 sampled residents. Findings include: A review of the facility Privacy Notice, with an effective date of 04/14/2003, contained the following information: . RESIDENTS' RIGHTS AND RESPONSIBILITIES OF FACILITIES . The management and staff of their center will make every effort to assist you in exercising your Residents' Rights. 8. Freedom of Choice- . […]