Shadescrest Health Care Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on staff interviews, record review, and review of Resident Identifier (RI) # 40's and RI #44's Care Plan Review sheets, there was no evidence the Administrator (ADM) who was identified as the second contact/responsible party attended the care plan meetings. This deficient practice affected RI #40 and RI #44, two of 41 sampled residents

Inspectors wroteBased on an observation, interviews, record review and review of a facility policy titled, Administration of medication, the facility failed to ensure the EMAR (electronic Medication Administration Record) screen was closed, and did not reveal information about Resident Identifier (RI) #77's medications. This deficient practice affected RI #77, one of one resident; and was observed on 02/05/2024, during the evening medication pass.

Inspectors wroteBased on observations, interviews, review of a facility policy titled, RESTRAINT and review of a facility form titled, PHYSICAL RESTRAINT CONSENT, the facility failed to ensure Resident Identifier (RI) #54 did not have all four side rails up when observed in bed on 02/08/2024. This deficient practice affected RI #54; one of one resident sampled for the use of restraints.

Inspectors wroteBased on observations, interviews, record review, and review of a facility policy titled, FINGERNAIL AND TOENAIL CARE, the facility failed to ensure Resident Identifier (RI) #70's toenails and fingernails were kept clean and cut. This deficient practice affected RI #70 one of one resident who was sampled for Activities of Daily Living Care.

Inspectors wroteBased on observations, interviews, resident record review, review of the Reference Manual for Cleaning and Disinfecting the Assure Prism Multi Glucometer and review of a facility policy titled, Hand Hygiene, the facility failed to ensure: 1) Licensed Practical Nurse (LPN) #7 effectively cleaned and disinfected the glucometer after obtaining a blood glucose check for Resident Identifier (RI) #36, 2) LPN #7 implemented Enhanced Barrier Precautions before entering the room of RI #46, which was clearly identified for the use of Personal Protection Equipment (PPE); and LPN #7 washed or sanitized her hands between touching RI #46 and RI #57. These deficient practice affected LPN #7, one of two licensed staff observed performing finger stick blood glucose monitoring; [...]

Inspectors wroteBased on interviews, discussion during the resident group meeting 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 residents received mail on Saturdays. This deficient practice affected eight of eight residents who attended the group meeting and has the potential to affect all residents who received mail at the facility.

Inspectors wroteBased on observations, an interview and review of a facility policy titled, Posted Nurse Staffing Information, the facility failed to ensure the required data was on the nurse staff posting form, the data was posted at the beginning of the shift and the data was posted in an area readily accessible to visitors. This deficient practice had the potential to affect visitors at the facility; and all 88 residents residing in the facility on five of five days of the survey.

Inspectors wroteBased on interviews, record review and review of a facility policy titled, CARE PLANS, the facility failed to ensure the required disciplines of the Interdisciplinary team (IDT), specifically the Certified Nursing Assistants (CNAs), attended the care plan meetings This deficient practice affected RI #'s 6, 9, 19, 23, 26, 30, 31, 34, 43, 44, 49, 52, 54, 62, 70, 75, 77, and 78, 18 of 41 sampled residents.

Inspectors wroteBased on observation, interviews and review of a facility policy titled, INFECTION CONTROL PREVENTING THE SPREAD OF INFECTION, the facility failed to ensure: 1. the nurse did not lay the tip of a tube feeding line on a resident's blanket then re-attach it to the Gastrostomy Tube (G-Tube) and 2. the nurse did not lay the plunger of the syringe on the bed and return it to a bag that contained the clean barrel of the syringe. These deficient practices affected Resident Identifier (RI) #4, one of six residents observed during the medication pass observation. Findings Include: Review of a facility policy titled, INFECTION CONTROL PREVENTING THE SPREAD OF INFECTION with an effective date of 4/20/19, revealed, . POLICY It is the policy of (name of the facility) to have knowledge regarding the factors associated with the spread of infection in the facility. PROCEDURE 1. [...]

Inspectors wroteBased on observation and interviews, the facility failed to promote a homelike dining atmosphere for residents consuming meals in both the dining room and in personal rooms. Food was served throughout the survey in the dining room on trays atop bare tables. All residents received beverages in Styrofoam cups or original supplement bottle, or milk carton rather than glassware and ceramic bowls. This affected all 95 residents who received meals during the course of this survey (07/29/19 through 08/01/19), including Resident Identifier (RI) #73 and #82.

Inspectors wroteBased on observations, interviews, record review, and review of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, the facility failed to ensure licensed staff did not place Resident Identifier (RI) # 53's nebulizer mask in a bag, while still wet with moisture after a treatment was administered. This was observed on 6/25/18 and affected one of one resident observed for nebulizer treatments and one of four nurses observed during medication administration. Findings Include: A review of of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, Chapter 29, Infection Prevention and Control, page 455, documented: .Cleaning. Cleaning is the removal of organic material .from objects and surfaces .When an object comes in contact with an infectious or potentially infectious material, it is contaminated .Reusable objects need to be cleaned thoroughly before reuse . [...]