Shady Nook Care Center

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate documentation was completed related to a resident's pain medication for 1 of 3 residents reviewed for accuracy of records. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident to resident abuse did not occur for 1 of 3 residents reviewed for abuse. (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident diagnosed with an irreversible brain disorder that slowly destroyed memory, thinking skills, and simple tasks received appropriate supervision and interventions to attain his or her psychosocial well-being for 1 of 3 residents reviewed for dementia care. (Resident C)

Inspectors wroteBased on interview, observation, and record review, the facility failed to monitor a resident's skin conditions related to bruising and scratches from the time of the occurrence for 1 of 19 residents reviewed for Quality of Care. (Resident 30)

Inspectors wroteBased on interview and record review, the facility failed to administer a resident's medication as the physician prescribe related to hypotension for 1 of 19 residents reviewed for pharmacy services. (Resident 30)

Inspectors wroteBased on interview, observation, and record review, the facility failed to document an incident in the Electronic Health Record (EHR) and monitor a resident's skin conditions for 2 of 19 residents' records reviewed. (Resident 30 and Resident 25)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was free from a significant medication error when Resident C received Resident L's morning medications. The deficient practice resulted in the resident's hospitalization, administrations of two doses of Narcan, monitoring of vitals, and laboratory values for 1 of 3 residents reviewed for medication errors. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with urinary incontinence received services to maintain continence in a timely manner for 1 of 5 residents reviewed for urinary incontinence. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and store foods in a sanitary manner for 2 of 2 kitchen observations and failed to maintain resident snack refrigerators in a sanitary manner related to the storage of non-food items and outdate foods for 3 of 3 snack refrigerators observed. This deficient practice had the potential to affect on 82 of 82 residents who receive food from the kitchen or snack refrigerators.

Inspectors wrote3. The clinical record for Resident 27 was reviewed on 11/13/24 at 2:02 P.M. A Quarterly MDS assessment, dated 08/22/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, hypertension, dementia, and chronic obstructive pulmonary disease. Section O special treatments, procedures, and programs indicated the resident was receiving Hospice care while he was a resident in the facility during the assessment review period. The August 2024 physician orders, provided by the Director of Nursing (DON) on 11/14/24 at 2:15 P.M., lack documentation that the resident received Hospice care. During an interview on 11/13/24 at 1:36 P.M., the MDS Coordinator indicated the resident didn't receive Hospice care. The Quarterly MDS assessment was incorrect and she referred to the RAI manual for completing MDS assessments. [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain physician ordered vital signs prior to medication administration for 1 of 21 residents reviewed for Quality of Care. (Resident 1)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to indwelling urinary catheters for a resident who had a Urinary Tract Infection for 1 of 2 residents reviewed for urinary catheters. (Resident 7)

Inspectors wroteBased on record review and interview, the facility failed to follow the physician's orders related to hold parameters for a medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 72)

Inspectors wroteBased on observation and interview, the facility failed to appropriately store medications for 3 of 4 medication carts reviewed. (C Street Medication Cart 1, C Street Medication Cart 2, and B Street Medication Cart 1)

Inspectors wroteBased on record review and interview, the facility failed to administer routine insulin in a timely manner for 1 of 3 residents reviewed for pharmacy services. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders related to insulin administration, notification, and hold parameters for 1 of 21 residents reviewed for quality of care. (Resident 48)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate fall interventions were implemented for 1 of 4 residents reviewed for falls. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who provided self care with an indwelling urinary catheter was educated on catheter care and infection control guidelines related to transmission based precautions for a urinary tract infection that required transmission base precautions for 1 of 4 residents reviewed for urinary tract infections. (Resident 77)

Inspectors wrote2. During an observation on 09/21/23 at 10:52 A.M., Resident 71 was sitting in her room watching the television. There were no concerns. The clinical record for Resident 71 was reviewed on 09/22/23 at 2:46 P.M. A Quarterly MDS assessment, dated 08/16/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, anemia, hypertension, and diabetes. A physician's order, with a start date of 06/13/23 and stop date of 08/04/23, indicated the resident was to be weighed daily. The MD was to be notified if the weight was up or down by 2 pounds in a day. The June, July, and August, 2023 EMAR/ETAR indicated the resident lacked a documented weight on the following dates. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident specific interventions to provide trauma informed care were in place for 1 of 1 resident with a diagnosis of Post Traumatic Stress Disorder. (Resident 11)

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a significant medication error related to insulin administration for 1 of 4 residents reviewed for medication administration. (Resident 48)