Shady Oaks Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 32 opportunities with two errors made, for an error rate of 6.25%, which affected two residents (Residents #41 and #53) out of 11 sampled residents. The facility census was 65. The facility did not provide a policy regarding insulin administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. This had the potential to affect all residents. The facility's census was 65. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide enhanced barrier precautions (EBP) when staff failed to implement EBP for one resident (Resident #56) and failed to wear a gown during wound care for one resident (Resident #71) with a chronic wound out of five sampled residents. The facility census was 65. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 64. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which includes a clean, sanitary and orderly environment with personalized furniture and room arrangements. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an appropriate diagnosis for the use of a psychotropic medication for five residents (Residents #15, #18, #38, #56) out of 16 sampled residents and one resident (Resident #42) outside the sample. The facility census was 64. The facility did not provide a policy. 1. Review of Resident #15's medical record showed: - An admission date of 07/08/24; - Diagnoses of vascular dementia with agitation (changes in memory, thinking, and behavior) and major depressive disorder (persistent depressed mood or loss in interest); - An order for Seroquel (antipsychotic used to treat schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations) 100 milligram (mg)1 tablet two times daily (BID); [...]

Inspectors wroteBased on observation, interview and record record review the facility failed to employ a qualified director of food and nutrition services. The facility did not have a Dietary Manager (DM) with a background or required years of experience in food preparation, food service and/or food storage. This deficient practice had the potential to affect all residents in the facility. The facility census was 64. Review of the facility's policy titled, Organizational Plan and Roles of Key Staff, dated 2016, showed: - The organizational plan shall be used to communicate clearly the functions of the Dining Services Department and the appropriate chain of command. The organization plan and department organization Chart will be shared with all staff and employees; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This deficient practice had the potential to affect all residents. The facility census was 64. Review of the facility's policy titled, Sanitation, revised November 2022, showed: - The food service area is maintained in a clean and sanitary manner; - All kitchens, kitchen areas and dining room areas are kept clean, free from garbage and debris, and protected from rodents and insects; - Ice machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions; - Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumspters/compactors with lids (or otherwise covered). 1. Observations made on 07/29/24 at 10:37 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during wound care for two residents (Residents #17 and #61) out of four sampled residents and one resident (Resident #8) outside the sample. The facility also failed to use proper infection control techniques for glove use during catheter care for one resident (Resident #60) out of two sampled residents. The facility census was 64. Review of the facility's policy, Wound Care, dated October 2010, showed: - Put on gloves; - Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers; - Wear sterile gloves when physically touching the wound or holding a moist surface over the wound; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the kitchen and main dining room. This deficient practice had the potential to affect all residents. The facility census was 64. Review of the facility's policy titled, Pest Control, revised May 2008, showed: - The facility shall maintain an effective pest control program; - This facility maintains an on-going pest control program to ensure the building is kept free of insects an rodents; - Windows are screened at all times; - Garbage and trash are not permitted to accumulate and are removed from the facility daily; - Maintenance services assist, when appropriate and necessary, in providing pest control services. 1. Observations made on 07/29/24 at 8:23 A.M., 07/30/24 at 8:43 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 54. Record review of the facility's Maintenance Service policy, revised December 2009, showed: - Maintenance service shall be provided to all areas of the building, grounds, and equipment; - The Maintenance Department shall be responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; - Maintenance personnel will maintain the building in compliance with current federal, state, and local laws, regulations, and guidelines; - Maintenance personnel will maintain the building in good repair and free from hazards; - Maintenance personnel will provide routinely scheduled maintenance service to all areas; [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff for three residents (Resident #10, #11 and #48) out of 14 sampled residents. The facility census was 54. Record review of the facility's Resident Assessment policy, revised March 2022, showed all personnel who complete any portion of the MDS, must sign attesting to the accuracy of such information. 1. Record review of Resident #10's admission MDS, dated [DATE], showed: - Resident received an anticoagulant (a blood thinner) medication daily. Record review of the resident's physician order sheet (POS), dated November 2022, showed: - No order for an anticoagulant. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's order for the use of supplemental oxygen therapy for one resident (Resident #12) out of two sampled residents and one resident (Resident #14) outside the sample. The facility census was 54. Record review of the facility's policy for Oxygen Administration, dated October 2010, showed: - Provide the guidelines for safe oxygen administration; - Verify the physician's order for this procedure; - Review the physician's orders or facility protocol for oxygen administration; - Review the resident's care plan to assess for any special needs of the resident. 1. Record review of Resident #12's Physician Order Sheet (POS), dated January 2023, showed: - Diagnosis of chronic obstructive pulmonary disease (COPD) (a lung disease that blocks airflow); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. The facility census was 54. Record review of the facility's Administering Medications policy, dated, April 2019, showed: - Insulin pens will be clearly labeled with the resident's name or other identifying information; - Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen will be used for that resident; - The expiration/beyond use date on the medication label will be checked prior to administering; - When opening a multi-dose container, the date opened will be recorded on the container. Record review of the manufacturer's directions for Lantus (a type of insulin) insulin pen dated 2022, showed: [...]