Shady Oaks Healthcare Center

Based 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.Review of the Humalog/insulin lispro (a fast-acting insulin) Pen's Manufacturer Guidelines for Priming Before Each Injection and Administration, revised 02/2023, showed:- Turn the dose selector to select two units;- Hold the pen with the needle pointing up;- Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge;- Keep the needle pointing upwards, press the push-button all the way in;- The dose selector returns to zero;- A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times;- Select your dose you want to give. 1. Review of Resident #41's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Review of the facility policy titled, Medication Labeling and Storage, revised February 2023, showed:- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner;- If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items;- Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices;- The medication label includes, at a minimum, the medication name (generic and/or brand), prescribed dose, strength, expiration date - when applicable, resident's name, route of administration, and appropriate instructions and precautions;- Multi-dose vials…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Review of the facility policy titled, Enhanced Barrier Precautions, dated 2024, showed:- All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions;- All staff receive training in high-risk activities and common organisms that require EBP;- The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities;- EBP will be initiated for residents with wounds, and/or indwelling/implanted medical devices even if the resident is not known to be infected or colonized with a multidrug resistant organism (MDRO), and infection or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Observations made on 07/29/24 at 8:23 A.M., 07/30/24 at 8:43 A.M. and at 07/31/24 at 8:10 A.M., of the library located next to the kitchen, showed two soiled blankets with dirt, debris and several dead flies laid on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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); - No documentation of an appropriate diagnosis for the Seroquel. 2. Review of Resident #18's medical record showed: - An admission date of 12/14/17; - Diagnoses of major depressive disorder (persistent depressed mood or loss on interest), senile…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; - The Administrator directly supervises the Dining Services Manager, providing support and assistance and guidelines from the Registered Dietician (RD) on a monthly basis; - The Dining Services Manager directs the food preparation and dining services activities of all other employees in the Dining Service Department at department head…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. and 07/30/24 at 08:17 A.M., of the kitchen area, showed: - The floors around the food preparation area dirty and with a greasy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; Review of facility's policy titled Catheter Care, Urinary revised August 2022, showed: - Perform hand hygiene and use clean gloves; - Place resident in dorsal recumbent (on back with knees bent, feet spread out to sides) position or supine position during care; - Place bed protector…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. at 07/31/24 at 8:10 A.M., of the library located next to the kitchen, showed: - Several dead flies laid on the bottom ledges of the left and right-side windows; - Multiple flies buzzed around the room. 2. Observations made of the assisted feeding dining room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; - The Maintenance Director will be responsible for maintaining the inspection of the building records and work order requests.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. During an interview on 1/22/33 at 4:00 P.M., the Director of Nursing (DON) said Resident #10 was not on an anticoagulant and would expect it not to be coded on his/her MDS. During an interview on 1/24/23 10:20 A.M., the MDS Coordinator said he/she should code anticoagulant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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); - An order for oxygen at 2 liters per minute (L/min) per nasal cannula (N/C) (supplemental oxygen administered through tubing into the nostrils) as needed (PRN) for shortness of breath, dated 6/6/20. Record review of the resident's care plan, dated 1/13/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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: - Lantus insulin pens should be discarded 28 days after first use, regardless of refrigeration. Record review of the manufacturer's directions for Novolog (a type of insulin) flexpen prefilled syringe, dated 6/2021, showed: - Novolog prefilled syringes should be thrown away after 28 days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.