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Deficiency Records for Hillcrest Shadow Lake LLC
A list of the most recent deficiencies for Hillcrest Shadow Lake LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Hillcrest Shadow Lake LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-04-04 | 2024-05-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-04-04 | 2024-05-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-04 | 2024-05-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-04 | 2024-05-01 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-04-04 | 2024-05-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-04-04 | 2024-05-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-04-04 | 2024-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-04 | 2024-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-04 | 2024-05-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-04 | 2024-05-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-04 | 2024-05-01 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-04-04 | 2024-05-01 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-04-04 | 2024-05-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-04-04 | 2024-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-04 | 2024-05-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-04-04 | 2024-05-01 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2024-04-04 | 2024-05-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-06 | 2024-01-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-06 | 2024-01-17 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-12-06 | 2024-01-17 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-15 | 2023-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-15 | 2023-05-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-15 | 2023-05-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-15 | 2023-05-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-14 | 2023-03-29 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-02-14 | 2023-03-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-14 | 2023-03-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-14 | 2023-03-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-14 | 2023-03-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-14 | 2023-03-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-14 | 2023-03-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-14 | 2023-03-29 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-17 | 2023-02-06 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-02-10 | 2022-03-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-10 | 2022-03-04 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-10 | 2022-03-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-15 | 2021-12-16 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-10-14 | 2021-11-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-14 | 2021-11-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-13 | 2021-11-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-10-13 | 2021-11-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-13 | 2021-11-15 | N |
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