Deficiency Records for Hillcrest Shadow Lake LLC
Updated as of September 01, 2021
This is not the most recent data for Hillcrest Shadow Lake LLC. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-06-24 | 2020-07-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-27 | 2020-03-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-27 | 2020-03-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-27 | 2020-03-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-27 | 2020-03-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-27 | 2020-02-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-27 | 2020-02-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-18 | 2018-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-17 | 2018-11-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-17 | 2018-11-09 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-10-18 | 2018-10-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-10-18 | 2018-10-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-10-18 | 2018-10-18 | N |
| Meet other general requirements. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2017-08-08 | 2017-09-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-08-14 | 2017-09-12 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-08-14 | 2017-09-12 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-14 | 2017-09-12 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-08-14 | 2017-09-12 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-08-14 | 2017-09-12 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-08-14 | 2017-09-12 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-14 | 2017-09-12 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-08-14 | 2017-09-12 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-14 | 2017-09-12 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2017-08-14 | 2017-09-12 | N |
