North Hills Life Care and Rehab

Based on observations, interviews, facility document review, and facility policy review, the facility failed to write the open date on medications for 4 (Resident #5, #32, #33, and #35) and maintained pharmacy packaging of a medication card for 1(Resident #5) of 2 medication carts observed for medication labeling and storage standards. The facility also failed to maintain possession of medication cart/room keys with authorized personnel for all residents in the facility. Findings include: A review of a facility policy titled, Medication Labeling and Storage, revised in February of 2023, indicated medications should remain stored in the packaging it was received from the pharmacy, multi-dose medication should be dated with the date it was opened, and only authorized personnel should have access to keys. During an observation and interview on 08/21/2024 at 2:27 PM, Licensed Practical Nurse (LPN) #2 was asked to retrieve medication for labeling review from the 200-hall medication cart. On inspection of Resident #32's Anoro Ellipita 62.5-25mcg (microgram) inhaler, Resident #33'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 observations, interviews, facility record review, it was determined that the facility failed to provide privacy during care for 1 (Resident #62) of 1 resident reviewed for privacy. Findings include: A review of the facility admission packet including the Resident Handbook, which provided the Arkansas Patient Rights Section 9, signed by the Resident #62 and admission Director #5 on 07/20/2024, indicated, residents have the right to have privacy in treatment. A review of the admission Record, indicated the facility admitted Resident #62 with diagnoses that included bacteremia and sepsis. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During an observation and interview on 08/20/2024 at 2:28 PM, the Assistant Director of Nursing (ADON) entered Resident #62's room to perform a peripherally inserted central catheter (PICC) line dressing change. Resident #62's roommate with two family members were also…

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, record review, and interview, it was determined the facility failed to ensure physician orders were followed for 1 (Resident #62) of 1 resident observed receiving medications from 1 (Licensed Practical Nurse (LPN) #9) of 3 nurses observed during medication pass. Findings include: A review of a facility in-service titled, 7 Rights of medication Administration, dated 08/15/2024, indicated, Must Check All Before Administering Any Medication: 1. Right Resident 2. Right Medication 3. Right Dose 4. Right Route 5. Right Time 6. Right Documentation 7. Right Reason. A review of the admission Record, indicated the facility admitted Resident #62 with diagnoses that included local infection of the skin and subcutaneous tissue of the right toe. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact and had an infection of the right toe and was receiving an antibiotic by intravenous (IV) route. A review of…

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 observations, interviews, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene during meal assistance; failed to utilize Enhanced Barrier Precautions (EBP), to maintain sterile and aseptic technique during a dressing removal and failed to maintain aseptic technique for IV tubing, specifically no cap was in place on the tubing to maintain a barrier from contamination for 1 (Resident #62) of 1 resident reviewed for dressing change. Findings include: 1. A review of a facility in-service titled, 400 Hall Certified Nursing Assistant (CNA) Meal Service, dated 08/16/2024, indicated, 1. Keep staff hands from crossing over cups/bowls (inf control). A review of Resident #26's Care Plan, revised on 05/28/2024, revealed the resident had an activity of daily living (ADL) related to muscle loss and had a potential for fluid deficit related to confusion. Interventions included providing care and assistance as needed and encouraging resident to drink fluids. During an observation on 08/19/2024 at 1:20 PM, CNA) #7 was sitting on a stool 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 observation, interview and record review, the facility failed to notify the Resident's representative of changes to medication for one (Resident #1) of three (Resident #1, #2, and #3) sampled residents. The findings are: Resident #1 with an admission date of 08/11/2024 had a diagnosis of Parkinson's disease. The admission Minimum Data Set [MDS] with an assessment reference date [ARD] of 8/18/23 documented a staff assessment of mental status [SAMS] of severely impaired. Physician Orders dated 08/11/2023 documented, Carbidopa Levodopa 25/250 mg [milligrams] take 3 tablets four times a day. A change made on 11/06/2023 showed, Carbidopa-Levodopa Oral Tablet 25-250 MG (Carbidopa-Levodopa) Give 2 tablet by mouth four times a day related to Parkinson's Disease . then on 12/08/2023 to, Carbidopa-Levodopa Oral Tablet 25-250 MG (Carbidopa-Levodopa) Give 1 tablet by mouth four times a day related to Parkinsonism for 7 Days, Decrease to 1 tablet four times a day [QID] x 7 days then discontinue .Amantadine HCl Oral Capsule 100 MGH. Give 1 capsule by mouth two times a day related to…

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 ensure a complete surgical history was obtained and surgical diagnosis history forwarded from the pre-admission screen for one Resident #1 of three (Resident #1, #2 & #3) sampled resident. This failed practice had the potential to have an adverse effect on the resident due to medical staff not having all the information to make an informed decision concerning care. The findings are: The pre-admission screen completed on 08/10/2023 documented, .has deep brain stimulator . Review of the pre-admission screen document Resident #1 was admitted on [DATE] and had a diagnosis of Parkinson's disease. The admission Minimum Data Set [MDS] with an assessment reference date [ARD] of 8/18/23 documented a staff assessment of mental status [SAMS] of severely impaired. Under section J of the MDS (Health Conditions), under neurological surgery, Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or drainage devices question is…

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, record review, and interview, the facility failed to ensure food was served in a sanitary manner to prevent cross contamination for 2 (Residents #26 and #65) of 5 (Residents #22 #26, #52, #63 and #65) sampled residents who are served meals in the 400 Hall Dining Room. This failed practice had the potential to affect 19 residents (total census: 75) who are served meals in the 400 Hall Dining Room as documented on a list provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. On 05/30/23 at 12:35 PM, Certified Nursing Assistant (CNA) #1 removed plastic wrap from cups and served chocolate cake, water, and tea to Resident #26 with her fingers on the rim of the cups and bowl. 2. On 05/30/23 at 12:37 PM, CNA #2 removed plastic wrap from cups and served chocolate cake, water, and tea to Resident #65 with her fingers resting on the rim of the cups and bowl. 3. On 05/31/23 at 3:16 PM, the Surveyor asked CNA #1 to explain the purpose of plastic wrap covering glasses and food when serving residents, and the process for serving food to the residents. CNA…

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 ensure Minimum Data Set (MDS) assessments were accurately coded for oxygen therapy for 1 (Resident #11) of 7 (Residents #5, #8, #9, #11, #22, #29 and #227) sampled residents with Physician Orders for oxygen therapy per a list provided by the Administrator on 06/01/23 at 8:58 AM, and failed to ensure MDS assessments were accurately coded for Preadmission Screening and Resident Review (PASARR) II for 3 (Residents #1, #2 and #5) of 4 (Residents #1, #2, #5 and #24) sampled residents with serious mental health diagnoses per a list provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. Resident #1 had diagnoses of Paranoid Schizophrenia and Anxiety Disorder, Unspecified. The Annual MDS with Assessment Reference Date (ARD) of 04/03/23 documented the resident was not currently considered by the Level II PASARR process to have a serious mental illness. a. A State Designated Professional Associates Assessment/Letter dated 08/17/94 provided…

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, record review, and interview, the facility failed to ensure oxygen was administered at the Physician Ordered rate for 2 (Residents #11 and #227) and oxygen tubing was changed weekly for 1 (Resident #29) of 7 (Residents #5, #8, #9, #11, #22, #29 and #227) sampled residents who received oxygen therapy and failed to ensure Continuous Positive Airway Pressure (CPAP) tubing was stored to prevent contamination for 1 (Resident #227) of 2 (Residents #8 and #227) sampled residents with Physician Orders for CPAP therapy as documented on lists provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. Resident #11 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Malignant Neoplasm of Bronchus or Lung. a. Physicians Orders dated 04/04/23 documented, Oxygen @ [at] 3 L [liters] as needed for shortness of breath 3 liters/min [minute] per nasal cannula PRN [as needed] . Oxygen @ 3 L every shift for shortness of breath . b. On 05/30/23 at 11:06 AM, Resident #11 was asleep in his wheelchair with oxygen (O2) via nasal cannula at 4 lpm [liters per…

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 generally accepted accounting principles were followed to ensure insurance premiums were paid timely for 1 (Resident #42) of 3 (Residents #2, #22 and #42) sampled residents whose personal funds were reviewed. The failed practice had the potential to affect 32 residents with resident trusts managed by the facility per a list provided by the Business Office Manager (BOM) on 06/01/23 at 10:08 AM. The findings are: 1. Resident #42's Annual Transaction Report provided by the BOM on 06/01/23 at 10:17 AM documented Dental Insurance Premiums of $111 - paid 02/28/23, 03/10/23 and 04/14/23. The Facility Notification dated 12/14/22 revealed the amount owed to Resident #42's dental insurance was $222 per month for the months of November 2022, December 2022, and January 2023, and the Facility Notification dated 05/05/23 revealed the amount owed to Resident #42's dental insurance was $111 per month from November 2022 through June 2023. 2. On 06/01/23 at 12:01 PM, the Surveyor asked the BOM if Resident #42's premium had been paid…

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, record review and interview, the facility failed to develop and implement the plan of care for oxygen use for 2 (Residents #11 and #227) of 7 (Residents #5, #8, #9, #11, #22, #29 and #227) sampled residents who had Physician Orders for oxygen therapy as documented on a list provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. Resident #11 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Malignant Neoplasm of Bronchus or Lung. The admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 04/14/23 documented the resident did not receive oxygen therapy. a. The Physician Orders dated 04/04/23 documented, Oxygen @ [at] 3 L [liters] as needed for shortness of breath 3 liters/min [minute] per nasal cannula PRN [as needed] . Oxygen @ 3 L every shift for shortness of breath . b. The Nsg (Nursing) Admit/Readmit Assessment and Care Plan dated 04/04/23 revealed oxygen at 3 liters via nasal cannula. c. The comprehensive Care Plan with an initiated date of 04/04/23 and a revision date of 05/11/23 did not address care…

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.