The Hills Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide dignity and respect for two out of two sampled residents (Resident 18 and 49) when: 1. Restorative Nursing Assistant 1 (RNA 1, a staff who is trained in activities to help residents with limited mobility and abilities) was observed standing over Resident 49 while assisting Resident 49 with eating. 2. Certified Nursing Assistant 3 (CNA 3, a staff who is trained in providing basic, hands-on patient care) was observed standing over Resident 18 while assisting Resident 18 with eating. These failures had the potential to negatively affect Resident 49's and Resident 18's self-esteem and self-worth during mealtimes in the facility. Findings: 1. During a review of Resident 49's admission record indicated the facility admitted the resident on 2/28/2024, including a readmission on [DATE], with diagnoses that included dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities). During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within accessible reach of the resident from for two of two sampled residents (Resident 23 and Resident 59) in the facility. This failure had the potential for residents in the facility to be unable to summon facility staff for help, as needed, which could have resulted in resident discomfort and/or harm due to the residents' inability to reliably call facility staff for help. Findings: 1. During a review of Resident 23's admission Record, the document indicated the facility admitted Resident 23 on 5/24/2022, including a readmission on [DATE], with diagnoses that included spinal stenosis (a narrowing of one or more spaces within your spinal canal), displaced fracture of left femur (fracture requiring realignment [putting back into its normal position] of the bone), and aphasia (a condition that makes it hard for…

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 licensed nurses provided non-pharmacological interventions prior to administering an as needed (prn) opioid medication on multiple days for two of two sampled residents (Resident 36 and Resident 61). These failures had the potential to result in Resident 36 and Resident 61 receiving unnecessary pain medications. Findings: 1. During a review of Resident 36's Face Sheet (admission record), the document indicated Resident 36 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included pelvic fracture. During a review of Resident 36's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/26/2024, the MDS indicated Resident 36 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 36 required moderate assistance (helper does less than half…

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 two of eight sampled residents were free from medication error by failing to ensure the Controlled Drug Record (CDR - accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR - a report detailing the drugs administered to a patient by the licensed nurses) for two (Resident 36 & Resident 61) of four residents sampled during the medication storage observation. These failures had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug) in the facility. Findings: 1. During a review of Resident 36's Face Sheet (admission record), the document indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included pelvic fracture. During a review of Resident 36's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/26/2024,…

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 the implementation of the Medication Regimen Review (MRR - a pharmacist's thorough evaluation of a resident's medication routine and recommendations) for two of three residents (Resident 49 and Resident 63). This failure could have resulted in preventable medication side effects, including up to bleeding, blood clotting, or seizures for Resident 49 and Resident 63. Findings: 1. During a review of Resident 49's admission Record, dated 11/24/2024, the document indicated Resident 49 was admitted on [DATE] with diagnoses that included hydrocephalus (an abnormal buildup of cerebrospinal fluid [CSF- a clear, colorless, watery fluid that flows in and around your brain and spinal cord] deep within the brain), presence of cerebrospinal drainage device (shunt - a passage, such as a tube that is made to allow blood or other fluid to move from one part of the body to another), dysphagia (swallowing difficulties), history of falling, and dementia (the loss…

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 residents' drug regimens were free from unnecessary drugs, by failing to adequately monitor valproic acid and heparin for two of three residents (Resident 49 and Resident 63). This failure could have resulted in medication side effects leading up to bleeding, blood clotting, or seizures for Resident 49 and Resident 63. Findings: 1. During a review of Resident 49's admission Record, dated 11/24/2024, the document indicated Resident 49 was admitted on [DATE] with diagnoses that included hydrocephalus (an abnormal buildup of cerebrospinal fluid [CSF- a clear, colorless, watery fluid that flows in and around your brain and spinal cord] deep within the brain), presence of cerebrospinal drainage device (shunt - a passage, such as a tube that is made to allow blood or other fluid to move from one part of the body to another), dysphagia (swallowing difficulties), history of falling, and dementia (the loss of remembering and reasoning to the extent that…

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 residents were free of any significant medication errors, when the facility continued to give medications without checking the therapeutic levels for two of three sampled residents (Residents 49 and Resident 63). This failure had the potential to result in bleeding, blood clots, or seizures for Resident 49 and Resident 63. Findings: 1. During a review of Resident 49's admission Record, dated 11/24/2024, the document indicated Resident 49 was admitted on [DATE] with diagnoses that included hydrocephalus (an abnormal buildup of cerebrospinal fluid [CSF- a clear, colorless, watery fluid that flows in and around your brain and spinal cord] deep within the brain), presence of cerebrospinal drainage device (shunt - a passage, such as a tube that is made to allow blood or other fluid to move from one part of the body to another), dysphagia (swallowing difficulties), history of falling, and dementia (the loss of remembering and reasoning to the extent…

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 the storage of food in accordance with professional standards by not labeling stored food with a use-by date (the indicated date that the food item should be used or consumed by). These failures had the potential for 66 of 67 facility residents who receive food from the facility kitchen to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 10/21/2024 at 8:00 a.m. with the Dietary Supervisor (DS), the refrigerator was observed and the following was noted: one clear zip-lock bag of garlic, one clear plastic container of ham, and one clear plastic container of apple sauce - none of these items were labeled with a use-by date. Further observation included the dry storage room and the following was noted: seven pistachio puddings and pie fillings, six vanilla pudding and pie fillings, five lime gelatine desserts, three cherry gelatine desserts, four strawberry gelatine desserts,…

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 their trash was stored in the dumpster areas while being maintained in a sanitary manner. Two of two facility garbage dumpsters in use had their lids open. These failures had the potential for harborage and feeding of pests. Findings: During a concurrent observation and interview on 10/23/2024 at 12:07 PM with the Dietary Supervisor (DS), there were two facility dumpsters observed outside of the facility that were filled with trash bags. Two dumpsters had the lids open and positioned in close proximity to the wall, making it impossible to close them. The DS stated, the dumpsters should have been closed. The DS further stated, if the dumpsters were not closed, the smell would attract flies and there could be an infection control issue, because the flies could get inside the facility and go into the resident's food. During an interview on 10/23/2024 at 12:15 PM with the Maintenance Supervisor (MS), the MS stated the dumpster lids should have been closed. The MS further stated, if the dumpster lids were…

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 the implementation of their policy titled, Enhanced Barrier Precautions (EBP - an infection control method that uses targeted gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial [a substance that kills microorganisms such as bacteria or mold, or stops them from growing and causing disease agents]]) when: 1. Licensed Vocational Nurse 2 (LVN 2) did not don (to put on) a gown while administering medication via gastrostomy (G-Tube, a tube inserted through the abdomen that delivers directly to the stomach) for one of one sampled resident (Resident 48). 2. Licensed Vocational Nurse 1 ( LVN 1) did not don a gown while administering medication through the rectum (the last part of the large intestine, where the body stores stool before it leaves through the anus [an opening at the end of the digestive system]) for one 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' clinical records were updated regarding advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one of three sampled residents (Resident 59), by failing to maintain a current copy of the resident's advance directives in Resident 59's active clinical record. This failure had the potential to cause conflict with Resident 59's wishes regarding health care services received. Findings: During a review of Resident 59's admission Record, the document indicated Resident 59 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses that included senile degeneration of the brain (a process of gradual decline of brain cells that is associated with memory loss and difficulty thinking clearly), aphasia (a condition that makes it hard for a person to speak, understand, read 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the activation of the correct setting of a Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) for one of one sampled residents (Resident 59) requiring a LALM, when Resident 59 was investigated for pressure injury (PI - localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care. This failure had the potential to place Resident 59 at risk for discomfort and development of avoidable pressure ulcers/injuries. Findings: During a review of Resident 59's admission Record, the document indicated Resident 59 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses that included senile degeneration of the brain (a process of gradual decline of brain cells that is associated with memory loss and difficulty thinking clearly), aphasia (a condition that makes it hard for a person to speak,…

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 medications were stored in a locked compartment, when the Station Two Nursing Station Medication Cabinet did not have a lock, which permitted any staff or resident access. This failure had the potential for residents to take medications, which could cause harmful adverse side effects for the residents. Findings: During a concurrent observation and interview on 10/21/2024 at 4:00 p.m. with the Director of Staff Development (DSD), in the facility's medication storage area, observed Nursing Station Two right-side drug cabinet. The cabinet did not have a lock as the left-side cabinet had. The right-side cabinet contained the following: 1. Two Iron Supplement (given to one with a low level of iron in the blood) Liquid 16 fluid ounce (fl. oz., a unit of measure for liquids) bottles. 2. Two Bismuth subsalicylate (commonly known as Pepto Bismol, given for treating diarrhea and upset stomach) 16 fl. oz. bottles. 3. One Liquid Multi-Vitamin 16 fl. oz. bottle. 4. Three Liquid Acetaminophen (also known as Tylenol,…

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 provide the necessary care and services in accordance with its policy and procedure for one of three sample residents (Resident 1), as evidenced by: 1. Failing to schedule an appointment for follow up care with cardiology (branch of medicine that specializes in diagnosing and treating diseases of the heart and blood vessels) within two weeks (per instructions from the General Acute Care Hospital [GACH]) after being re-admitted to the facility on [DATE] and within one week (per instructions from the GACH) after being re-admitted to the facility on [DATE]. 2. Failing to schedule an appointment for follow up care with pulmonology (branch of medicine dealing with diseases involving the respiratory tract [the organs that are involved in breathing]) within one week (per instructions from the GACH) after being re-admitted to the facility on [DATE]. 3. Failing to ensure monitoring was provided to Resident 1 after a change in condition (COC- when there is a…

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 develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) to address a diagnosis of heart failure (a condition in which the heart doesn't pump blood as well as it should) for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1 due to the absence of the comprehensive care plan. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 10/19/2023 and readmitted Resident 1 on 10/28/2023. Resident 1's last re-admission was on 12/20/2023 with diagnoses that included Non-ST-Elevation Myocardial Infarction (NSTEMI- a type of heart attack that usually happens when your heart's need for oxygen can't be met), heart failure, and unstable angina (chest discomfort or pain caused by insufficient blood and oxygen flow to the heart). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the history and physical (H&P- is the starting point of the resident health concerns that explain why a resident sought medical attention or why a resident is now receiving medical attention) for one of three sampled residents (Resident 1) was completed by the attending physician upon Resident 1 ' s first admission to the facility on [DATE]. This deficient practice had the potential for inconsistent care coordination due to incomplete records. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 10/19/2023 and readmitted Resident 1 on 10/28/2023. Resident 1 ' s last re-admission was on 12/20/2023 with diagnoses that included Non-ST-Elevation Myocardial Infarction (NSTEMI- a type of heart attack that usually happens when your heart's need for oxygen can't be met), heart failure (a condition in which the heart doesn ' t pump blood as well as it should), and unstable angina (chest discomfort…

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 implement their facility ' s medication administration policy by failing to ensure Licensed Vocational Nurse 1 (LVN 1) signed and documented on the Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) for one of three sampled residents (Resident 1) when LVN 1 did not administer Plavix (a medication used to prevent stroke and blood clots) on 12/21/2023. This deficient practice had the potential to result in medication errors and had the potential to result in confusion on the delivery of care and services. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 10/19/2023 and readmitted Resident 1 on 10/28/2023. Resident 1 ' s last re-admission was on 12/20/2023 with diagnoses that included Non-ST-Elevation Myocardial Infarction (NSTEMI- a type of heart attack that usually happens when your heart's need for oxygen can't be met), heart failure (a condition in which the heart doesn ' t pump blood…

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 implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report within two (2) hours to the State Survey Agency (SSA) one incident of injury of unknown origin (injuries resulting without knowing how it happened) that occurred on 3/6/2024 for one of four sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 1/23/2024 and readmitted the resident on 3/8/2024 with diagnoses that included age-related osteoporosis (a disease in which bones become fragile and more likely to break) with pathological fracture (a broken bone caused by a disease rather than an injury), and unspecified dementia (the loss of cognitive functioning, thinking, remembering, and reasoning). A…

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 licensed nurses administered the prescribed dose of Clozaril (an Antipsychotic medication [medications that are used for some types of mental distress or disorder] to treat schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves]) 200 milligrams (mg-unit of measure) to one of nine sampled residents (Resident 1) from 11/23/2023 to 1/29/2024. Resident 1 was administered a total of 31 incorrect (higher than prescribed) doses of Clozaril. The deficient practice of failing to administer medications in accordance with physician's orders placed Resident 1 at risk for serious health complications as a result of being administered a higher dose of Clozaril than prescribed. Findings: A review of Resident 1 ' s Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses that included schizophrenia. A review of Resident 1' s Minimum Data Set (MDS, a standardized assessment…

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 an environment free from accidents and hazards by failing to: 1. Ensure that a resident who was at high risk for falls had their bed in a low position for one (Resident 44) of five sampled residents investigated for accidents. 2. Ensure the information for a resident's pacemaker (a small electrical device that's implanted in the chest or abdomen to help your heartbeat at a normal rate and rhythm) was readily available in the resident's medical record for one (Resident 9) of five sampled residents investigated for accidents. 3. Ensure that a licensed nurse did not leave a resident's blood pressure medication at the bedside for one (Resident 13) of five sampled residents investigated for accidents. 4. Ensure one of five sampled residents (Resident 56) investigated for Accidents did not have an opened bottle of 0.9 percent (%-unit of measure) Sodium Chloride Irrigation solution (Normal Saline [NS], a sterile solution composed 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 interview and record review, the facility failed to: 1. Ensure licensed nurses followed up with the pharmacy when a resident's Isosorbide (a medication used to prevent angina [chest pain] in residents with a certain heart condition) medication had not been delivered for one (Resident 112) out of six sampled residents observed during medication administration. 2. Ensure licensed nurse staff documented either at the start of the shift, or the end of the shift on Medication Cart 2 Floor Narcotic (a type of medication that is used to relieve pain but has a high potential for abuse) Release form (a form that is signed by both the oncoming shift licensed nurse and the outgoing shift licensed nurse after they have both verified by counting that all controlled medications [medications that can cause physical and mental dependence such as narcotics]) for 12 of 127 shifts. 3. Ensure licensed nurses documented the administration of Ativan (a medication used to treat anxiety [a persistent feeling of worry, nervousness, or unease]) for one of five sampled resident's (Resident 38) for 15…

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: 1. Ensure medication bubble packs (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) were not stored in an unlocked drawer in Nursing Station 2 for two of two sampled residents (Resident 26 and Resident 34) investigated for Medication Storage and Labeling. 2. Label one open vial (small container) of glucometer test strips (an absorbent strip that soaks up blood to be read by the glucometer [medical device used for determining the approximate concentration of sugar in the blood]) found in one of two medication carts (Nursing Station 2 Medication Cart) investigated during the facility task Medication Storage and Labeling. These deficient practices had the potential to result in residents or unauthorized personnel accessing Resident 26 and Resident 34's medications and had the potential to compromise the accuracy of glucometer tests strips readings resulting in inaccurate blood…

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 kitchen staff failed to ensure the proper storage, preparation, and distribution of food in accordance with professional standards for food service safety for 60 of 61 residents who receive food from the kitchen by: 1. Failing to ensure food items such as ham, cups of wild berry frozen desserts, lemons, apples, cheese, yogurt, and milk were labeled and dated with the received and/or open date (when staff write on the item the date it was received or the date it was first opened). 2. Failing to ensure the Meat Freezer temperature was maintained below 0 degrees Fahrenheit (?, a unit of measurement) for 16 of 31 logged temperature checks for 10/2023. 3. Failing to ensure the low temperature dishwashing machine (a device that applies water and a chemical sanitizing solution [destroys or prevents the growth of disease-causing microorganisms] to the surfaces of dishes and equipment) chlorine (a sanitizing solution) solution concentration (the amount of chemical dissolved in water) measured a minimum of 50 parts per million (ppm- a…

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 implement infection control practices by: 1. Failing to ensure a resident's oxygen tubing (connects to an oxygen source to deliver oxygen to a resident) was labeled with the date it was last changed and was kept off the floor for one (Resident 110) of five sampled residents investigated for infection control. 2. Failing to ensure that, the wound treatment nurse (Licensed Vocational Nurse 1 [LVN 1]), who was observed wearing two sets of gloves on at the same time, performed hand hygiene (washing of hands) when removing one set of gloves during a wound care dressing (sterile [free from germs] pad applied to a wound to promote healing and protect the wound from infection) change observation for two (Residents 47 and Resident 16) of five sampled residents investigated for infection control. 3. Failing to ensure that during a medication administration observation, Licensed Vocational Nurse 2 (LVN 2) performed hand hygiene before and after administering…

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 it followed its policy and procedure for the implementation of the physical restraint (the use of a manual hold or device to restrict freedom of movement of all or part of a resident's body) of a soft belt (a foam-padded pelvic restraint with ties secured around the back of wheelchair designed to help prevent forward sliding in wheelchairs) for one of one sampled resident investigated for restraints (Resident 38) by failing to: 1. Ensure informed consent (the process in which a health care provider educates a resident about the risks, benefits, and alternatives of a given procedure or intervention and ensures that a decision is made voluntarily) was obtained by the physician for Resident 38's soft belt restraint. 2. Ensure a pre-restraint assessment was completed prior to placing the soft belt on the resident on 9/8/2023. 3. Ensure the physician's order for the soft belt included the specific reason for the restraint, how the restraint will benefit the resident's medical symptom, and the period of time…

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 develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for two of 17 sampled residents (Resident 9 and Resident 38) by failing to: 1. Ensure a care plan for oxygen therapy (a treatment that provides extra oxygen to help people with lung diseases or breathing problems) was developed for Resident 9. 2. Ensure a care plan for Resident 9's pacemaker (a small electrical device that's implanted in the chest or abdomen to help your heartbeat at a normal rate and rhythm) was developed. 3. Ensure a care plan for the use of a soft belt restraint (a foam-padded pelvic restraint with ties secured around the back of wheelchair designed to help prevent forward sliding in wheelchairs) was developed for Resident 38. These deficient practices had the potential to result in a delay in or lack of delivery of care and services. Findings: 1. A review of Resident 9's admission Record…

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 a resident receiving oxygen had a physician's order for oxygen therapy (a treatment that provides extra oxygen to help people with lung diseases or breathing problems) for one of one sampled resident (Resident 9) investigated for oxygen therapy. This deficient practice had the potential to result in Resident 9 experiencing adverse effects due to inadequate or higher than necessary rates of oxygen administration leading to a negative impact to the resident's overall health. Findings: A review of Resident 9's admission Record indicated the facility originally admitted Resident 9 on 4/7/2023 and readmitted Resident 9 on 7/14/2023 with diagnoses that included pneumonia (an infection that inflames the air sacs in one or both lungs) and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days). A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/20/2023, indicated Resident 9 had…

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 one of five sampled residents (Resident 38) was free from unnecessary psychotropic medication (medications capable of affecting the mind, emotions, and behavior) by failing to limit the duration of an as needed (PRN) order for Ativan (a controlled substance [medication with a high potential for abuse] used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) to 14 days. This deficient practice had the potential to result in adverse reaction or impairment in the resident's mental or physical condition. Findings: A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 1/26/2023 with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination ) and neurocognitive disorder with Lewy Bodies (a form of progressive dementia [the loss of cognitive functioning ; thinking, remembering, and reasoning ; to such an extent that…

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 a resident received his Isosorbide (a medication used for high blood pressure that works by dilating [widens] blood vessels) medication for 12 days as ordered by the physician for one (Resident 112) of six sampled residents observed during medication administration. This deficient practice had the potential to place Resident 112 at increased risk of experiencing adverse effects, such as uncontrolled blood pressure, from not receiving his blood pressure medication. Findings: A review of Resident 112's admission Record indicated the facility admitted Resident 112 on 10/19/2023 with diagnoses that included hypertension (HTN - high blood pressure) and atrial fibrillation (a type of arrhythmia, or abnormal heart rhythm, that causes the heart to beat irregularly). A review of Resident 112's physician orders dated 10/19/2023, indicated an order to administer Isosorbide 240 milligrams (mg- unit of measure) by mouth (PO) daily for HTN. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, observed…

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 maintain complete and accurate medical records for two of six sampled residents (Resident 112 and Resident 14) by: 1. Failing to ensure licensed nurses did not sign on the Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional) when a resident's Isosorbide (used for the management of angina [chest pain]) medication was not available during medication administration observation. 2. Failing to ensure a licensed nurse did not sign on the MAR when a resident's Apixaban (medication that helps to prevent blood clots) was not available during medication administration observation. These deficient practices resulted in Resident 112 and Resident 14's medical records being inaccurate and not in accordance with professional standards of practice; and had the potential to result in confusion regarding Resident 112 and Resident 14's condition and what care and services were provided to Resident 112 and Resident 14. Findings: 1. A review of Resident 112's admission…

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 develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA, the Department) two incidents of injuries of unknown origin (injuries resulting without knowing how it happened), which occurred on 3/5/2023 and 7/22/2023 for one of three sampled residents (Resident 1). These deficient practices resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: 1. A review of Resident 1 ' s admission Record, dated 10/27/2023, indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses hemiplegia (a condition that causes inability to move half of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (area of dead tissue in the brain…

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.