Hildebrand Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for four of four medication storage carts.Specifically, the facility failed to:-Date residents' insulin pens and inhalers with the date they were opened;-Label residents' medications the resident's name; -Discard insulin vials and epinephrine (used to treat life threatening conditions, including allergic reactions) medication that had expired; and,-Ensure loose pills in a medication cart were discarded.Findings include:I. Professional referenceAccording to the manufacturer, Viatris, How to Use a Wixela Inhub (inhaler used to treat asthma and lung disease), 2021, retrieved on [DATE] from https://www.wixelahcp.com/-/media/Project/Common/WixelahcpCom/PDF/[NAME]-2020-0047_V4_US_How-to-Use_PDF.pdf, Take Wixela Inhub out of the foil pouch just before you use it for the first time. Write the pouch opened and use by dates on the label. The use by date is one month from the date you opened the pouch for your…

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, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for one (#7) of five residents reviewed for use of psychotropic medication out of 51 sample residents. Specifically, the facility failed to ensure the physician's order for Resident #7's as needed (PRN) lorazepam (antianxiety medication) was reevaluated and a rationale was provided by the physician to justify the continued use of the psychotropic medication beyond the 14-day limit.Findings include:I. Facility policy and procedureThe Antipsychotic Medication Use policy was provided by the director of nursing (DON) on 9/25/25 at approximately 10:00 a.m. The policy read in pertinent part, All antipsychotic medications will be used within the regulation guidelines for psychotropic medications or clinical justification will be documented for dosages that exceed the listed guidelines for more than 48 hours. The need 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 observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for two (#10 and #39) of five residents reviewed for accidents out of 51 sample residents.Specifically, the facility failed to ensure Resident #10 and #39 were transferred appropriately and according to their plan of care.Findings include: I. Facility policy and procedure The Safe Lifting and Movement of Residents policy, revised July 2017, was received from the director of nursing (DON) on 9/24/25. It read in pertinent part, ln order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Manual lifting of residents shall be eliminated when feasible. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in…

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 observations, record review and interviews, the facility failed to honor resident choices for one (#37) of one out of 31 sample residents. Specifically, the facility failed to ensure Resident #37 received anti-nausea medication in a timely manner upon request. Findings include: I. Facility policy and procedure The Resident Self Determination and Participation policy and procedure, revised August 2022, was provided by the director of nursing (DON) on 11/16/22 at 2:00 p.m. It read, in pertinent part, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Each resident is allowed to choose activities, and schedule health care and healthcare providers, that are consistent with his or her interests, values, assessments and plans of care, including: daily routine, such as sleeping and waking, eating, exercise and bathing schedules; personal care needs, such as bathing methods, grooming…

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 interviews and record review, the facility failed to ensure one (#6) out of 31 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to document and provide a resolution to Resident #6's missing item. Findings include: I. Facility policy and procedure The Resident Grievance Policy, revised April 2018, was provided by the director of nursing (DON) on 11/16/23 at 2:00 p.m. It revealed, in pertinent part, It is the policy of the facility to help residents, their representatives (sponsors), and other interested family members, or resident advocates file grievances or complaints when such requests are made. Any resident, his/her representative, family member, or advocate may file a grievance or complaint concerning his/her treatment, medical care, behavior of other residents, or staff members, and theft of property without fear of threat of reprisal in any form. The Administrator has delegated the responsibility of grievance and/or complaint…

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 observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#121) of one resident reviewed for visual problems out of 31 sample residents. Specifically, the facility failed to ensure Resident #121 was assisted to wear his glasses. Findings include: I. Resident #121 status Resident #121, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), the diagnoses included multiple sclerosis, dementia without behavioral disturbance, cognitive communication deficit and paraplegia. The 11/6/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. He required total assistance with all activities of daily living. It indicated the resident had impaired vision with the use of corrective lenses. A. Observations On 11/13/23 at 2:48 p.m. Resident #121 was observed sitting in his…

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 observations, record review and interviews, the facility failed to ensure one (#121) of three out of 31 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to agency staff were aware of Resident #121 ' s history and risk of elopement. Findings include: I. Facility policy and procedure The Wandering and Elopement policy and procedure, reviewed May 2019, was provided by the director of nursing (DON) on 11/16/23 at 2:00 p.m. It revealed, in pertinent part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident ' s care plan will include strategies and interventions to maintain the resident ' s safety. II. Resident #121 status Resident #121, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), the diagnoses…

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 resident observations, record review, and staff interviews, the facility failed to ensure residents received respiratory treatment as ordered for two (#20 and #64) of two residents reviewed for supplemental oxygen use out of 31 sample residents. Specifically, the facility failed to ensure Resident #20 and Resident #64 received oxygen at the liter flow prescribed by the physician. Findings include: I. Facility policy and procedure The Oxygen Administration policy and procedure, revised October 2021, was provided by the director of nursing (DON) on 11/16/23 at 2:00 p.m. It read, in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician ' s order for this procedure and review the physician orders or the facility protocol for oxygen administration. II. Resident #20 status Resident #20, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician ' s orders (CPO), diagnoses included unspecified…

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 and interviews the facility failed to ensure two out of two medication refrigerators stored narcotic medications in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications. Specifically, the facility failed to: -Ensure the treatment cart and medication cart was locked when left unattended; and -Ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, revised April 2007, was provided by the director of nursing (DON) on 11/16/23 at 2:00 p.m. It read in the pertinent part, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. II. Observations On 11/13/23 at 9:00 a.m. the treatment cart on the west…

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 that residents had reasonable access to send and receive mail during the routine United States Postal Service hours of operation. Specifically, the facility failed to ensure residents' personal mail was delivered timely on Saturday. Findings include: I. Facility policy and procedure The resident's handbook and admission packet, dated March 2021, page eight, item number 17, was received from the director of IT (DIT) on 7/28/22 at 12:33 p.m. It read in pertinent part, the facility and its staff are committed to total compliance with all State and Federal regulations. Mail will be delivered unopened to the resident. Mail delivery is Monday through Friday. II. Resident interview and observation The resident council president, Resident #64 was interviewed on 7/26/22 at 3:00 p.m. He said the mail was not delivered on the weekend. Resident #4, #52, #63, and #46 were interviewed on 7/26/22 at 3:05 p.m. The residents were a part of the resident council. The residents said the mail was not delivered on Saturdays.…

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 observations, record review, and interviews, the facility failed to honor the bathing preferences for four residents (#61, #47, #21, #23) of five residents reviewed for choices out of 37 sample residents. Specifically, the facility failed to provide routine bathing consistent with the residents' preferences for Resident #61, #47, #21 and #23. Findings include I. Facility policy The Nursing Home Residents ' Rights ' policy, not dated, was provided via email by the director of nursing (DON) on 7/28/22 at 12:15 p.m. It was revealed in pertinent part;, It is the policy of our facility to promote and protect your rights as a resident. We believe that you have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Therefore, as a resident, you have: The right to choose activities, schedules, and care consistent with your interests, assessments, and plan of care. The facility will allow you to make choices about what you…

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 IV. Resident #23 A. Resident status Resident #23, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2022 CPO, diagnoses included depression, anxiety, hypertension, gastroesophageal reflux disease (GERD), long-term use of antibiotics, history of urinary tract infections, hypothyroidism and chronic pain. The 5/23/22 MDS assessment revealed Resident #23 was cognitively intact with a BIMS score of 15 out of 15. The resident exhibited physical, verbal and other behavioral symptoms directed toward others one to three days including rejection of care for the past seven days. B. Record review Review of the July 2022 CPO revealed Resident #23 received the following medications were added on 3/31/22 and the month April 2022: -Biofreeze 5% topically three times daily as needed for pain, (the site for application was not documented), ordered on 3/31/22; -Hydrocodone 5-325 mg by mouth three times daily for pain, ordered on 4/4/21; and, -Fiber lax tablets give two tablets by mouth every morning…

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.