Skilled Nursing Facility At North Hill (the)

Based on record reviews and interviews, the facility failed to ensure one Resident (#10), out of a total sample of 18 residents, was free from unnecessary psychotropic medications. Specifically, the facility failed to ensure an as needed (PRN) dose of Seroquel (antipsychotic) was limited to no more than14 days as required. Findings include:Resident #10 was admitted to the facility in April 2022 and has diagnoses including visual hallucinations.Review of the Minimum Data Set (MDS) assessment, dated 3/13/25, indicated Resident #10 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15, and received antipsychotic medication on a PRN basis only.Review of the medical record indicated but was not limited to the following physician's orders:-Seroquel 25 milligrams (mg) give 2 half tabs for a total dose of 25 mg by mouth twice a day as needed x 30 days and evaluate for hallucinations (7/12/24, stop date: 8/11/24)-Seroquel 25 mg twice a day as needed x 30 days and evaluate for hallucinations/restlessness (9/6/24, stop date:…

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 develop an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs of one Resident (#12), out of a total sample of 18 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the use of psychotropic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment. Findings include:Review of the facility's policy titled Care Planning, last revised April 2014, indicated but was not limited to:-Upon entrance into the Health Center, the Minimum Data Set (MDS) Coordinator and Admitting Nurses begin the assessment process utilizing facility identified, industry standard assessment tools.-The comprehensive care plan is utilized in collaboration with each other to ensure that information related to the care of the individual resident is communicated to all team members.Resident #12 was admitted to the facility in October 2023 with diagnoses including…

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 staff interview, the facility failed to ensure that for one Resident (#9), of a total sample of 18 residents, that drugs and biologicals used in the facility were labeled accurately and in accordance with the physician's order. Findings include:Review of the facility's policy titled Administering Medications, revised in April 2019, included but was not limited to the following:2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. 4. Medications are administered in accordance with prescriber orders, including any required time frame.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. On 7/17/25 at 9:50 A.M., the surveyor observed Nurse #4 enter Resident #9's room to administer their medications. Nurse #4 verified the Resident's medication orders in the electronic Medication Administration 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, document review, and interview, the facility failed to implement policies and procedures to ensure residents who were eligibility to receive the recommended pneumococcal vaccine (PCV-20), were offered the vaccination and they or their legal representatives were educated on the benefits and potential side effects of the vaccine in a timely manner for three Residents (#52, #59, and #41), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled Pneumococcal Vaccine Timing for Adults, dated March 2023, indicated the following: Make sure your patients are up to date with pneumococcal vaccination. Adults >= [AGE] years old, Complete Pneumococcal Vaccine Schedules: -PCV13 (pneumococcal conjugate vaccine) only at any age - give PCV20 (pneumococcal 20-valent conjugate) or PPSV23 (pneumococcal polysaccharide vaccine) >= 1 year later -PPSV23 only at any age - give PCV20 or PCV15…

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 record review and interviews, the facility failed to develop and implement a person-centered plan of care which included care and management for one Resident (#59) who had been determined to exhibit a behavior of wandering and was determined by the staff to be a risk of elopement (an incident when a resident leaves the premises or a safe area without authorization or the necessary supervision to do so safely), out of a total sample of 15 residents. Findings include: Resident #59 was admitted to the facility in May 2024 with diagnoses including: Dementia, chronic gastritis (swelling and inflammation of the stomach lining), and lower back pain. During an initial tour Resident #59 was observed in his/her room with a wanderguard device on their right ankle. Review of the medical record indicated, but was not limited to the following: - The Healthcare proxy was activated on 5/23/24 for a 3 month period for cognitive deficits and then to be re-evaluated at that time - Nursing admission assessment indicated the Resident was a risk for wandering but no wanderguard was put in place,…

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 document review, the facility failed to ensure their staff wore personal protective equipment (PPE) in accordance with the requirements to prevent unnecessary exposure and the potential spread of COVID-19 infections while providing care and attending to the needs of a COVID-19 positive resident. Findings include: Review of the Centers for Disease Control (CDC) guidance titled: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated: March 18, 2024 indicated but was not limited to the following: Personal Protective Equipment: Healthcare providers who enter the room of a patient with suspected or confirmed SARS-CoV-2 (COVID-19) infection should adhere to Standard Precautions and use an approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of the facility policy titled: Transmission based precautions, last reviewed: 5/2024, indicated but…

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 record review, policy review, and staff interviews, the facility failed to implement and follow their abuse policy related to the need to immediately report an allegation of potential abuse to the Administrator or the Director of Nursing to protect other residents from potential abuse for one Resident (#4), out of a total of 26 sampled residents. Findings include: Review of the facility's Abuse Policy and Procedure, with a revision date of January 2023, indicated the following: When abuse, mistreatment, financial exploitation/misappropriation of resident property or neglect of a resident is observed, reported, or suspected by any team member; immediate action is required. -the team member will notify the immediate nursing supervisor. -the supervisor will immediately notify the Administrator and the Director of Nursing Services. -interviews will be conducted. If a team member is involved or implicated, his/her knowledge or version of the incident is to be documented. -the Administrator, Director of Nursing Services or designee, will send an initial report to the appropriate…

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 record review, policy review, and staff interviews, the facility failed to report allegations of abuse to the state agency in a timely manner for one Resident (#4), out of a total of 26 sampled residents. Findings include: Review of the facility's Abuse Policy and Procedure, with revision date of January 2023, indicated the following: When abuse, mistreatment, financial exploitation/misappropriation of resident property or neglect of a resident is observed, reported, or suspected by any team member; immediate action is required. -the team member will notify the immediate nursing supervisor. -the supervisor will immediately notify the administrator and the Director of Nursing Services. -interviews will be conducted. If a team member is involved or implicated, his/her knowledge or version of the incident is to be documented. -the Administrator, Director of nursing Services or designee, will send an initial report to the appropriate regulatory agency to report any alleged or suspected abuse, mistreatment or neglect within two (2) hours of obtaining knowledge of an incident 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.

Based on records reviewed and interview, the facility failed to complete a comprehensive (Annual) Minimum Data Set (MDS) assessment in a timely manner for one Resident (#14) and failed to complete discharge MDS assessments in a timely manner for two Residents (#60 and #46), out of a total sample of 26 residents. Findings include: Review of the Resident Assessment Instrument (RAI) Manual 3.0 indicated the following: -The Annual and Quarterly MDS must be completed no later than 14 days from the assessment reference date (ARD). -A discharge MDS must be completed no later than 14 days 1.) For Resident #14, review of the annual MDS indicated an annual assessment with an ARD of 3/31/23. Further review indicated a completion date of 5/17/23, which was completed 48 days after the ARD date. 2.) For Resident #60, review of the discharge MDS indicated a discharge assessment with an ARD of 1/23/23. Further review indicated a completion date of 5/17/23, which was completed 115 days after the ARD date. 3.) For Resident #46, review of the discharge MDS indicated a discharge assessment with an ARD…

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.