Hillsdale Hospital McGuire & Macritchie Long Term

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide justification for the continued use of a as needed antipsychotic beyond 14 days for one (Resident #27) out of five reviewed for medication review. Findings include: Review of the medical record reflected Resident #27 (R27) was admitted to the facility on [DATE], with diagnoses that included history of falling and muscle weakness. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/29/25, reflected R27 scored 10 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician Order revealed an active order dated 10/8/25 for Ativan Oral Tablet 0.5 MG (Lorazepam), Give 0.5 mg by mouth every 12 hours as needed for Anxiety/Agitation. In an interview on 12/22/2025 at 10:15 AM, Registered Nurse (RN) C acknowledged that R27 had an as needed order that extended past the 14 days and that the expectation would be to discontinue the order after 14 days and reevaluate as…

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 notify the ombudsman in writing of a discharge in one (Resident #1) of one reviewed for discharge. Findings include:Review of the medical record reflected Resident #1 (R1) was admitted to the facility on [DATE] and discharged on 11/27/25, with diagnoses that included urinary tract infection. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/27/25, reflected R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R1 was no longer in the facility. On 12/22/2025 at 10:44 AM, Registered Nurse (RN) C stated that the ombudsman was not notified of the discharge in writing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to competently assess and monitor for changes in condition and notify the physician of pertinent findings in a timely manner for 1 residents (Resident #3) resulting in potential for unrecognized, clinically significant changes in condition. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R3 was a [AGE] year old female admitted to the facility on [DATE], with re-admission post hospital admission 4/18/24 following displaced spiral fracture of the right femur and multiple pulmonary emboli with other diagnoses that included muscle weakness, repeat falls, history right hip replacement, lumbar vertebra fracture(low back), heart failure, hypertension(high blood pressure), and developmental delay. The MDS reflected R3 had a BIM (assessment tool) score of 13 which indicated her ability to make daily decisions was cognitively intact with no behaviors including rejection of care. Continued review of the…

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 provide written notification to the State Long-Term Care (LTC) Ombudsman of facility-initiated transfers/discharges over past 12 months, resulting in the potential for all residents to be discharged without an advocate who can inform them of their options and rights. Findings include: During an interview on 10/04/24 at 11:00 AM, Admission/Discharge (ADM) staff T responsible for providing residents and or responsible party discharge/transfer documents with Ombudsman and facility contact information at time of discharge or transfer. Reported no knowledge of communication with Ombusdman related to resident discharges. During an interview on 10/04/24 at 11:40 AM, Nurse Manager B reported not aware of system in place to report resident transfers and/or discharges to the State Long-Term Care Ombudsman on a routine basis and not aware of regulation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 1) accurately assess pressure ulcers (Resident #6) and 2) failed to prevent a pressure ulcer (Resident #27) in 2 of 2 residents reviewed for pressure ulcers resulting in the development of a pressure ulcer and inaccurate assessments. Findings include: Resident #6 (R6) Review of the medical record revealed Resident #6 (R6) was admitted to the facility on [DATE] with diagnoses that included dementia, type 2 diabetes and heart failure. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R6 had severe cognitive impairment. On 10/01/24 at 10:41 AM, R6 was observed in bed, dressed in a nightgown, and listening to the television. R6 smiled and interacted when interviewed. R6 acknowledged that she had a wound (pressure ulcer) on her bottom, however, reported that her memory was not good therefore, could not recall any details regarding the pressure ulcer. Review of the facility provided Pressure Ulcer history timeline revealed R6…

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 the nursing staff was evaluated for appropriate competencies and skill sets resulting in the potential for residents of the facility to be unable to maintain the highest practicable physical, mental, and psychosocial well-being and the potential for decreased resident safety for all residents who resided in the facility. Findings include: NHA A provided one Incident Accident Report for R3 on 10/02/24 at 1:55 PM, dated 4/3/24 at 8:25 p.m. Review of the report titled, Fall During Staff Assist, reflected, Incident Description .In response to CNA[Certified Nurse Aide] call for assistance the Resident Writer walked into Resident room followed by Day-shift nurse to discover Resident suspended by arms in sling on sit-to-stand in upright position with bilateral legs bend to the downwards. Continued review of the incident report reflected, Reported by CNA, Resident let go of sit-to-stand bar during transfer, knees together and bent over to one side. The report reflected R3 responsible party was notified 4/3/24(three days…

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, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 31 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased warewashing sanitization. Findings include: On 10/02/23 at 10:17 A.M., An initial tour of the food service was conducted with Director of Food Service (Registered Dietician) I. The following items were noted: The Walk-In Freezer was observed with ice [NAME] protruding from the ceiling and side wall surfaces. Director of Food Service (RD) I indicated she would contact maintenance for necessary repairs. The cafeteria microwave oven interior surfaces were observed soiled with accumulated and encrusted food residue. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other…

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 a Do-Not-Resuscitate (DNR) document was signed by the physician for one (Resident #12) of three reviewed for Advance Directives, resulting in the potential for code status wishes not being followed in an emergency situation. Findings include: Review of the medical record reflected Resident #12 (R12) admitted to the facility on [DATE], with diagnoses that included Alzheimer's, chronic obstructive pulmonary disease (COPD), chronic kidney disease, diabetes and heart failure. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/3/23, reflected R12 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R12's electronic medical record (EMR) reflected a DNR Physician Order, with a revision date of 3/1/21. Review of R12's DNR form reflected it was signed by a resident representative and two witnesses on 3/5/21. There was no physician signature on the…

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.