Hillview Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 2 (Resident #1 and #2) of 4 residents reviewed for quality of care. 1. The facility failed to ensure staff conducted neurological assessments on Resident #1 after his unwitnessed fall on 12/05/24. 2. The facility failed to ensure staff conducted neurological assessments on Resident #2 after her unwitnessed fall on 01/31/25. These deficient practices could place residents at risk of head injuries, brain bleed and developing undiagnosed conditions. Findings include: Resident #1 Review of Resident #1's admission Record, dated 02/28/25, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE], readmitted on [DATE], and discharged on 01/28/25. Resident #1 had diagnoses including cellulitis of right lower limb, neurocognitive disorder with Lewy bodies, dementia, and delusional disorders. Review of Resident #1's Significant Change…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with profession standards for food safety for 1 of 1 kitchen reviewed for food and safety and sanitation. 1. The facility failed to ensure dietary staff practiced proper hand hygiene and glove use. 2. The facility failed to seal, label, and date tortillas and failed to label and date two large bags of ice-covered chicken in one of one freezer located in the dry storage area. These failures could place residents at risks for health complications and foodborne illnesses. Findings included: 1. Observation on 09/24/2024 at 9:15 AM Dietary [NAME] was not wearing gloves. She touched her shirt and touched a cleaning towel. She did not wash or sanitize her hands prior to touching the fourchettes of the gloves when she was placing the gloves on her hands. She touched clean plates and inside of a scoop. In an interview on 09/24/2024 at 9:19 AM the Dietary [NAME] stated she did touch her shirt and touched the cleanser towel to clean different surfaces. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for the 27 residents, in the memory care unit, reviewed for a safe, clean, comfortable, and homelike environment The facility failed to report maintenance issues to the MNTD and make repairs to a loose hand railing, in the memory care unit community bathroom . This failure could have placed the residents in the memory care unit to falls. Findings included: Observation on 9/24/2024 at 11:38 AM revealed a handrail, inside the community bathroom on the facility's memory care unit, was loose. The handrail was still attached firmly to the wall in the bathroom but had 1 to 2 inches of vertical movement. There were no sharp edges. Interview on 09/24/24 at 11:41 AM with CNA A revealed the handrail was loose. She stated she was trained to report maintenance issues to the MNTD by writing the area of concern in the facility's maintenance book and telling the MNTD. She stated the book was in the main room, at the front of the facility, near the nurse's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of eight residents (Resident # 23, Resident # 29, and Resident #104) reviewed quality of life. The facility failed to ensure Resident #23's, Resident #29's, and Resident #104's nails were cleaned. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. 1. Record review of Resident # 23's Face Sheet dated, 09/25/2024, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of other frontotemporal neurocognitive disorder (a rare brain disease that causes gradual damage to the frontal and temporal lobes of the brain), dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance ( a medical condition that refers to a moderate stage of dementia- decline with…

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 ensure a therapeutic diet was prescribed by the attending physician for 3 of 13 residents (Resident #18, Resident #26, and Resident 30) reviewed for dietary services. The facility failed to ensure Resident #18, Resident #26, and Resident #30 received their prescribed diet for 09/24/2024 lunch. This deficient practice could place residents, who were provided a mechanically altered diet, at risk of choking, aspiration (inhaling food,) and diminished quality of life. Resident #18 Record review or Resident #18's AR, dated 09/24/2024, reflected an [AGE] year-old man, born on 7/11/1942, who admitted to the facility on [DATE]. He was diagnosed with Alzheimer's Disease (which was a progressive disease having caused mild memory loss, inability to execute conversations, and the inability to respond to the environment) and diabetes mellitus type 2 (which was a condition of the body that disrupted how the body used sugar for fuel.) Record review…

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 review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 5 of 5 resident (Resident #20, #22, #32, #33, and #42) reviewed for infection control. The facility failed to ensure MA performed proper hand hygiene when passing medications on Residents #20, #32, and # 33. The facility failed to ensure CNA-A and CNA-B sanitized equipment between residents. This failure could place residents at risk for development of communicable diseases and infections. Findings included: Record review of Resident 22's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Parkinsonism, Anxiety, Depression, HTN, and Hyperlipidemia. Record review of Resident 22's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 05, which indicated the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide advance notice of change in services and charges not covered under Medicare for 2 of 3 residents (Residents #27 and Resident #28) reviewed for Medicaid and Medicare Coverage Liability Notices. 1. The facility failed to ensure Resident #27 was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055 (SNF ABN) when he was discharged from Medicare Part A skilled nursing services. 2. The facility failed to ensure Resident #28 was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055 (SNF ABN) when he was discharged from Medicare Part A skilled nursing services. This failure could place the residents, or their representatives, at risk of not being fully informed about services covered by Medicare Part A, and unknowingly being charged for Skilled Nursing Services. Findings included: Resident #27 Record review or Resident #27's AR, dated 6/26/2024, reflected a [AGE] year-old…

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 review, the facility failed to adequately equipp residents the ability to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, from the bathroom for 2 of 8 Residents (Resident #4 and Resident #50) who were reviewed for resident call systems. The facility failed to ensure Resident #4 and Resident #50's shared bathroom had a pull string attached to the call light switch making the call light button accessible if the resident were lying on the floor. This failure could place residents at risk of harm by not being able to call for help when needed. Findings included: Resident #4 Record review of Resident #4's AR, dated 9/24/2024 reflected a [AGE] year-old man, born on [DATE], who admitted to the facility on [DATE]. He was diagnosed with Schizophrenia (which was a severe mental disorder having caused hallucination, delusions, and disorganized speech,) hypertension (which was 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 interviews, and record reviews, the facility failed to ensure the residents right to be free from misappropriation of property for 1 (Resident #1) of 6 residents reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Ondansetron (generic Zofran), a medication used to treat nausea by CMA-A. This failure placed the resident at risk of not receiving the prescribed medication. Findings include: Record Review of Resident #1's Face Sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses include Alzheimer's Disease (brain disorder that causes problems with memory), heart disease (disease that affects the heart), Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectorisis (arteries leading to the heart are blocked), Edema (swelling caused by fluid accumulation) and Insomnia (trouble falling or staying asleep). Record Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score 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 observation interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure injectable insulin of the staff was not stored with food items in the refrigerator. The facility failed to ensure food items in the refrigerator were not expired. These failures could place residents at risk for transmittable diseases, food-borne illness, and food contamination. Findings included: A.Observations and interview of the refrigerator in the kitchen on 07/24/23 beginning at 9:30 AM revealed there was an insulin injection syringe in a plastic bag stored with other food products in the refrigerator. The insulin label reflected Toujeo (insulin glargine) injection 300 Units/mL (U-300). For subcutaneous use only. Do not remove insulin with syringe. Always use new needle. Do not mix with other insulins. Staff member DA A stated it was her insulin injection syringe. B.Observations of the refrigerator in the kitchen on 07/24/23 beginning at 9:30 AM…

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 residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #02) of two residents reviewed for unnecessary medications. The facility failed to attempt a gradual dose reduction (GDR) for Resident #02's Clonazepam . These failures could place residents at risk for possible adverse side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included Record review of Resident #02's quarterly MDS assessment, dated 05/19/23, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident had a BIMS score of 10. She had no signs and symptoms of delirium, no hallucinations or delusion, no physical behavioral symptoms and had not rejected care. She had diagnoses which included stroke, non-traumatic brain dysfunction, traumatic 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 7 residents (Residents #39, #36, #15 and #17) reviewed for infection control in that: a) LVN A and MA A did not clean and disinfect the wrist blood pressure monitor when it was used on Resident #39, Resident #36, and Resident #15. b) NA A and NA B used soiled gloves for handling clean gloves while providing incontinent care for Resident #17. These failures could place the residents at the facility at risk of transmission of diseases and infection. Findings included: Record review of Resident #36's face sheet dated 07/25/23 reflected Resident #36 was admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with Heart Disease, Edema (swelling), Insomnia, Hypertension (High blood Pressure), Anxiety Disorder, Major Depressive Disorder, Pain, Chronic Kidney Disease, Hypothyroidism (Low…

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 have reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #1 and #3), reviewed for a call light system, in that: The facility failed to ensure Resident #1 and Resident #3's call buttons were accessible in the event of an emergency or to meet care needs. This failure could affect residents by not having access to call for assistance resulting in needs not being met. Findings include: Record Review of Resident #1's profile revealed she was a [AGE] year-old female. She was admitted to the facility on [DATE] and had diagnoses of Chronic A-Fib, AMS, HTN, Anxiety Disorder, Schizoaffective Disorder, Neurocognitive Disorder w/Lewy Bodies (progressive Dementia that affects movement, thinking skills, mood, memory, and behavior), Anal Prolapse and Nontraumatic Chronic Subdural Hemorrhage (bleeding of the brain that does…

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 Resident #5 Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 out of 1 resident (Residents #05) reviewed for respiratory care. The facility failed to change and/or label Resident # 05's oxygen equipment per the facility policy and procedure. This failure has the potential to affect residents by placing them at risk for infections and complications associated with respiratory equipment failure due to exposure to equipment that has been used for an amount of time beyond appropriate or intended use limits. Findings included: Record review of Resident #05's History and Physical revealed a [AGE] year-old male. His diagnoses included paranoid schizophrenia, extrapyramidal ( relating to movement of nerve cells in the spine) and movement disorder depressive disorder, gastroesophageal reflux disease, hepatomegaly ( enlarged liver), shortness of breath, dyspnea (…

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.