Harris Hill Nursing Facility, L L C

Inspectors wroteBased on observation, interviews, and record reviews conducted during the survey, the facility failed to ensure that each resident was treated with respect and dignity, cared for in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality for one (1) (Resident #111) of five (5) residents reviewed for dignity. Specifically, two (2) staff members were in Resident #11's room on their personal cell phones, while the resident was calling out for assistance versus engaging with and assisting the resident.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the survey, the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for one (1) (Resident #19) of one (1) resident reviewed for positioning. Specifically, Resident #119 did not to have their foot buddy (a device that is strapped to the calf and foot pedals of a wheelchair to prevent legs/feet from slipping behind or off of the wheelchair pedals) in place as per their care plan.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the survey, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for three (3) (Residents #8, #32 and #58) of seventeen (17) residents reviewed for quality of care. Specifically, weights were not obtained daily as ordered by the physician (#8), lack of identification and documentation of a bruise (#32) and medications that were left at the bedside for self-administration without a physician's order (#58).

Inspectors wroteBased on observations, interviews, and record reviews conducted during the survey, the facility failed to ensure developed and prepared menus to meet resident choices including their nutritional, religious, cultural, and ethnic needs were met for one (1) of four (4) dining rooms. Specifically, Resident's #17, #52, and #119 were not served with all the fluids and/or food items listed on their meal tickets and Resident #52 was not provided with their inner lip plate as documented on their meal ticket.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the survey, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for two (2) (Unit A and Unit D) of four (4) unit servery refrigerators. Specifically, the unit servery refrigerators contained unlabeled, out-of-date food and drink items, and personal food was stored with residents' food. In addition, Unit A servery floor was soiled with food debris/dried spills and Unit D's refrigerator's handle was sticky with an unknown substance, and the front was soiled with food debris.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 6/28/24, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for one (Resident #12) of one resident reviewed. Specifically, Resident #12 was observed with medications in their room and self-administered those medications without being evaluated as to whether they could safely do so.

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed on 6/28/24, the facility did not ensure that a resident is free from abuse, neglect or exploitation for one (Resident #71) of five residents reviewed for abuse and neglect. Specifically, a Certified Nurse Aide did not follow Resident #71's care plan when they transferred the resident using a mechanical lift by themselves and the resident sustained an injury to their left lower leg. The finding is: The policy and procedure titled Abuse Prohibition revised on 2/2023, documented that residents have the right to be free from verbal, sexual, physical, mental abuse, mistreatment, neglect, involuntary seclusion, misappropriation of property, and exploitation. [...]

Inspectors wroteBased on record review and interviews conducted during the Standard survey completed on 6/28/24, the facility did not ensure that the facility's infection prevention and control program included antibiotic use protocols and a system to monitor antibiotic use for one (Resident #12) of one resident reviewed. Specifically, Resident #12 received prophylactic Rifampin and Bactrim (antibiotics) since 10/18/22 and there was no ongoing monitoring by the Antibiotic Stewardship Program including laboratory tests, communication, or appointments with the Infectious Disease Physician. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review completed during the Standard survey started 9/15/22 and completed 9/21/22, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #16) of three residents observed for pressure ulcers. Specifically, pressure ulcer wounds on the resident's bilateral heels were not cleansed with normal saline (NS- mixture of sodium chloride and water used for cleaning wounds) after removal of dressing, moderately soiled with serosanguineous (yellow, pink wound drainage) drainage, prior to application of clean dressing, as ordered by the physician. The finding is: [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey started 9/15/22 and completed 9/21/22, the facility did not ensure each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #135) of three residents reviewed for falls. Specifically, Resident #135 had a history of falls with injury, was observed without anti-tippers on the front of their wheelchair as planned. The finding is: The facility policy and procedure (P&P) titled Accident/Incident Report Investigation and Prevention dated 4/2015 documented the facility provides an environment that is free from accident hazards and provides supervision and assistive devices to each resident to prevent avoidable accidents. It is the responsibility of licensed nursing professional to implement care plan changes to prevent repeat incidents. 1. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey started 9/15/22 and completed on 9/21/22, the facility did not ensure that a resident with an indwelling catheter (foley-tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTIs) to the extent possible for one (Resident #315) of three residents reviewed for urinary catheters. Specifically, issues involved the lack of appropriate urinary catheter care and the lack of maintaining infection control measures for a resident on transmission-based precautions (TBP) and a history of UTIs. The finding is: The facility policy and procedure (P&P) titled Incontinent Care dated 1/1/2000 documented the purpose was to prevent skin breakdown caused by bacteria from urine/feces and to avoid infections and odor. [...]

Inspectors wroteBased on observation, record review, and interview conducted during a Standard survey started on 9/15/22 and completed on 9/21/22, the facility did not provide food and drink that was at a safe and appetizing temperature. Specifically, two (A wing, B wing) of four resident units reviewed for food temperatures during meals had issues involving food items that were not served at safe and appetizing temperatures. Residents #5, 13, 110, 138, and 467 were involved.

Inspectors wroteBased on interview and record review, conducted during the Standard survey started on 9/15/22 and completed on 9/21/22, the facility did not ensure that each resident receives an assessment that accurately reflects their status at the time of the assessment for 4 (Residents #23, 73, 80, and 135) of four residents reviewed for accuracy of the Minimum Data Set, (MDS - a resident assessment tool). Specifically, the MDS assessments were inaccurately coded for anticoagulants (#23, #73), did not include the use of an antibiotic (#135), and did not indicate falls with injury (#80).

Inspectors wroteBased on observation and interview conducted during a Standard survey started on 9/15/22 and completed on 9/21/22, it was determined that the facility did not ensure that they stored, prepared, distributed, and served food in accordance with professional standards for food service safety for one of one facility kitchen observed. Specifically, the hot rack utensil holder was soiled with a white debris layer covering it from the ceiling to where utensils were hung, an area of the kitchen floor was soiled with black, brown, green, and white debris.