Heather Hill Healthcare Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure monitoring and supervision for the safety of one resident (#1) out of three sampled residents. Resident #1 suffered a fall with major injury requiring transfer to a higher level of care for treatment.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents were served food in a manner that was appealing in appearance and that was palatable for consumption for six (#1, #2, #3, #4, #5, and #6) of six sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II upon having a qualifying mental health diagnosis for 7 of 20 residents sampled (Residents #80, #54, #19, #62, #22, #52, and #33).

Inspectors wrote2. An observation on 06/03/24 at 9:13 a.m. revealed Resident #5 laid in bed with a bloody forehead. Further observation showed Resident #5 had a bloody area on the left side of her chest area. Resident #5 was non-verbal and did not response to Surveyor. During an interview on 06/03/24 at 9:13 a.m., Staff N Certified Nursing Assistant (CNA) stated Resident # 5 was known to pick her skin and she must have been picking this weekend as she had new picking spots especially on her chest. Review of the admission Record showed Resident #5 was initially admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's Disease, Dementia in other diseases classified elsewhere unspecified severity with behavioral disturbances, disorganized Schizophrenia and generalized anxiety disorder. Review of the Order Summary Report showed Resident #5 had the following orders: [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure sufficient staff to meet the needs of 30 residents on one (400 - secure) of four units during mealtime and for 30 residents on one (400 - secure) of four units for activities over three (06/03/2024, 06/04/2024 and 06/06/2024) out of four days observed.

Inspectors wroteBased on interviews and record review, the facility did not ensure residents who entered arbitration agreements understood the contract contents for three residents (#342, #22 and #87) of three residents sampled.

Inspectors wroteBased on observations, interview, and policy review, the facility failed to ensure proper infection control practices during medication pass for three out of three observations, for one of one CPR backboard, and during dining on one (100) out of four hallways.

Inspectors wroteBased on observation, interview, and policy review, the facility did not ensure dignity was maintained for residents in one (400) out of two dining rooms and on one (200) out of four units related to staff standing while assisting residents with eating, not serving residents at a single table their meals at the same time, and having residents eat in the hallway.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prompt efforts were made to resolve grievance for one (Resident #30) out of three (3) residents sampled.

Inspectors wroteBased on record review, interview, and policy review facility did not ensure Preadmission Screening and Resident Review (PASRR) Level 1 Screen was updated when new diagnoses were added for three residents (#9, #11, and #17) out of twenty-six reviewed for PASRR screening.

Inspectors wroteBased on record review, interview and review of the facility's policies Care Plans, Comprehensive Person-Centered and Pain Assessment and Management, the facility failed to develop a care plan for pain management for one Resident (Resident #22) and diabetic management with insulin use for one Resident (Resident #80) out of twenty sampled residents reviewed for development of care plans.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the Quality Assurance Committee was actively involved in the effective creation, implementation, and monitoring of the plan of correction (POC) for deficient practice identified during the annual recertification survey, conducted on 3/13/22 to 3/16/22. The facility developed a plan of correction with a completion date of 4/16/22. During a revisit survey conducted on 5/11/22 deficient practice was again identified at F758, F761, and F656 with an additional deficiency identified at F757.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure dependent diners were treated with dignity during a meal service for two (Residents #3, and #68) of two residents as evidence by staff assisting residents while standing next to the resident and above eye level.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure medication self-administration orders were in place for one (Resident #27) of 30 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure care plan interventions and physician orders were followed for one (Resident #52) of five sampled residents related to catheter care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (Resident #49) of thirty sampled residents , was set up and assisted with Eating Activities of Daily Living (ADL) during three meals.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to apply splints and braces to one (Resident #57) of seven residents requiring the use of supportive devices.

Inspectors wroteBased on record reviews, interviews, and observations, the facility failed to ensure two (#28 and #64) of three sampled residents for unnecessary medications received insulin within the accepted parameter of before meals as ordered by the physician.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure psychotropic medications were monitored for patient-specific behaviors and staff documented observed behaviors for two (Residents #28 and #64) of five residents sampled for unnecessary medications.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and two errors were identified for two (Resident s #44 and #16) of seven residents observed. These errors constituted a 7.69% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to (1) ensure medications were inaccessible to unauthorized personnel, residents, and visitors as evidence by leaving ten Insulin pens on top of one (200-hall) of four medication carts and (2) ensure medications were not left at bedside for one (Resident #27) of 30 sampled residents

Inspectors wroteBased on record review and interview, the facility failed to ensure all essential members of the Quality Assurance Committee attended the meeting and were involved with the discussion and implementation of the plan of correction regarding the deficiencies identified during the annual recertification survey conducted on 3/13/22 to 3/16/22.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that the residents on one (200 hall) of four wings sampled were treated with dignity during meal tray distribution in regards to not knocking and asking permission to enter residents' rooms.

Inspectors wroteBased on interview and record review the facility failed to ensure that the comprehensive care plan was revised to reflect residents' currents needs related to falls and Activities of Daily Living (ADL's) for 2 of 21 (#46, #65) sampled residents.

Inspectors wroteBased on observation, interview and record review the facility failed to administer Intravenous medications (IV) consistent with physician orders for two (#59 and #48) of two residents receiving IV fluids. Findings Included: 1. An observation was conducted on 1/12/21 at 9:30 a.m. of Resident #59 lying in bed with an IV pole positioned by the bed near the door, IV fluids were not running. An observation was conducted of Resident #59 on 1/12/21 at 12:00 p.m. sitting up in bed drinking fluids during lunch. The IV was observed not running or attached to Resident #59. An observation conducted of Resident #59 on 1/12/21 at 2:45 p.m. revealed the IV pole without an IV bag; a replacement IV bag was on the bedside table with IV tubing. Staff member O, LPN was present and stated that the resident pulled out the IV last night some time and the IV team will be coming to put the IV back in. [...]