Heights Care & Rehabilitation LLC

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure appropriate use of gloves when handling ready-to-eat foods.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs per speech therapy recommendation, physician orders and the residents care plan. Specifically, the facility failed to ensure soft and bite size chicken was produced and serviced according to the International Dysphagia Diet Standardisation Initiative (IDDSI) standards.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of four units. Specifically, the facility failed to:-Ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents' rooms and high frequency touched areas (call lights, door handles, light switches and bed controls);-Ensure housekeeping staff followed disinfectant dwell times (amount of time required to ensure germs are eliminated) when cleaning residents' rooms;-Ensure housekeeping staff performed appropriate hand hygiene between glove changes; and,-Ensure Resident #6's catheter tubing was not touching the floor.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for one (#1) of three residents reviewed for grievances out of 53 sample residents. Specifically, the facility failed to report, document and follow-up on grievances reported by Resident #1 concerning her care preferences.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for activities of daily living (ADL) received the necessary care and services out of 53 sample residents. Specifically, the facility failed to utilize language communication tools to support effective interaction for Resident #1 during care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#24 and #80) of seven residents received treatment and care in accordance with professional standards of practice out of 53 sample residents. Specifically, the facility failed to:-Ensure physician's orders for wound care were followed for Resident #24; and,-Ensure Resident #80 was consistently administered pain medication per physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%). Specifically, the facility had a medication error rate of 7.41%, which was two errors out of 27 opportunities.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#43) of four residents out of 53 sample residents. Specifically, the facility failed to ensure Resident #43 was administered an insulin medication per physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#1) of four residents received adequate supervision to prevent accidents out of four sample residents. Specifically, the facility failed to ensure staff did not leave Resident #1, who had a history of falls and required maximal assistance with showering, alone in the shower room during her showers.

Inspectors wroteBased on record review and interviews, the facility failed to ensure four (#1, #2, #3 and #4) of four residents reviewed for abuse out of four sample residents were free from abuse. Specifically the facility failed to: -Prevent verbal and physical abuse between Resident #2 and Resident #4. -Protect Resident #1 from physical abuse by Resident #2; and, -Protect Resident #3 from physical abuse by Resident #4.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one (#1) of three residents reviewed for abuse were kept free from abuse out of five sample residents. Specifically, the facility failed to protect Resident #1 from physical abuse by Resident #2.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring and worsening for one (#9) of three residents out of 14 sample residents. Resident #9 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and type II diabetes mellitus with diabetic chronic kidney disease. On 2/29/24, Resident #9 was identified to have developed a stage 3 pressure ulcer to his left heel. Record review and interviews revealed the facility failed to identify the skin breakdown on the comprehensive care plan and identify and implement person-centered interventions to prevent the worsening of the pressure injury to the left heel. Additionally, the facility failed to implement interventions ordered by the wound care physician (WCP). [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (#8) of three out of 14 sample residents. Specifically, the facility failed to follow infection control practices while providing wound care to Resident #8.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#3) out of three out of seven sample residents. Specifically, the facility failed to ensure a self-administration assessment was completed for Resident #3 to perform her own wound care treatments.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure services provided to two (#3 and #4) of seven sample residents met professional standards of practice. Specifically, the facility failed to ensure wound care dressings were dated for Resident #3 and Resident #4.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure infection control practices were observed during wound care for Resident #4 and Resident #3.

Inspectors wroteBased on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for two (#80 and #281) of two residents reviewed for psychosocial well-being out of 44 sample residents. Both residents had expressed suicidal ideations. The facility's failures in response created a situation of immediate jeopardy for serious harm. -The facility failed to ensure Resident #80 received the appropriate level of support and supervision to ensure she did not engage in self-harm after making a suicidal ideation with a plan to self-harm. Resident #80 was admitted with diagnoses of bipolar disorder and major depressive disorder and had a history of suicide attempts. [...]

Inspectors wroteBased on record review and interviews, the facility failed to have an effective system to identify deviations in performance and adverse events, and to develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct quality deficiencies. Specifically, the QAPI program committee failed to identify and address concerns related to suicidal ideations and the prevention of incidents of self-harm that rose to the level of immediate jeopardy. Cross-reference F740.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure that residents had reasonable access to send and receive mail and packages at the facility. Specifically, the facility failed to ensure residents' personal mail was delivered timely on all days Monday through Saturday.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean, comfortable and homelike environment for the residents on four out of four hallways. Specifically, the facility failed to ensure resident rooms, bathrooms and shower rooms were odor free and received necessary repairs.

Inspectors wroteBased on record review, observations and interviews, the facility failed to the facility made to make prompt efforts to resolve grievances. Specifically, the facility failed to address and provide resolutions to resident grievances expressed by the resident group and individual residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#6, #63 and #47) of three residents reviewed for activities of daily living were provided with services or treatments to prevent the reduction in range of motion out of 44 sample residents. Specifically, the facility failed to ensure a restorative program was in place for Residents #6, #63 and #47.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the environment remained as free from accident hazards as possible for three (#2, #14 and #67) of three residents reviewed for falls out of 44 sample residents. Specifically, the facility failed to: -Ensure Resident #67 had effective fall interventions implemented and that the fall interventions in place were consistently implemented; -Ensure post-fall documentation and interventions were added to Resident #67's care plan; and, -Consistently implement fall interventions for Resident #14 and Resident #2.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received food prepared in a form designed to meet their needs. Specifically, the facility failed to provide meals prepared according to the prescribed food orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide snacks for residents who ate at non-traditional times or outside of scheduled meal times. Specifically, the facility failed to ensure snacks were consistently available according to resident preferences on the units.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure residents received hand hygiene prior to meals; and, -Ensure residents' items were labeled and stored appropriately in shared rooms.

Inspectors wroteBased on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of at least 12 hours of annual training, including continuing competence. Specifically, the facility failed to ensure CNAs had completed competencies prior to providing skilled services for five out of five CNAs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#180) of five residents reviewed for unnecessary medication of out 44 sample residents. Specifically, the facility failed to obtain consent for psychotropic medications from Resident #180 prior to the use of a psychotropic medication for Resident #180.

Inspectors wroteBased on record review and interviews, the facility failed to provide written notification of room change for one (#54) out of one out of 44 sample residents. Specifically, the facility failed to provide Resident #54 and his family with written notification upon moving the resident to another room.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect residents from abuse for one (#36) of seven residents reviewed for abuse out of 44 sample residents. Specifically, the facility failed to protect Resident #36 from an altercation with Resident #48.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for three (#13, #72 and #7) of seven residents reviewed for abuse out of 44 sample residents. Specifically, the facility failed to: -Ensure an allegation of sexual abuse made by Resident #13 was reported to the State Agency timely; and, -Ensure an incident of verbal aggression by Resident #72 to Resident #7 was reported to the State Agency.

Inspectors wroteBased on record review and interviews, the facility failed to investigate an allegation of abuse for two (#72 and #7) of seven residents reviewed for abuse of 44 sample residents. Specifically, the facility failed to ensure an investigation was conducted for a resident to resident incident between Resident #72 and Resident #7 on 12/20/23.

Inspectors wroteBased on record review and interviews, the facility failed to permit two (#80 and #281) of two out of 44 sample residents to return to the facility following a facility initiated transfer. Specifically, the facility failed to readmit Resident #80 and Resident #281 to the facility following a facility initiated transfer. The facility failed to provide the residents with an involuntary discharge notice prior to or after the transfer and did not permit the residents to be readmitted to the facility. Cross-reference F740: The facility failed to ensure residents received the proper care and services to maintain highest psychosocial well-being. The facility failed to ensure residents were protected by identifying and implementing safety interventions with residents who voiced they were suicidal, ensuring lethality assessments were completed upon suicidal ideations; [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for two (#66 and #2) of three residents reviewed for visual problems out of 44 sample residents. Specifically, the facility failed to ensure: -Resident #66 had an eye exam; and, -Resident #2 was provided and encouraged to wear her glasses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received person-centered dementia care that met their needs for two (#2 and #72) of three residents reviewed for dementia care out of 44 sample residents. Specifically, the facility failed to: -Develop and implement individualized interventions for Resident #2 and Resident #72, who had a dementia diagnosis; and, -Provide meaningful activities that promoted Resident #2 and Resident #72's interests and preferences.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents maintained adequate hydration for one (#2) out of one resident reviewed for hydration out of 44 sample residents. Specifically, the facility failed to encourage fluid intake for Resident #2.

Inspectors wroteBased on record review and interviews, the facility failed to inform three (#80, #82 and #57) of three residents reviewed for beneficiary notices out of 44 sample residents in a timely manner of changes in their services covered by Medicare. Specifically, the facility failed to ensure the appeal phone number was written accurately on the Notice of Medicare Non-Coverage (NOMNC) or identified at all for Resident #80, #82 and #57.

Inspectors wroteBased on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full time basis. Specifically, the facility utilized the nurse home administrator (NHA) to also serve as the DON and she was unable to work full time hours as the DON.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident with limited mobility receives appropriate services, equipment and assistance to maintain or improve mobility for three (#15, #9 and #8) of five residents reviewed for activities of daily living out of 16 sample residents. Specifically, the facility failed to provide restorative care services to Resident #15, #9 and #8 on a regular basis, recommended by physical or occupational therapy.

Inspectors wroteBased on observation, interviews, record review, document review, and review of the facility policies, the facility failed to ensure 5 of 18 sampled residents were free from physical abuse (Residents #2, #24, #48, #69, and #173). Resident #26 displayed physically aggressive/abusive behavior toward residents and staff. The facility failed to modify/revise Resident #26's care plan and implement adequate supervision for the resident to protect other facility residents from abuse. From 04/14/2022 through 09/14/2022, Resident #26 had physically abused (hit/kicked/grabbed/pushed) Residents #2, #24, #48, and #173; and physically abused Resident #69 twice.

Inspectors wroteBased on interview and record review, it was determined the facility failed to provide written notice to the resident and the resident's representative(s) of a hospital transfer for three (3) of three (3) residents (Resident #72, Resident #172, and Resident #67) reviewed for hospitalization.

Inspectors wroteBased on interview, record review and policy review, it was determined the facility failed to provide the resident and/or the resident's representative(s) written noticed of the bed hold policy when a resident was transferred to the hospital for three (3) of three (3) residents (Resident #72, Resident #172, and Resident #67) reviewed for hospitalization.

Inspectors wroteBased on observation, interview, document and policy review, it was determined the facility failed to ensure a communication system relayed a call light directly to a staff member or to a centralized staff work area for two (halls 100 and 200) of four halls observed.

Inspectors wroteBased on interviews, record review, and a review of facility policy, it was determined the facility failed to protect one (Resident #66) of 18 residents' rights to formulate an advanced directive. Specifically, the facility failed to ensure Resident #66's advanced directive and/or the Medical Orders for Scope of Treatment (MOST) was completed and available in the resident's medical record.

Inspectors wroteBased on interview, record review, document review, and review of facility policies, the facility failed to thoroughly investigate one of three abuse allegations, which involved a resident-to-resident altercation between Resident #26 and Resident #48.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure that a comprehensive care plan was developed for one (Resident #58) of four residents reviewed for pain management. Specifically, Resident #58 had pain in the left arm and back and required pain medication. The resident's pain evaluation revealed the resident required a pain management care plan; however, the facility failed to develop a care plan to manage Resident #58's pain.

Inspectors wroteBased on interview, record review, document review, and review of facility policies, the facility failed to review and revise the plan of care for one (Resident #26) of 18 residents reviewed following resident-to-resident altercations. The facility developed a care plan with interventions to minimize Resident #26's physically aggressive behavior; however, Resident #26 continued to exhibit aggressive/abusive behavior and the facility failed to review/revise Resident #26's to prevent further potential abuse. Resident #26 abused five residents (Residents #2, #24, #48, #69, and #173) from 04/14/2022 through 09/14/2022.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs), received assistance with hygiene, specifically shaving, for one (1) of one (1) resident (Resident #19) reviewed for activities of daily living (ADLs).