Hill Nursing Home, Inc.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from abuse for one (#1) of three sampled residents reviewed for abuse. The deficient practice resulted in skin tears to the resident's wrists. The administrator identified five allegations of abuse in the last six months.

Inspectors wroteBased on record review and interview, the facility failed to implement their written abuse policies and procedures for one (#1) of two sampled residents reviewed for abuse. The administrator identified five allegations of abuse in the last six months.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse within the two hour required timeframe to the Oklahoma State Department of Health for one (#1) of three sampled residents reviewed for abuse. The administrator identified five allegations of abuse in the last six months.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure menus were: a. prepared in advance, b. followed, and c. reviewed by the facility's dietitian or other qualified nutrition professional for the residents. The administrator identified 38 residents who ate meals prepared by the kitchen and two resident who received nutrition via feeding tube.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner for the residents. The administrator identified 38 residents who ate meals prepared by the kitchen and two resident who received nutrition via feeding tube.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received proper pain management for one (#31) of one sampled resident who was reviewed for an injury of unknown origin. The administrator identified 40 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical record was accurate for one (#31) of one sampled resident who was reviewed for an injury of unknown origin. The administrator identified 40 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facilty failed to impliment their policy regarding monitoring and measures to prevent the growth of Legionella bacteria for the facility. The administrator identified 40 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facilty failed to provide documentation regarding offering or given the pneumococcal vaccine for three (#5, 8, and #24) of five residents reviewed for immunizations. The administrator identified 40 residents who resided in the facility.

Inspectors wroteOn 05/12/23 at 3:30 p.m., an Immediate Jeopardy situation was determined to be in existence related to the facility failing to ensure background screenings were completed for 45 of 66 employees. On 05/12/23 at 3:50 p.m., the Oklahoma State Department of Health verified the existence of the Immediate Jeopardy situation. On 05/12/23 at 4:00 p.m., the administrator was notified of the IJ situation. On 05/12/23 at 6:00 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Preparation and/or completion of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. [...]

Inspectors wroteOn 05/10/23 at 11:45 a.m., an Immediate Jeopardy situation was determined to be in existence related to the facility failing to ensure residents were served hot liquids at a safe temperature to prevent injury or harm. On 05/10/23 at 11:55 a.m., the Oklahoma State Department of Health verified the existence of the Immediate Jeopardy situation. On 05/10/23 at 12:00 p.m., the Administrator was notified of the IJ situation. On 05/10/23 at 4:00 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Preparation and/or completion of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop a care plan for a resident with burns from drinking hot liquid for one (#22) of two sampled residents who had burns from hot liquids. The DON identified 32 residents who drank hot liquids.

Inspectors wroteBased on record review and interview, the facility failed to revise a care plan with interventions to prevent falls for one (#11) of one sampled resident reviewed for falls. The DON identified 25 residents who had falls since October 2022.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician was notified of out of parameter blood sugars and failed to obtain a physician's order to hold insulin for one (#1) of one sampled resident on insulin. The DON identified five residents on insulin.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure physician's orders were obtained for oxygen therapy and oxygen tubing was changed and labeled for one (#6) of one sampled resident reviewed for oxygen therapy. The DON identified four residents who were on oxygen therapy.

Inspectors wroteBased on observation and interview, the facility failed to ensure puree diets were prepared in a sanitary manner. The Dietary Manager (DM) identified two of two sampled residents who received a pureed diet.

Inspectors wroteBased on observation and interview, the facility failed to ensure pasteurized eggs served to residents were fully cooked for one (#7) of one sampled resident served over easy eggs. The administrator identified 29 residents received food from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure policies were in place to track vaccination status for six (CNA #11, medical director, nurse practitioner, pharmacist, dietician, and the quality assurance consultant) of 62 employees. The HRA identified 62 staff were employed at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure: A. documentation of staff vaccination status for one, (CNA #11), of 62 facility employees reviewed and five (medical director, nurse practitioner, pharmacist, dietician, and the quality assurance consultant) of five individuals who provided services. B. the development and implementation of COVID-19 vaccination policies and procedures for staff. The HRA identified 62 staff were employed at the facility and five personnel provided services under contract.