Hillcrest Care Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically the facility failed to ensure residents were offered hand hygiene before meals in both the dining room and during the delivery of room trays.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Level II preadmission screening and resident review (PASRR) was completed for one (#27) of two residents out of 23 sample residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being. Specifically, the facility failed to ensure a Level II PASRR was in place for Resident #1.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were provided services that meet professional standards for one (#1) of five residents out of 23 sample residents. Specifically, the facility failed to ensure Resident #1's insulin was administered according to the physician's orders.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services to prevent complications for one (#26) of one resident reviewed for tube feeding out of 23 sample residents. Specifically, the facility failed to ensure Resident #26's physician's orders were updated and accurate; and, -Ensure Resident #26's feeding tube was flushed to maintain patency (prevent clogging).

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to develop a maintenance program to ensure environmental concerns in the dish room, kitchen and serving area were identified and corrected in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to address and/or act promptly upon the grievances and recommendations during resident council on issues of resident care and quality of life in the facility that were important to the residents. Specifically, the facility failed to ensure resident council grievances were addressed to resolve resident concerns related to residents being left in the dining room for up to an hour after meals, lack of staff in the dining room, inappropriate staff conversations, rude staff members and call light response times.

Inspectors wroteIII. Resident #32 A. Resident status Resident #32, age of 93, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included unspecified dementia, diabetes and history of falls. The 2/2/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident required one-person assistance with transfers, dressing, walking, toilet use, bathing, and personal hygiene. The resident had unsteady balance but could stabilize themselves without assistance. The resident used a cane for ambulation. The MDS assessment marked the resident had no falls in the six months prior to admission. B. Observations Observations made from 8:30 a.m. to 5:30 p.m. on 3/27/23 through 3/30/23 revealed: [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure professional standards of infection control were followed while cleaning resident rooms; -Ensure that different cleaning cloths were used to clean and disinfect different potentially contaminated surfaces; -Ensure housekeeping staff changed gloves and performed hand hygiene consistently when moving from a task where the staffs hand became contaminated form cleaning and or touching a contaminated surface within a resident's room before cleaning the next surface; [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain a system of documenting grievances and demonstrating prompt action for residents. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to: -Ongoing food and pest control concerns; and, -Grievances brought up in the resident council.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and vermin. Specifically, the facility failed to utilize a method for pest control that was effective and sanitary.

Inspectors wroteBased on record review and interview, the facility failed to provide training to their staff that at a minimum educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically the facility failed to: -Provide annual abuse identification and prevention training for one of out of six certified nurse aides (CNA) reviewed; and, -Provide initial hire orientation and/or annual dementia management training for four out of six CNAs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide appropriate treatment and services to maintain or improve the ability to perform activities of daily living (ADLs) for for one (#32) of two residents reviewed for ADLs out of 29 residents. Specifically, the facility failed to provide supervision, oversight, encouragement and cueing with eating for Resident #32.

Inspectors wroteBased on interviews and record review, the facility failed to establish parameters for pain medication for one (#29) of three residents in a manner consistent with professional standards of practice out of 29 sample residents. Specifically, the facility failed to: -Pain parameters and assessments were established and implemented for a physician ordered scheduled and as needed (PRN) pain medication; and, -Non-pharmacological interventions were established or implemented.

Inspectors wroteBased on observations and interviews, the facility failed to ensure mechanical equipment was in safe, operational condition. Specifically, the facility failed to ensure necessary kitchen equipment was maintained in safe, working condition.

Inspectors wroteBased on interview and record review, the facility failed to prevent a fall with injuries during facility transportation of one (#28) of three out of 23 sample residents. The facility failed to ensure Resident #28 was provided safe transportation. Due to the facility ' s failures Resident #28 was loaded into the van and was not secured properly before being left unattended while the transportation driver left the residents side to open the door on the other side of the vehicle. Because of this failure the resident's wheelchair was unstable and rolled forward out of an open door and out of the van causing the resident to fall approximately three feet down out of the van, face-forward onto the asphalt. As a result of the fall, the resident was seen in the emergency room for assessment and treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the correct installation, use and maintenance of transfer bar, (fixed bed rail assistive device) for five of 14 residents (#18, #28, #15, #13 and #29) using bed canes or transfer bars (type of bed rail) for positioning; out of 22 sample residents. Specifically, the facility did not ensure resident safety risk when the use of transfer bar/rails were in use, for Resident #18, #28, #15, #13, and #29 by failing to: -Attempt to use appropriate alternatives prior to installing bed rails/transfer bars/rails; -Assess each resident for risk of entrapment from bed rails prior to installation; -Assess and review the risks and benefits of the bed transfer bar assistive device with the resident and or the resident's representative; [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure four (#24, #4, #20 and #15) of five residents reviewed out of 23 total sample residents were as free from unnecessary drugs as possible. Specifically, the facility failed to ensure residents and/or their responsible parties were informed of psychotropic medications with black box warnings (the Food and Drug Administration's strictest and most serious type of warning which describes a medication's serious or life-threatening side effects or risks) for Residents #24, #4, #20, and #15.

Inspectors wroteBased on observations and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions for one out of one dining rooms and two room trays. Specifically, the facility failed to ensure residents were offered and encouraged to complete hand hygiene prior to eating their meals.

Inspectors wroteBased on record review and interviews, the facility failed to notify the state mental health authority promptly after a significant change in condition for one (#17) of four residents reviewed for Pre-admission Screen Annual Resident Review (PASARR) program compliance of 36 sample residents. Specifically the facility failed to notify the Omnibus Budget Reconciliation Act (OBRA) coordinator when Resident #17's was diagnosed with new psychiatric conditions.

Inspectors wroteBased on resident observation, record review and interviews, the facility failed to ensure one (#24) of three residents reviewed for pressure ulcers out of 23 total sample residents, received care consistent with professional standards of practice to prevent pressure injuries. Specifically, the facility failed to: -Update the comprehensive care plan to include implemented interventions to prevent potential pressure ulcers for Resident #24; and, -Ensure interventions for the prevention of pressure ulcers were followed for Resident #24. I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; [...]