Hillcrest Health Care, LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure body pillows used as positioning devices were not implemented as physical restraints for 3 of 3 residents (R5, R10 and R11) reviewed for restraints.

Inspectors wroteBased on interview and document review the facility failed to timely report a fall with major injury to the state agency (SA) within the required timeframe for 1 of 1 resident (R5) reviewed for falls.

Inspectors wroteBased on observation, interview, and document review the facility failed to complete a comprehensive fall analysis, evaluate and revise the care plan, and failed to implement fall interventions for 2 of 3 residents (R5, R11) who had severe cognitive impairment, impulsivity, and at high risk for falls.

Inspectors wroteBased on interview and record review the facility failed to comprehensively assess and monitor fluid intake to ensure adequate hydration for 1 of 3 residents (R3) reviewed for dehydration.

Inspectors wroteBased on observation, interview, and document review the facility failed to safely store medications by allowing medications to be removed from their original labeled containers, permitting loose and unidentified medications to remain in medication carts, failing to properly label medications after opening, and failing to remove expired medications from active stock on 2 of 2 medication carts observed.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 1 of 3 residents (R13) observed during incontinence cares. In addition, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during a transfer for 1 of 3 residents (R13).

Inspectors wroteBased on observation and interview, the facility failed to maintain a wheelchair in a clean and sanitary manner for 1 of 1 resident (R32) and ensure fans in resident rooms were kept clean for 3 of 3 residents (R2, R52 and R21) reviewed for safe, clean, comfortable, and home-like environment.

Inspectors wroteBased on observation, interview, and document review the facility failed to identify a change in condition, comprehensively assess weight gain, monitor, and notify the physician for 1 of 1 residents (R1). As a result R1 had a total weight gain of 37 pounds over 13 days that resulted in heart attack, respiratory failure, and death. This resulted in a past non-compliance at an Immediate Jeopardy (IJ). The Immediate Jeopardy (IJ) began on [DATE] when R1 had a 7.1 pound (lb.) weight increase that was not reported to the physician nor comprehensively assessed and monitored. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 5:48 p.m. The facility had implemented immediate corrective action on [DATE] to prevent recurrence, the IJ was issued at past non-compliance (PNC).

Inspectors wroteBased on observation, interview, and document review the facility failed to follow the care plan for safe transfers for a full body mechanical lift for 1 of 3 residents (R1) who required lifts for transfers. The facility's failures resulted in harm when R1 fell out of the lift and sustained subgaleal hematoma (bleeding between the skull and the scalp) and head laceration that required three staples. The facility implemented immediate corrective actions prior to survey and is issued at past non-compliance.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an allegation of staff to resident sexual abuse was reported to the State Agency (SA) within two hours for 1 of 1 resident (R1) who reported a male staff member inappropriately touched her.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a person centered comprehensive care plan was developed for 1 of 3 residents (R1) who requested no male caregivers provide care.

Inspectors wroteBased on interview and document review, the facility failed to implement a process for antibiotic review in order to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any residents who had infections requiring antibiotic use.

Inspectors wroteBased on observation and interview the facility failed to ensure a mechanical transfer lift was cleaned after resident use for 3 of 3 residents (R9, R45, R26) and that appropriate sanitizer was used to clean the lift observed for infection control practices. Findings Include: R9's Face Sheet printed 6/13/24, included diagnoses of obesity, bipolar disorder, difficulty in walking and unsteadiness on feet. R9's significant change Minimum Data Set (MDS) dated [DATE], indicated R9 was dependent on staff for all transfers and required assist of 2 and a lift. During observation on 6/11/24 at 3:36 p.m., nursing assistant (NA)-E and NA-F with the assist of a mechanical lift (device utilized for transfer) transferred R9 from her bed to her wheelchair. NA-F removed the lift from the room and moved it to another hallway and parked it in room [ROOM NUMBER]. NA-F left the room. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure 4 of 5 vents in the 400 hallway, and 5 of 5 vents in 500 hallway were clean when they had a black substance present on the 3 tiered vents. This deficient practice had the potential to affect all residents, staff, and visitors on the 400 and 500 wings. In addition, the facility failed to ensure resident rooms were maintained in a clean, sanitary manner for 13 of 60 residents (R7, R163, R16, R29, R39, R57, R2, R4, R162, R260, R37, R45, R22) whose rooms and/or bathrooms lacked upkeep, and who were reviewed for environment.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R16) who was observed to have medications in his room, had been appropriately assessed and deemed safe to self-administer medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to update the care plan and the [NAME] with behavioral interventions for 1 of 1 resident (R39) reviewed for care plans.

Inspectors wroteBased on observation, interview and document review the facility failed to provide timely incontinence care for 1 of 2 residents (R42) who was dependent upon staff for assistance with activities of daily living (ADL).

Inspectors wroteBased on observation, interview and document review the facility failed to provide timely repositioning for 1 of 1 resident (R42) who was dependent upon staff for repositioning and high risk for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff were educated and following the fall risk interventions for 1 of 2 residents (R42) identified at risk for falls to prevent further falls.

Inspectors wroteBased on interview, observation, and document review the facility failed to ensure activities of daily living (ADLs) including timely assistance with toileting and changing soiled clothing were provided for 1 of 1 resident (R57) who needed assistance with toileting and hygiene.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure personal privacy was maintained for 1 of 5 residents (R6) reviewed who required staff assistance with personal care. R6's face sheet identified R6 admitted on [DATE] with diagnoses of type 2 diabetes, obesity, dementia, unspecified psychosis. R6's current care plan identified an alteration in behavior and interventions included to go into room with two staff when completing care. On 3/27/24 at 10:22 a.m., nursing assistant (NA)-D came into room to change roommate d/t a strong urine odor in room. Curtain was drawn between roommates. NA-D yelled from the R6's side of the room [LPN-A] he keeps throwing his fists up at me, his sheet is wet. NA-D came over to R3's side of the room angrily with a garbage bag and stated, He just keeps laughing now, it isn't funny. NA-D then left the room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate, comprehensively assess, monitor, and treat skin conditions for 4 of 4 residents (R2, R3, R4, and R5) reviewed for impaired skin integrity. R2's face sheet undated identified an admission date of 7/2021. Diagnoses morbid obesity (obesity categorized by a body mass index greater than 40), type 2 diabetes, urinary incontinence, and erythema intertrigo (inflammatory skin condition caused by skin-to-skin friction (rubbing) that is intensified by heat and moisture). R2's Minimum Data Set (MDS) dated [DATE], identified R2 needed maximum assistance with movement and complete dependence with toileting. R2 used a motorized wheelchair. R2's current care plan identified an alteration in skin integrity with a goal to remain free of skin breakdown. Interventions included: [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to follow manufacturers instructions for cleaning and sanitizing two ice machines used for resident consumption. This had the potential to affect all 59 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to implement and maintain an infection control program that included thorough data collection, analysis of facility infections, and tracking and trending to reduce the spread of infections within the facility. The facility failed to include in their surveillance viral-like illnesses not treated with an antibiotic for staff or residents. The facility had no process in place to identify and monitor other types of infection in the facility and there was no analysis of the data collected. This had the potential to affect all 59 residents residing in the facility. Furthermore, the facility failed to ensure staff were implementing standard precautions for infection control and prevention, appropriately disinfecting reusable resident medical equipment including a scissors (R13) and glucometer (R29). [...]

Inspectors wroteBased on interview and document review, the facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any of the 59 residents at the facility.

Inspectors wroteBased on interview and document review the facility failed to inform resident/resident representative in advance of care, of the risks and benefits, possible alternatives to treatment, and receive consent of proposed care prior to initiating psychotropic (mood) medication for 1 of 4 residents (R44) reviewed for dementia care.

Inspectors wroteBased on interview and document review, the facility failed to ensure adequate and required information was documented and communicated to a receiving healthcare facility to ensure continuity of care for 1 of 1 resident (R44) reviewed for hospitalization, had transferred to hospital emergently. This deficient practice had the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure activities of daily living (ADLs) were provided, including nail care for 1 of 6 residents (R112) reviewed, who needed staff assistance to maintain good personal hygiene.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess and provide proper wheelchair positioning to prevent foot drop/contractures for 1 of 2 residents (R16) reviewed for positioning needs.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure restorative services to maintain and/or improve mobility was received for 1 of 3 residents (R49), reviewed for mobility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff were implementing fall risk prevention measures for 1 of 3 residents (R44) reviewed for accidents.

Inspectors wroteBased on interview and document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 2 of 5 residents (R8, R12) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were free of significant medication errors for 1 of 1 resident (R29) reviewed for insulin administration using an insulin pen.

Inspectors wroteBased on observation and interview, the facility failed to ensure doses of controlled substances were stored in a manner to reduce the risk of theft and/or diversion in 1 of 2 refrigerators observed in use for medication storage. This had potential to affect 2 of 2 residents (R15 and R48) residing in the facility who receive this medication.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident bathroom call light cords were within reach from the bathroom floor for 3 of 3 residents (R2, R43, R47), reviewed for call lights.

Inspectors wroteBased on interview and document review the facility failed to ensure the acting infection preventionist (IP) had completed specialized training in infection prevention and control. This had the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to prevent worsening and prevent additional pressure ulcers (PU)'s from developing for 1 of 1 resident (R28) who had two unstageable PU's (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) and one stage 2 PU (partial thickness skin loss of the dermis) This failure resulted in actual harm when R28's pressure ulcers worsened and additional PU's were acquired.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement an effective pest control program to eliminate mice in the building. This failure affected R4, and had the potential to affect all 66 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a system for routine reconciliation of controlled substances medication for 1 of 1 emergency kit (E-Kit) to prevent potential loss/diversion.

Inspectors wroteBased on observation and interview, the facility failed to ensure 8 of 71 rooms (rooms 101, 103, 111, 112, 113, 115, 201, 216) were maintained in good repair and in sanitary conditions, impacting 11 residents (R21, R264, R1, R55, R46, R57, R13, R213, R59, R9, R4). In addition, the facility failed to ensure fans used in resident resident rooms (rooms [ROOM NUMBERS]), impacting residents (R3, R32) were kept in a clean and sanitary manner; free of dust and debris.

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop a comprehensive care plan for 1 of 1 resident (R26) reviewed for smoking,1 of 2 residents (R4) reviewed for transmission based precautions.

Inspectors wroteBased on interview and document review, the facility failed to update the code status for 1 of 1 resident (R18) reviewed for advanced directives. In addition, the facility failed to accurately document resident's code status throughout the medical record.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess and monitor the progress of finger lesions for 1 of 1 resident (R28) with non-pressure related skin concerns.

Inspectors wroteBased on interview and document review, the facility failed to ensure consulting pharmacist recommendations were acted upon, addressed, and documented in the medical record for 1 of 5 residents (R17) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review the facility failed to follow transmission-based precautions by ensuring closure of room doors for 2 of 3 residents (R14, R50) symptomatic and known to be positive with COVID-19. The facility's failure to ensure implementation of proper precautions to prevent or mitigate the risk of COVID-19 outbreak had the potential to affect all other 63 residents and staff within the facility.

Inspectors wroteBased on interview and document review the facility failed to provide evidence pneumococcal vaccinations were up to date for 1 of 5 residents (R51) reviewed for vaccinations.

Inspectors wroteBased on interview and document review, the facility failed to ensure COVID-19 vaccination doses were offered to 3 of 5 residents (R41, R49, R51) reviewed for COVID-19 vaccination status.