Hillcrest Heights Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a high risk elopement resident (1) from leaving the facility unnoticed. In addition, the facility failed to ensure transfer safety coordination was in place when the facility did not ensure the front entrance was secured and monitored in a manner that prevented the resident from leaving the facility unnoticed. As a result, Resident 1 eloped from the facility and required evaluation and observation in the emergency department (ED) after testing positive for methamphetamine (a highly addictive stimulant drug). The facility's failure to ensure safety coordination of transfer and monitoring resulted in Resident 1 not entering the facility and remained unattended in the community until located by emergency medical services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and coordinated discharge for one of three sampled residents (Resident 1). This failure placed Resident 1 at risk for an unsafe discharge and rehospitalization.

Inspectors wroteBased on interview and record review, the facility failed to develop an effective discharge plan that ensured residents' discharge goals were identified and addressed for one of three sampled residents (Resident 2). As a result, Resident 2 felt rushed, unheard, and unprepared to transition to the next care setting, which affected the continuity of care. (Cross-reference: F-655, Baseline Care Plans)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan for discharge (leaving the facility) was developed and implemented for two of three sampled residents (Resident 1 and Resident 2). This failure increased the risk that the residents' wishes would not be honored.

Inspectors wroteBased on an interview and record review, the facility failed to (1) Notify the physician of the change of condition [rashes on the head] and monitor skin changes for one of three sampled residents (Resident 3) and (2) Thoroughly assess and document Resident 3's condition following an unwitnessed fall. As a result, Resident 3 experienced delayed care, and the medical record did not accurately reflect the resident's condition, potentially impacting their health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accountability of controlled medications (those with high potential for abuse and addiction) and failed to accurately and timely administer resident medications, when: 1. The Controlled Drug Records (accountability records) for four out of seven randomly selected residents (Residents 91, 86, 81, and 11) did not reconcile with the Medication Administration Records (MAR). This failure resulted in inaccurate accountability of controlled medications and the potential for accidental duplicate medication administration; and 2. The pharmacy did not provide Resident 30's Creon (brand name for pancrelipase, a medication for the pancreas) for 13 days. This failure could result in ineffective management of Resident 30's pancreatic insufficiency (inability to properly digest food due to pancreas dysfunction); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident (Resident 30) was free of a significant medication error when the facility did not give Creon (brand name for pancrelipase, a medication for the pancreas) to Resident 30 for 13 days. This failure resulted in Resident 30 having digestive symptoms and had the potential for worsening of her medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident food preferences listed on their resident's meal tickets, for five of 88 residents (Residents 1, 11, 49, 75, 151), reviewed for Resident Accommodations. This failure had the potential for resident's wishes, likes, and dislikes to be ignored.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were accurate and concise for two of two residents (Residents 30 and 71), reviewed for medical records accuracy when: 1. Resident 30's medication administration records (MARs) for Creon (brand name for pancrelipase, a medication for the pancreas) incorrectly indicated nine doses were administered between 12/25/24 - 1/9/25, when the medication was not administered and was unavailable; and 2. Resident 71's Dialysis Communication Form, post assessment listed a graft, (an internal surgically created connection between an artery and a vein that allows for hemodialysis treatment), instead of a Perma-cath, (a central line inserted into a main vein). These failures had the potential to result in inaccurate documentation of the resident's medical history and response to care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety for one of three residents (Resident 50), identified as requiring a smoking apron while smoking, when reviewed for accidents. This failure had the potential for Resident 50's clothing to catch fire when smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the posted menu. In addition, two of 88 residents (Resident 32 and 86) did not receive a fortified (foods with nutrients added to them), meal as ordered, when reviewed for nutritional needs. This failure had the potential for residents' nutritional needs to not be met.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of two residents (Resident 1). This failure had the potential to cause psychosocial harm because Resident 1 was unable to understand instructions and explanations of treatments and care that was being given by the facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of missing money for one of three residents (Resident 1) reviewed for Resident Rights under Grievances. As a result, Resident 1 ' s grievance was not promptly resolved and there was limited documentation to prove a thoughtful, meaningful investigation was conducted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the care plan for one of three residents (Resident 1) reviewed for falls. As a result, Resident 1 had the potential to have further incidences of falls and/or injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify residents and/or the resident representatives when their care plans and physician ' s orders were updated to reflect exposure to Legionella bacteria (bacteria causing a serious lung disease) for three of three sampled residents (Resident 1, Resident 2 and Resident 3). As a result, residents and/or the resident representatives were not aware of the risks involved in being exposed to Legionella bacteria. In addition, the residents and/or the resident representatives were not involved in their plan of care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. The [NAME] (CK) 1 did not perform hand hygiene consistently during food preparation, 2. The Dietary Aide (DA) crossed over from dirty station to clean station while working in the dishwashing station, and 3. [NAME] (CK) 1 and the Dietary Assistant Manager (DAM) were unable to verbalize the cool down process. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne pathogens to come in contact with the residents' food and may cause food borne illness to the residents. The facility's census was 91.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician regarding a significant weight loss for one of two sampled residents reviewed for nutrition. (Resident 69) This deficient practice had the potential to delay necessary care and services to prevent Resident 69 to have further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean fan for Resident (5) to use. In addition, the facility failed to provide a homelike environment for one of two sampled residents (5) reviewed for homelike environment whose room had bubbling in the ceiling surface. As a result, Resident 5 did not feel comfortable with using a dirty fan or looking at a ceiling in need of repair.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident's right to be free from abuse when Resident 17 wandered into Resident 78's room. As a result, Resident 78 was punched on the right upper chest by Resident 17.

Inspectors wroteBased on interview and record review the facility failed to submit a PASARR Level 1 (Preadmission Screening and Resident Review- a federally required document to ensure residents are appropriately placed) when one resident, Resident 17, received a new mental health diagnosis while living in the facility. This failure resulted in Resident 17's mental health needs potentially being unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review Level 1 (PASRR-- a federal requirement to prevent individuals with mental illness [MI], developmental disability [DD], intellectual disability [ID], or related conditions from being inappropriately placed in nursing homes for long term care) was accurately completed for one of two residents reviewed. (Resident 79) This failure resulted in the resident to not be appropriately evaluated through the PASARR process and had the potential for the facility to not be aware of possible services needed to address Resident 79's mental illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive resident-centered care plans were developed for two of 25 sampled residents reviewed for care plans: 1. Resident 17 did not have a care plan to address his behavior of going into other residents' rooms. 2. Resident 79 did not have a care plan to address Resident 79's diagnosis of PTSD (post-traumatic stress disorder- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Cross reference F 699. These failures could potentially affect residents not receiving the proper treatment and care. This includes protection of other residents from Resident 17 and the prevention of potential triggers that will cause re-traumatization for resident 79. The facility did not ensure a care plan was developed for 2 residents related to PTSD and wandering.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a resident's range of motion (ROM-how far or stretch a part of body that can be moved around a joint) for one of two residents reviewed for activities of daily living (ADL-bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating). (Resident 48) This failure resulted in Resident 48 to have contractures (shortening of muscles and tendons, often leading to permanent deformity and stiffening of joints) of the left hand and left elbow.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care to three of nine sampled residents (5, 14 and 75), reviewed for Activities of Daily Living (ADL, activities related to personal care). As a result, Resident 5, Resident 14, and Resident 75's health and wellbeing were at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen (O2) was administered per physician's order for one of two sampled residents (1) reviewed for respiratory therapy. This failure had the potential for Resident 1 to develop oxygen toxicity.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify one of two residents reviewed for Trauma Informed Care (TIC - an intervention and organization approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health), received care and services in accordance with professional standards when Resident 79's PTSD (post-traumatic stress disorder- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) was not identified and addressed by the healthcare providers. This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience).

Inspectors wroteBased on observation, interview and record review the facility failed to provide a routine dental hygiene appointment for one resident, Resident 11. This failure resulted in Resident 11's dental needs being unmet.

Inspectors wroteThe facility failed to follow infection control practices when a Licensed Nurse (LN) 1, did not consistently perform hand hygiene during wound treatment for one resident. This failure had the potential to spread germs and placed residents at risk for infections. During a review of Resident 1's admission Record dated 10/31/18, the admission Record indicated Resident 1 was readmitted to the facility from acute care hospital with diagnoses which included stage four pressure ulcer (a bedsore affective muscle and bone). During a review of Resident 1's history and physical (H&P) dated 6/28/23, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During an observation of Resident 1 in her room on 1/29/24 at 10:40 A.M., Resident 1 was lying in bed, and did not respond when her name was called. On 1/30/24 at 3:24 P.M. [...]

Inspectors wroteBased on interview and record review the facility failed to monitor and re-evaluate antibiotic therapy prescribed for one resident, Resident 251. This failure had the potential for Resident 251 to receive the wrong antibiotic and or to develop antibiotic resistance.

Inspectors wroteBased on interview and record review, the facility failed to arrange transportation for 1 of 2 sampled residents (1) who should receive a hemodialysis (HD) treatment (a procedure done by a trained professional to remove waste and excess fluid from the body) as ordered by the physician. As a result, Resident 1 missed the HD treatment appointment, and Resident 1 had to be transferred to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to document sufficient preparation and orientation before discharge for 1 of 2 sample residents (1), when Resident 1, who has a diagnosis of Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities) was transferred to an Independent Living Facility (ILF- a place where resident need no to assistance). As a result, Resident there was a potential for unsafe discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide showers and/or bed baths to three of four dependent residents (Residents 1, 2, and 3), reviewed for Activities of Daily (ADL). As a results, Resident 1, 2, and 3 had the potential for low self-esteem and possible skin infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote a safe, homelike environment when: 1. Sections of ceiling panels were missing in the front north and south hallways, and in the back south hallway, exposing wires, cables, and air conditioning vents; and 2. A shared male resident bathroom sink remained clogged for months; and 3. A shared female resident bathroom had missing linoleum on the floor, directly in front of the sink area. These failures had the potential of placing residents at risk for low self-esteem and living in an unkempt environment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the staff followed the recipes and therapeutic menus as planned and printed, according to facility policy when: 1. Kitchen staff did not follow the facility recipe for pureed (liquid food for easy swallowing) meats. 2. Kitchen staff did not use the correct utensil size for portion control. This failure had the potential to result in weight loss of residents due to reduced food intake, which could have resulted in a decline in activities of daily living, and may have further compromised their nutritional status.

Inspectors wroteBased observation, interview and record review, the facility failed to ensure proper, safe and sanitary food practices, storage, and sanitation requirements were met when: 1. Stored utensils, plate warmer and can opener had visible residue on them. 2. There was no air gap underneath the three-compartment sink. 3. The kitchen flooring had several areas of uneven surfaces and cracks. 4. A kitchen fan had thick black dust on its frame. These failures had the potential to result in harmful bacteria growth and cross-contamination that could lead to food-borne pathogens (disease-causing organism) to come in contact with the residents' food; and can cause food-borne illnesses to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to demonstrate safe infection control practices when: 1. Resident 72's dentures were left out on a shared shelf sink; and 2. A visitor was inside Resident 193's, designated yellow zone room (a room on isolation precautions for COVID-a highly transmittable virus), without wearing personal protective equipment (PPE); and 3. A urinary catheter bag (a flexible tube inserted into the body that drains urine into a drainage bag via gravity) was in contact with the floor for one of one resident, (Resident 12), reviewed for catheter care; and 4. An emergency eyewash station was not routinely cleaned and maintained. These failures had the potential for cross-contamination of microorganisms.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 92's needs and preferences were met. As a result, 1. Resident 92 did not have a working bathroom and 2. Resident 92's preferred in-room activity of watching television (TV) was not provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Follow a physician's order regarding the necessity of oxygen use for one of one resident (Resident 19) reviewed for oxygen administration; and 2. Develop and implement a person-centered plan of care for one of one resident (Resident 19), reviewed for limited ROM (range of motion). As a result, there was a potential for oxygen dependency and worsening contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion (ROM) services to one of three residents (Resident 19), reviewed for limited ROM. This failure had the potential for a decline in Resident 19's already limited ROM.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that was free from accident and hazards in the resident dining room when a microwave was placed into service and staff were unaware of its presence. This deficient practice had the potential to result in resident(s) risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff carried out the tasks of the food and nutrition services department in accordance with the standard of practice for the following kitchen competencies: 1. A kitchen DSW (dishwasher) did not know how to correctly test PPM concentration of the dishwashing solution with the chlorine test strip. 2. Kitchen staff did not know how to calibrate food thermometers. 3. The kitchen staff did not follow policy and procedure for fortifying resident diets. These failures had the potential to expose all residents who consumed food from the kitchen to practices associated with the transmission of food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 74's mechanical bed was maintained in a safe condition. As a result, Resident 74, staff and visitors were exposed to a potential hazard, exposed electrical wires.