Hillcrest Manor Nursing Center

Inspectors wroteBased on record review and interview, the facility failed to ensure a CMA provided supervision to prevent a resident from falling for 1 (#2) of 3 sampled residents reviewed for falls. The ADON stated 55 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's care plan was updated to include an intervention to prevent an identified pattern of falls for 1 (#39) of 2 sampled residents reviewed for accidents. The DON stated 54 residents at the facility had care plans.

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff provided supervision to prevent falls which resulted in a fracture for 1 (#39) of 2 sampled residents who were reviewed for accidents. The DON stated 54 residents resided at the facility.

Inspectors wroteBased on observation, records review, and interview, the facility failed to ensure a resident who self-administered their medication had been assessed for the ability to safely administer to do so for 1 (#13) of 9 sampled residents observed during medication administration observations. The DON stated one resident had self-administered medication at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was provided a written notice of transfer prior to being transferred to a hospital for 1 (#33) of 2 sampled residents reviewed for hospitalizations. The DON stated 54 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure: a. a psychotropic medication had an appropriate diagnosis for 1 (#50), and b. the physician addressed a GDR for 1 (#39) of 5 residents sampled for unnecessary medications. The DON reported nine residents received antipsychotic medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive assessment contained accurate health care information for 1 (#4) of 24 sampled residents reviewed for comprehensive assessments. The DON stated 54 residents resided at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were completed and submitted to Centers for Medicare and Medicaid Services for 1 (#21) of 19 sampled residents who were reviewed for resident assessments. The DON identified 54 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were bathed as scheduled for 1 (#1) of 3 residents reviewed for assistance with ADL's. The DON identified 54 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure labs were completed as ordered by the physician for 1 (#24) of 6 sampled residents whose labs were reviewed. The DON reported 54 residents resided in the facility.

Inspectors wroteBased on observation, recored review, and interview, the facility failed to ensure enhanced barrier precautions were implemented for 1 (#7) of 3 sampled residents reviewed for enhanced barrier precautions. The DON reported 14 residents were on enhanced barrier precautions.

Inspectors wroteBased on record review and interview, the facility failed to provide supervision to prevent elopement for one (#1) of three sampled residents who were reviewed for elopement. The administrator identified 12 residents who were high risk for elopement.

Inspectors wroteBased on record review and interview, the facility failed to post the accrued interest on three (#12, 23, and #28) of five residents whose funds were deposited in the facility trust. The DON documented 13 residents with funds in the trust. Facility census:

Inspectors wroteBased on record review and interview, the facility failed to maintain an accurate accounting of resident monies for one (#28) of five residents whose funds were managed in the facility trust and failed to ensure the accuracy of vendor payments for two (#34 and #43) of five residents whose funds were managed in the facility trust. The DON documented 13 residents with funds in the trust. Facility census:

Inspectors wroteBased on record review and interview, the facility failed to maintain a bond greater than the balance of the facility managed residents' trust. The DON documented 13 residents with funds in the trust. Facility census:

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the correct dose of an ordered medication was administered for one (#9) of seven residents observed for medication administration. The DON stated 53 residents received medications. Facility census:

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. CMA #1 dispensed an oral medication without touching the medication with their bare hands; b. the registered nurse rinsed a nebulizing mask clean after use; c. LPN #1 cleansed a wound in a manner to prevent contamination of the wound bed; and d. Paid Feeding Assistant #1 fed each spoonful of food to a resident in a manner which minimized the risk of infection. The DON stated 53 residents received medications. The DON documented four residents received nebulizing breathing treatments. The DON documented seven residents received wound care. The administrator stated there was one feeding assistant. Facility census:

Inspectors wroteBased on record review and interview, the facility failed to ensure that the proper SNF ABN or NOMNC for two (#100, and #101) of three sampled residents who where reviewed for SNF beneficiary notices. A Beneficiary Notices form, undated, documented 15 residents had been discharged from skilled services with days remaining in the past six months.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure bathing was provided to dependent residents for three (#1, 17, and #44) of three sampled residents reviewed for bathing and nail care had been provided to two (#1 and #17) of three sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 11/28/22, documented 48 residents resided in the facility, 37 residents required one to two person assistance for bathing, and 11 residents were dependent on staff for bathing.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure: a. a treatment was provided as ordered, b. staff washed their hands during wound care treatments, and c. pressure relieving boots were applied as ordered for one (#1) of one sampled resident reviewed for pressure ulcers.

Inspectors wroteBased on record review, and interview, the facility failed to ensure RN coverage seven days a week, eight hours a day for the following: a. five out of 30 days in April 2022, b. five out of 31 days in May 2022, and c. two out of 30 days in June 2022. The Resident Census and Conditions of Residents report, dated 11/28/22, documented 48 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure: a. staff were face masks in the facility during a COVID-19 outbreak and the facilities community transmission rate high, and b. staff wore the appropriate PPE while providing care for one (#149) of one sampled resident reviewed for infection control. The Resident Census and Conditions of Residents report, dated 11/28/22, documented 48 residents resided in the facility. The DON identified one resident who was COVID-19 positive and they were in outbreak status.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure kitchen equipment was maintained clean for the deep fat fryer and the stove top. The DON identified 48 residents received services from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff who were not fully vaccinated, had been granted an exemption or temporary delay from the COVID-19 vaccine for one (#4) of 33 staff members reviewed for COVID-19 vaccination status. The COVID-19 Staff Vaccination Status report, undated, documented the facility had 33 staff members and one staff member was partially vaccinated.