Hillcrest Post Acute

Inspectors wroteBased on observation, interview, and record review the facility failed to implement an infection prevention and control program when:Personal Protective Equipment (PPE-specialized clothing or equipment used to provide a barrier and reduce exposure to hazards or infections) was not disposed correctly outside of Resident 67's room. Seven of seven residents (Resident 18, 24, 32, 45, 52, 66, and 73) were on Enhanced Barrier Precaution (EBP-infection control intervention used to prevent the spread of MDROs- bacteria that is resistant to most antibiotics) and did not have PPE available immediately outside the resident's room in accordance with The Center for Disease Control and Prevention (CDC) guidelines. These failures had the potential to place residents at risk for cross contamination that could lead to illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four outside dumpsters' were covered. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 56 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary and comfortable homelike environment for one of 25 resident rooms when:1. room [ROOM NUMBER] bed A's privacy curtain was visibly soiled with a thick brown substance.2. room [ROOM NUMBER]'s ceiling vent had visible accumulation of a thick brown dripping substance. These failures had the potential to result in the spread of infection in four medically fragile residents that resided in room [ROOM NUMBER].

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five Certified Nursing Assistants (CNA) underwent a background check prior to employment. This failure had the potential to result in the facility not preventing individuals with a criminal history of abuse, neglect and exploitation to provide care to a medically vulnerable population of 56 residents.

Inspectors wroteBased on interview and record review, the facility failed to assess and submit accurate data for one of 14 sampled residents (Resident 27) when the Minimum Data Set (MDS- an assessment tool used to guide resident care) did not reflect Resident 27's current status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 43) received a shower or bed bath for 16 days. This failure resulted in Resident 43 expressing a level of dissatisfaction with grooming and wanting to be groomed more often.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the prescribed left hand roll (rolled up wash cloth or towel used to support and position the hand and wrist to prevent contractures-permanent shortening or tightening of muscles resulting in limited range of motion and stiffness in the hand) was applied as ordered by the physician for one of 14 sampled residents (Resident 54). This failure had the potential to result in Resident 54's decline in functional abilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5 percent when one of two licensed nurses were observed and made the following medication errors:1. Resident 74 did not receive the correct dosage of Baclofen (muscle relaxant medication used to treat muscle stiffness, spasms and pain) in accordance with the physician order.2. Metformin (medication used to treat type 2 diabetes- chronic condition when the body does not regulate blood sugars) was not given with breakfast in accordance with the physician order for Resident 12. These failures resulted in two identified medication errors out of 30 opportunities for medication administration. The facility's overall medication error rate was 6%.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely store drugs in accordance with acceptable standards of practice when Resident 30's Naloxone (fast-acting medication that reverses an opioid [pain medication] overdose) had an expiration date of [DATE] and stored in a medication cart. This failure had the potential for Resident 30 to be administered an expired medication.

Inspectors wroteBased on interview and record review, the facility failed to provide a Report of the results of their investigations to the State Survey Agency, within 5 working days of the incident. This was for one of one reports of alleged elder abuse. This failure has the potential for the facility to miss data and not make the needed changes to prevent abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the posted daily staffing schedule had an additional required information such as census (number of residents in the facility), the total numbers of Licensed and Unlicensed staff and the actual hours worked individually, reflect staff absences on that shift due to call-outs and illness, and clearly identify the staff's name in a clear and readable format. This failure had the potential to result in poor and inadequate care that compromised the health and safety of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a fully credentialed Infection Preventionist (nurse who surveys and monitors infection prevention and control). This failure had the potential for Residents to obtain infections and be placed on unnecessary medications due to lack of infection control surveillance. During an interview with the DON on 4/16/24 at 10:30 a.m., DON queried as to who the Infection Preventionist is for the facility. DON stated, the nurse who has been working as the Infection Preventionist (Licensed Staff H) resigned 12/29/23. DON stated, Licensed Staff H and Licensed Staff I have been filling in. DON queried for the facility's staffing sign in sheets for Licensed Staff H and Licensed Staff I from 1/3/24 to 4/15/24. DON also queried for the timecard accounting for License Staff H and Licensed Staff I from 1/3/24 to 4/15/24. [...]

Inspectors wroteBased on interviews and records review, the facility failed to assess and monitor for signs of after surgery complications for one of 15 sampled residents (Resident 20) when Resident 20 had left eye surgery. This failure had the potential for Resident 20 to develop an unidentified bacterial eye infection which could result in Resident 20's discomfort.

Inspectors wroteBased on interviews and records review, the facility failed to ensure Ophthalmic (pertaining to the eye) medications were administered according to the doctor's order for two of 15 sampled residents (Resident 20 and Resident 41) when: 1. a. Resident 20 who had left eye surgery did not receive the ordered Ofloxacin Ophthalmic Solution 0.3%, (an antibiotic used to treat bacterial infections of the eye) three days after the medication was ordered, and (b) Resident 20 did not receive the medication according to the ordered administration time. These failures had the potential risk for Resident 20 to develop bacterial eye infection and eye discomfort. (Cross reference F684) 2. Resident 41 who had a diagnosis of Glaucoma (an eye diseases that can cause vision loss and blindness) did not receive his eye medications according to the ordered administration time. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two residents, Resident 9 and Resident 19, received action, obtain feedback, and conduct systematic investigations to improve quality of care, quality of life and resident's safety during Quality Assurance and Performance Improvement (QAPI) meetings when: 1) The Director of Staff Development (DSD) did not report an incident reported by an Ombudsman of verbal abuse and mocking (imitating behavior) towards Resident 9 by Unlicensed Staff L. DSD did not inform the Administrator of the abuse allegation. ADM was the abuse coordinator. 2) Resident 19 attempted to complain to DSD regarding an alleged verbal abuse by Unlicensed Staff M & Unlicensed Staff N . [...]

Inspectors wroteBased on interviews and records review, the facility failed to develop and implement person-centered care plans for one of 15 sampled residents (Resident 20) when Resident 20 had left eye surgery. This failure resulted in a lack of communication between disciplines and care givers that could potentially cause negative outcomes for Resident 20. (Cross reference F684)

Inspectors wroteBased on observation interview and record review, the facility failed to follow their Medication Storage Policy, when 3 expired COVID 19 Vaccines and 1 box of Arginaid (wound healing nutrition) were found in the facility's Medication Storage room and another expired box of Arginaid was found in Medication Cart 1. This failure had the potential to result in Residents being injected with an expired ineffective COVID 19 vaccine resulting in an unvaccinated status as well as expired deteriorated Arginaid being ineffective for wound healing.

Inspectors wroteBased on observation, interview, and record review, residents were made to feel uncomfortable when staff spoke Spanish in front of residents and during care for two of 15 sampled residents (Residents 35 and 28), and seven of seven residents in a group interview. This caused Resident 35 to feel disoriented and wished staff would speak English in front of her, caused Resident 28 to feel upset, and caused residents in the group interview to feel left out.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure accurate MDS assessments (The Minimum Data Set is a tool for implementing standardized assessment and for facilitating care management in nursing homes) were submitted for two of two sampled residents (Residents 46 and 145) when they: 1. Failed to document the correct discharge disposition for one Resident, Resident 46. This failure led to an incorrect discharge disposition submitted on Resident 46 MDS which indicated Resident 46 was discharged to a hospital. 2. Failed to identify risk for pressure ulcers on one Resident, Resident 145. This failure could have potentially lead to Resident 145 not getting the pressure ulcer prevention she needs.

Inspectors wroteBased on observation, interview and record review, one of 15 sampled residents (Resident 21's): 1. Fall Risk care plan and 2. Risk for Constipation care plan were not adequately updated with interventions to prevent falls from occurring and constipation. These failures contributed to Resident 21: 1. falling twelve times from 5/20/21 through 3/4/22, which had the potential to lead to harm, hospitalization, and in severe cases death and 2. Resident 21's abdomen feeling full, bloated, and in pain, hard stools causing hemorrhoids (swollen veins in your lower rectum), unexplained weight loss, amongst other health issues, which could lead to Resident 21 being hospitalized .

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's Protocol for Constipation and Resident 21's Risk for Constipation care plan for one of 15 sampled residents (Resident 21) causing Resident 21 to not have a bowel movement (BM) anywhere from four to seven days in a row. This had the potential for Resident 21's abdomen feeling full, bloated, and in pain, hard stools causing hemorrhoids (swollen veins in your lower rectum), unexplained weight loss, amongst other health issues, which could lead to Resident 21 being hospitalized .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident safety when staff did not evaluate, develop, and implement adequate interventions for 1 of 15 sampled residents (Resident 21), who had poor safety awareness and a history of falls, to prevent multiple falls. This failure contributed to Resident 21 falling twelve times from 5/20/21 through 3/4/22, which had the potential to lead to harm, hospitalization, and in severe cases death.

Inspectors wroteBased on food storage observation, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by: 1. Foods were not stored in the refrigerator per facility storage guidelines including bread, premade cheese sandwiches, and gelatin, tomatoes had brown spots and felt mushy, and Romaine lettuce was not sealed and no open date, and 2. Test tray evaluation of lunch on 3/2/2022 at 12:57 p.m., found pureed Risotto tasted bland and had a gluey texture causing pureed risotto difficult to swallow, broccoli mushy and gray/green in color, and test tray evaluation of dinner on 3/2/2022 at 5:10 p.m., found the bottom bun of the grilled hamburger bun was hard, dry, and over cooked. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to assess for self-administration of medication for 1 of 15 sampled residents (Resident 36) when Resident 36 was allowed to self-administer her oral inhaler. This failure had the potential for Resident 36 to develop medication side effects if medication was self-administered inappropriately.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan for 1 of 15 sampled residents (Resident 36) when: 1. The facility did not develop a care plan for weight gain to indicate how the facility would monitor and maintain Resident 36's weight. 2. The facility did not develop a Congestive Heart Failure (CHF - weakness of the heart that leads to a buildup of fluid in the lungs) care plan to indicate what symptoms to expect, how often and what to monitor. (Reference F684) This failure resulted to Resident 36's continued weight-gain due to worsening bilateral leg edema and subsequently was transferred to the acute hospital due to shortness of breath.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to do a respiratory assessment and identify a large fluid filled blister approximately 8 cm in diameter for 1 of 15 sampled residents (Resident 36) when Resident 36 had bilateral (both sides) leg edema (swelling caused by fluid). This failure resulted in Resident 36 to experience discomfort and was subsequently sent to the acute hospital for shortness of breath and worsening of leg edema.

Inspectors wroteBased on observation, interview and record review the facility failed to re-order one Resident's (Resident 95) blood thinner medication in a timely manner to ensure there were no missed doses. This failure caused Resident 95 to miss two doses of his blood thinner and had the potential to cause Resident 95 to develop a blood clot.

Inspectors wroteBased on interview and record review, the facility failed to provide proper monitoring of drug adverse effects when one of five residents sampled for unnecessary medication review (Resident 27) did not have ordered monitoring for signs and symptoms of bleeding while taking a blood thinner. This failure could potentially lead to Resident 27 having undetected bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly secure residents' medications when two of 15 sampled residents, Residents 28 and 36, had inhalers stored on their bedside tables. This failure had the potential to result in other residents misusing the inhalers when they had unrestricted access to prescription medications.

Inspectors wroteBased on observation, interview, and record review, one resident's urinary catheter bag and tubing (a device that drains urine from the bladder through a tube to a collection bag) were on the floor. This could potentially lead to the resident developing a urinary tract infection (UTI).