Hillcrest Village

Inspectors wroteBased on interview and record review, the facility failed to ensure medication administration records reflected the administration of narcotic pain medication (Residents C, D, E and F) for 4 of 5 residents reviewed for medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure qualified medications aides practiced within the scope of practice for 3 of 4 residents reviewed for qualified personnel. (Residents D, E and F)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (Resident D) blood pressure medication was held when the blood pressure was out of parameter for 1 of 5 residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure wound treatments were completed, as ordered by the physician (Resident C and Resident D) and failed to ensure the treatment administration record reflected the completion of wound treatments (Resident C, Resident D and Resident E) for 3 of 4 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation and interview, the facility failed to ensure nursing staff primed the insulin pen's needle prior to dialing the ordered dose during 1 of 4 insulin administrations. (Resident 53)

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure fall prevention was maintained for residents with muscle weakness during 1 of 5 residents reviewed for accident hazards. (Resident 53)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure glucometers were cleaned per guidelines for infection control when obtaining blood sugar readings for 2 of 5 residents observed. (Residents 26 and 103)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff to resident abuse did not occur for 1 of 3 residents reviewed for abuse. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' (Resident C, Resident D and Resident E) medication administration records accurately reflected the administration of narcotic medications for 3 of 4 residents reviewed for documentation.

Inspectors wroteBased on interview and record review, the facility failed to ensure blood pressure medications were held for out-of-parameter readings for 2 of 3 residents reviewed for medication administration. (Resident B and Resident D)

Inspectors wroteBased on record review and interview, the facility failed to ensure showers were provided consistently for 1 of 3 residents reviewed for Activities of Daily Living care. (Resident 84)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received medications as ordered and administered in a timely manner for 2 of 3 resident reviewed for pharmacy services. (Residents 62 and 64)

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified when a resident's (Resident B) blood pressure was not within set parameters for 1 of 3 residents reviewed for notification of change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications for a resident, without a self-administration assessment, were not left at bedside for 1 of 3 residents reviewed for medication self-administration. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure increased monitoring and interventions were in place for a resident (Resident B) with consistent high blood pressures and a history of a cardiovascular accident for 1 of 3 residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's record accurately reflected the administration of medications for 1 of 3 residents reviewed for medical records. (Resident B)

Inspectors wroteBased on interview and record review, the facility management failed to report an incident to the Indiana Department of Health when a resident (Resident B ) reported an allegation of abuse for 1 of 3 residents reviewed for verbal abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's blood pressure was obtained prior to medication administration (Resident D) for 1 of 3 residents reviewed for quality of care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate oversight of medication administration during 5 of 25 random observations. (Residents 104, 12, 98, 134, and 97)

Inspectors wrote- Resident 62 indicated the nurse left his aspirin at bedside and did not wait for him to take it. He indicated he would get to it at some point and take it. The resident's Annual MDS assessment, dated 10/12/23, indicated the resident had moderate cognitive impairment and required cues for recall. - Resident 71 indicated staff had a hard time waking her up between 4:00 to 6:00 a.m. If they were unable to wake her, then they would leave her medication at bedside for her to take when she did become awake. The nurse was not there when she took her medication. The Annual MDS assessment, dated 11/8/23, indicated the resident was cognitive intact. - Resident 20 indicated if she was not awake when they came in to give her the morning medications, they would leave them at beside and leave the room. She indicated she would take them when she got up. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure appropriate social services follow-up and monitoring of residents with hallucinations, concerns, and mood changes for 4 of 5 residents reviewed for Social Services (Residents 2, 12, 79, and 115)

Inspectors wrote2. During an observation on 12/11/23 at 1:14 p.m. a test tray was provided. The green beans were lukewarm. The potatoes were cool to taste. The temperature of the chicken was room temperature, and the meat was very dry on the end of the breast and moderately dry in the middle. a. The record for Resident 12 was reviewed on 12/12/23 at 9:35 a.m. The Significant Change MDS assessment, dated 11/6/23, indicated the resident was cognitively intact. During an interview on 12/11/23 at 10:45 a.m., Resident 12 indicated she did not like the food. The resident's had talked to dietary staff several times and they didn't feel like they were doing anything. There was no flavor too it. The food was horrible. The grilled cheese sandwiches could be used as ammo because they were so hard. The hamburgers were burnt. The vegetables were overdone, and the soups often were watered down. b. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure meals were served at the designated times and residents were offered a nourishing snack at night. This deficient practice had the potential to affect 116 of 116 residents currently residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of neglect and mistreatment to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services) in accordance with State law through established procedures for 1 of 2 residents reviewed for abuse. (Resident B)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure accurate documentation in the Controlled Drug Administration Record sheets of the administered narcotics for 3 of 56 residents receiving narcotics (Residents 64, 95, 20, 226, and 87) and failed to ensure oral and intravenous antibiotics were available for administration. (Resident 68)

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered, as ordered by the physician, for 19 of 20 residents reviewed for medication administration on the west wing. (Residents B, C, D, E, F, G, H, K, L, M, N, O, P, Q, R, S, T, U and V).

Inspectors wroteBased on interview and record review, the facility failed to prevent a significant medication errors related to insulin and anticoagulant administration for 4 of 20 residents reviewed for medication administration on the west wing. (Residents C, M, Q, and V).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe discharge for a resident (Resident B) for 1 of 3 residents reviewed for discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident H ) was provided adequate supervision and assistance of two staff members with a transfer in accordance with the resident's plan of care for 1 of 3 residents reviewed for accident hazards.