Hillsboro Health and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the State Agency for 2 of 2 sampled residents (#s 6 and 10) reviewed for abuse. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate allegations of abuse for 2 of 2 sampled residents (#s 6 and 10) reviewed for abuse. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 sampled resident (#5) reviewed for accidents. This placed residents at risk for injury due to accidents.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to develop a resident centered care plan for 1 of 1 sampled resident (#1) reviewed for activities. This placed residents at risk for a lack of meaningful, purposeful and preferred activities and unmet psychosocial needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide the necessary care and assistance to maintain good grooming and hygiene for 1 of 4 sampled resident (#43) reviewed for ADLs. This placed residents at risk for poor grooming.

Inspectors wroteBased on interview and record review it was determined the facility failed to respond to a change of condition and provide respiratory interventions timely for 1 of 1 resident reviewed (# 41) for change of condition. This placed residents at risk for respiratory distress.

Inspectors wroteBased on interview and record review it was determined the facility failed to conduct weekly skin observations and evaluations to identify pressure ulcers and administer treatments timely treatment for 1 of 3 sampled resident (#359) reviewed for pressure ulcers. This placed residents at risk for complications related to unavoidable skin breakdown and not receiving care to treat pressure ulcers in a timely manner.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide appropriate dosing of opioid medications for 1 of 6 sampled residents (#45) reviewed for medications. This placed residents at risk for complications related to narcotic medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 5 of 7 days reviewed for RN staffing. This placed residents and visitors at risk for inaccurate staffing information.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a homelike environment for 1 of 1 facility reviewed for homelike environment. This placed residents at risk for adverse health conditions and an unclean environment.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure physician orders were followed for 4 of 8 sampled residents (#s 32, 34, 36 and 42) reviewed for choices, care plans and medications. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports were completed for 21 out of 67 sampled days reviewed for staffing. This placed residents at risk for incorrect staffing information.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a medication administration error rate of less than 5%. There were seven errors in 29 opportunities resulting in a 24.14% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects.

Inspectors wrote3. On 2/7/24 at 12:05 PM Staff 16 (Cook) was observed working at the kitchen's steam table preparing and plating food for the lunch meal. She was observed touching the food with utensils and her gloved hands. She then stepped away from the steam table to retrieve a salad from the refrigerator adjacent to the food preparation area. She was observed to open the refrigerator with her gloved hand, retrieve a salad that was covered in cling film and close the refrigerator door with her gloved hand. Without changing her gloves or completing hand hygiene, she returned to the steam table, removed the cling film from the prepared salad, placed it on a tray for delivery to a resident and continued to handle food using utensils and her gloved hands. [...]

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications prior to leaving medications unattended at the resident's bedside for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for unsafe medication administration.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a written summary of a baseline care plan was reviewed and provided to residents within 48 hours of admission for 1 of 2 sampled residents (#36) reviewed for care planning. This placed residents at risk for being uninformed about their plan of care.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 3 of 8 sampled residents (#s 2, 36 and 42) reviewed for care plans, medications and accidents. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to obtain and provide routine medications for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for not receiving prescribed medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow-up on pharmacist recommendations for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for medication errors.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure antibiotics were administered as ordered for 1 of 5 sampled residents (#36) reviewed for medications. This placed residents at risk for receiving unnecessary medications, experiencing adverse medication effects and developing antibiotic resistance.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were comprehensively assessed for the use of psychotropic medications and failed to ensure GDR (gradual dose reduction) was attempted for 1 of 5 sampled residents (# 36) reviewed for medications. This placed residents at risk for receiving unnecessary medications.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident narcotic medications were not misappropriated for 1 of 1 resident (# 9) reviewed for anti-anxiety medications. This placed residents at risk for loss of property.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders were followed for 2 of 5 sampled residents (#s 29 and 34) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident assessments were accurate for 1 of 1 sampled resident (#26) reviewed for contractures. This placed residents at risk for unmet needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure comprehensive, person-centered care plans for vision were developed for 1 of 1 sampled resident (#29) reviewed for vision and hearing. This placed residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received restorative services for 1 of 1 sampled resident (#34) reviewed for restorative services. This placed residents at risk for decreased mobility.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 2 of 5 sampled residents (#s 29 and 34) reviewed for unnecessary medications. This placed residents at risk for inaccurate clinical records.