Hillside Plaza

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure documentation for medication administration was completed timely. This affected one resident (#10) out of three resident records reviewed for medication administration. The facility census was 38.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure a sanitary kitchen. This had the potential to affect all 43 of 43 residents who resided in the facility and received meals.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to ensure Resident #23's open area to the right inner heel was identified and treated timely and failed to ensure weekly skin assessments were completed as ordered. This affected one resident (Resident #23) out of three residents reviewed for wounds. The facility census was 43.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to ensure Resident #8 had comprehensive assessments of her dialysis access site post dialysis treatments. This affected one resident (Resident #8) of one resident reviewed for dialysis.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #4 was free from significant medication error. This affected one resident (Resident #4) of one resident reviewed for significant medication administration. The facility census was 43.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure appropriate infection control practices were implemented during Resident #10's medication administration and Resident #23's incontinence care. This affected one resident (Resident #10) of five residents reviewed for medication administration and one resident (Resident #23) of one resident reviewed for incontinence care.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure care plans were updated to include new interventions for falls. This affected two (Residents #1 and #29) of three residents reviewed for falls. The facility census was 41 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure fall prevention interventions were implemented. This affected two (Residents #1 and #29) of three reviewed for falls. The facility census was 41 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure oxygen tubing was changed as ordered. This affected one (Resident #1) of three residents reviewed for oxygen administration. The facility identified three (Residents #1, #7 and #25) who received oxygen. The facility census was 41 residents.

Inspectors wroteBased on record review, interview, review of the facility self-reported incident (SRI) tracking number (#)253244 and facility investigation, review of staffing schedules and punch detailed report and review of the facility abuse policy, the facility failed to enforce their abuse policy including reporting an allegation of abuse promptly, immediately investigating the allegation of staff-to-resident abuse and ensuring the alleged perpetrator did not continue providing direct care to all residents after the alleged allegation was made on 10/04/24. This affected one resident (#28) and placed a potential risk of abuse for all 40 residents residing in the facility.

Inspectors wroteBased on record review, interview, review of the facility self-report incident (SRI) tracking number (#)253244 and investigation, staffing schedules and punch detailed report, and review of the facility abuse policy, the facility failed to immediately investigate and implement protective measures upon receiving an allegation of staff-to-resident abuse to prevent further abuse including not allowing the alleged perpetrator to continue to provide direct care from 10/04/24 to 10/23/24 while a thorough investigation was completed. This affected one resident (#28) and had the potential to affect all 40 residents residing in the facility.

Inspectors wroteBased on interview, record review and review of facility policy, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee that met at least quarterly consisted of the required members, including the medical director or his/her designee. This had the potential to affect all 40 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility did not notify the physician and/or designee regarding Resident #13's change in condition. This affected one resident (#13) out of six residents reviewed for change in condition. The facility census was 40.

Inspectors wroteBased on record review, interview, review of the facility self-report incident (SRI) tracking number (#)253244 and investigation, and review of the facility abuse policy, the facility failed to promptly report an allegation of staff-to-resident sexual abuse to the Ohio Department of Health (ODH), local police department, and physician from 10/04/24 until 10/23/24. This affected one resident (#28) out of six residents reviewed for abuse. The facility census was 40.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure call lights were within reach. This affected two residents (#33 and #36) out of six residents reviewed for call lights. This had the potential to affect 38 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #24, #25, #26, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, and #40) identified by the facility as capable of utilizing their call light to ring for assistance. The facility census was 40.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure oxygen was being administered according to physician orders and failed to ensure there was appropriate signage indicating oxygen was in use. This affected one resident (#13) out of two residents reviewed for oxygen use. This had the potential to affect six additional residents (#15, #20, #21, #24, #28, and #38) identified by the facility with an order for oxygen. The facility census was 40.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of the memorandum from the Department of Health & Human Services, the facility failed to ensure proper infection control measures were implemented at all times. The facility failed to initiate and use enhanced barrier precautions (EBP) for Resident #13. This affected one resident (#13) of one resident observed for EBP and had the potential to affect 11 residents (#1, #7, #11, #12, #13, #18, #20, #21, #24, #26, and #38) identified by the facility that were to be on EBP. The facility failed to ensure staff did not carry medications against their chest/body potentially causing infection control cross contamination affecting one resident (#13) of three residents reviewed for medication administration. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure dialysis residents were monitored before and after dialysis treatments. The facility also failed to ensure resident dialysis catheters were assessed as ordered by the physician. This affected three (Resident's #12, #22, and #140) of three residents receiving dialysis. The facility census was 40.

Inspectors wrote4. Review of the medical record for Resident #18 revealed an admission date of 08/18/2020 with diagnoses including dementia with behavioral disturbance, schizoaffective disorder, delusional disorder, and depression. Review of the physician's order dated 10/01/21 revealed Resident #18 had an advance directive including palliative care program for chronic kidney disease. There were no physician's orders for hospice services. Review of the quarterly MDS 3.0 assessments dated 01/18/22 and 04/18/22 and the significant change MDS 3.0 assessment dated [DATE] revealed hospice services had been documented for Resident #18. Interview on 07/11/22 at 12:44 P.M. with Resident #18's daughter revealed Resident #18 had never received hospice services while in the facility. She verified Resident #18 received palliative care. Interview on 07/11/22 at 1:29 P.M. [...]

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure medications were administered as ordered. This affected three (Resident's #1, #20 and #22) of 11 residents reviewed for medications being administered as ordered. The facility census was 40.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure pressure relieving interventions were implemented and pressure ulcer treatments were performed for Resident #35. This affected one (Resident #35) of one resident reviewed for pressure ulcers. The facility census was 40.

Inspectors wroteBased on interview, record review, and review of the facility policy on falls, the facility failed to ensure new fall prevention interventions were implemented after Resident #18 experienced falls. This affected one (Resident #18) of one resident reviewed for falls. The census was 40.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure scheduled pain medications were administered to Resident #22 as ordered by the physician. The facility also failed to ensure pain assessments were performed as ordered by the physician for Resident #22. This affected one (Resident #22) of one resident assessed for pain management. The facility census was 40.

Inspectors wroteBased on record review and interviews, the facility failed to ensure Resident #20 was free of significant medication errors. This affected one (Resident #20) of one resident reviewed for significant medication errors. The facility census was 40.

Inspectors wroteBased on observation, staff interview, and review of the facility's administration procedures for all medications, the facility failed to ensure medications were dated when opened and disposed of when expired or discontinued. This affected two (Resident's #1 and #20) of two residents whose insulins were stored in the medication cart. The facility census was 40.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure medications in the [NAME] wing cart were secured under lock when the nurse was not in attendance. This had the potential to affect 17 residents (Resident #1, #4, #5, #6, #9, #13, #14, #15, #16, #18, #22, #24, #26, #35, #36, #187 and #189) on the [NAME] hall who received medications administered by the nursing staff. The facility census was 40. Findings Include: Observation on 05/15/19 at 4:30 P.M. in the [NAME] hallway revealed an unlocked medication cart stationed to the east of room [ROOM NUMBER]. No nurse was observed in the hallway or looking into the hallway. On 05/15/19 at 4:33 P.M. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure the most recent State survey results were readily accessible to its residents, staff and the general public. This had the potential to affect all 40 residents residing in the facility. Findings Include: Review of the facility publicly accessible survey results binder on 05/15/19 at 9:28 A.M. revealed the last noted survey results in the book were from a complaint survey dated 10/03/18. The Ohio Department of Health conducted complaint surveys at the facility on 03/07/19 and 03/12/19, the results of these surveys were not readily available in the survey book at the time of discovery. Regional Nurse Consultant #99 verified the lack of results in an interview on 05/15/19 at 9:32 A.M.

Inspectors wroteBased on record review and interview the facility failed to properly verify the nursing license of Licensed Practical Nurse (LPN) #100 prior to the employee working in the facility. This affected one LPN (LPN #100) of four LPNs whose personnel files were reviewed and had the potential to affect all 40 residents residing in the facility.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Notices of Medicare Non-Coverage issued to residents contained all of the required information. This affected three residents (Resident #138, #139 and #140) of three residents reviewed for beneficiary notices. Findings Include: 1. Review of Resident #138's Notice of Medicare non coverage (NOMNC) form for services ending 12/13/18 and signed 12/07/18 revealed the notice contained no specific information about what services would be discontinued. 2. Review of Resident #139's Notice of Medicare non coverage (NOMNC) form for services ending 03/20/19 and signed 03/13/19 revealed the notice contained no specific information about what services would be discontinued. 3. [...]