Hillview Health Care Ctr

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure a care plan was developed to provide effective and person-centered care and services that meets the professional standards of quality of care for 5 of 22 sampled residents (R1, R2, R9, R27, and R30).

Inspectors wroteBased on observations, interview, record review, and policy review, the facility failed to ensure the urinary catheter drainage bag was covered for privacy and dignity for 1 of 2 Residents (R9) reviewed for urinary catheters out of a total sample of 22.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to provide a notice of hospital transfer and appeal rights for one resident (R28) in a total sample of 22.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to obtain a signed declination which contained education on the risks/benefits of the influenza vaccine for 2 of 5 Residents (R18 and R30) reviewed for vaccines.

Inspectors wroteBased on interviews, record reviews, and facility policy reviews, the facility failed to follow infection control and prevention guidelines for environmental cleaning of floors in resident areas for 34 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 51 residents who reside in the facility. Facility staff did not conduct appropriate hand hygiene and were observed touching ready to eat foods with contaminated gloved hands. This is evidenced by: Facility's policy Hand Hygiene-Kitchen with the revised date of 08/31/22 read in part, 2. How to wash hands: .c. Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Pay close attention to the fingernails using a brush as needed. Scrub for a minimum of 10 to 15 seconds within the 20 second hand washing procedure. Apply vigorous friction between the fingers and fingertips. Rinse with clean, running warm water. d. Rinse thoroughly. e. Dry hands with paper towel. f. [...]

Inspectors wroteExample 3 R102 was admitted to the facility with diagnoses of displaced fracture of shaft of left clavicle, Parkinson's disease, dementia, and nephrostomy. On 11/12/24 at 9:57 AM, Surveyor observed RN D provide care to R102's nephrostomy tube site. RN D sanitized hands, applied a gown, and set up supplies with a barrier on the over the bed tray table. RN D removed the nephrostomy site dressing and noted the dressing had a little serosanguineous drainage. RN D removed gloves, sanitized hands, applied gloves, and cleaned the site with gauze and saline. RN D removed gloves, sanitized hands, and applied clean gloves. RN D dried area with a clean gauze. RN D removed gloves, sanitized hands, removed gown, sanitized hands, and left the room with the gown not contained in a bag, to gather supplies of split gauze. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, did not ensure only authorized personnel had access to medication carts, and did not ensure expired medications were removed from stock supply. This occurred for 3 of 4 medication carts/storage rooms observed. During the three-day survey, 4 of 7 observations were made of medication carts left unlocked when unattended and out of view of staff. One observation was made of resident (R) medications left on top of the medication cart when the cart was unattended and out of view of staff. (R8) One observation was made of a stock bottle of Maalox 3/4ths empty not labeled with an open or expiration date stored in the stock supply room. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections. This affected 14 of 55 residents (R) in the building. (R4, R36, R33, R25, R7, R20, R32, R37, R44, R31, R34, R49, R1, and R30) Staff did not sanitize mechanical lift between use for residents R33, R36 and R4. Staff did not provide hand hygiene for residents prior to meals for 12 residents. (R33, R25, R4, R7, R36, R20, R32, R37, R44, R31, R34, and R49) Staff did not perform hand hygiene when changing gloves during wound care for R1. Staff administered nasal spray to R30, that was stored without a cap and comingled with other resident medications.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain confidentiality of resident medical record information for 4 of 7 sampled and supplemental residents (R) reviewed. During the three-day survey, Surveyor had four observations of computer screens left open and unattended on medication carts with resident identifiable information visible for R28, R46, R36 and R8. This is evidenced by: Surveyor requested and reviewed the facility policy titled HIPAA-Notice of Privacy Practices dated February 2023. The policy in part reads: ~Hillview Health Care Center is required by law to maintain the privacy of your health information. ~We will not use or disclose your health information without your authorization in this notice. ~We will share your protected health information with members of your treatment team . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 2 of 16 residents (R) R29 and R16, reviewed for comprehensive care plans had a developed care plan specific to the resident. R29 had a diagnosis of deep vein thrombosis (DVT) and atrial fibrillation, requiring the use of anticoagulation medication (Eliquis). R29 did not have a comprehensive care plan to include the risk of bleeding due to the use of Eliquis. R16 has a Suspected Deep Tissue Injury (SDTI). R16 did not have a comprehensive care plan to address the SDTI. This was evidenced by: Example 1 On 9/26/23, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] with diagnoses in part to include DVT, atrial fibrillation, long term (current) use of anticoagulants, and dementia. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's environment remained as free of accident hazards as possible, and residents received adequate supervision and assistive devices to prevent accidents. This occurred for 2 of 4 residents (R) who were reviewed for falls (R29 and R37) and 1 of 1 Resident (R37) who was reviewed for wandering. R29 and R37 had falls while at the facility and both residents did not have fall risk assessments completed at the required frequency. R37 was identified as an explorer but had never had an elopement risk assessment completed.