Hillview Terrace

Inspectors wroteBased on observations, interviews, and review of policies: Personal Cleanliness and Standards and Beard Restraints, as well as current (2017) Food Code regulations, the facility failed to ensure staff: 1) covered all hair during the preparation and distribution of food on the 03/04/20 lunch tray line; and 2) washed hands after handling soiled equipment and before putting on another pair of gloves to resume food handling tasks. This had the potential to affect all 124 residents for whom meals were prepared and served at the time of this survey.

Inspectors wroteBased on observations, interviews, medical record reviews, a review of the facility policies titled, Hand Hygiene and Administration of Medication, and review of [NAME] and Perry's, FUNDAMENTALS OF NURSING, the facility failed to ensure: 1) Employee Identifier (EI) #6, Registered Nurse (RN), did not take a stethoscope from a bowl on the nurse's station into Resident Identifier (RI) #18's room to auscultate placement of RI #18's gastrostomy tube without cleaning the stethoscope before or after use. Further, the nurse failed to wash hands prior to medication administration, and prior to rinsing the plunger and syringe before storage; 2) EI #7, Licensed Practical Nurse (LPN), did not turn off an oxygen concentrator with her bare hand and then apply gloves to administer RI #91's nebulizer treatment without washing her hands. [...]

Inspectors wroteBased on observation, interviews, medical record review and review of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, the facility failed to ensure Employee Identifier (EI) #6, Registered Nurse (RN), followed a physician's order to administer 30ML (milliliters) of water prior to medication administration for Resident Identifier (RI) #18. This affected RI #18, one of eight residents observed during medication administration observation, and one of five nurses observed. Findings Include: A review of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, Chapter 23, Legal Implications in Nursing Practice, page 311, revealed: .Health Care Providers' Orders .Nurses follow health care providers' orders unless they believe that the orders are in error . RI #18 was admitted to the facility on [DATE], with diagnoses including, Dysphagia following Cerebral Infarction. [...]

Inspectors wroteBased on interview, record review, review of the facility's document titled, Resident Rights and the facility's policy and procedure titled, RESIDENT RIGHT TO ACCESS AND VISITATION, the facility failed to ensure staff did not open Resident Identifier (RI) #15's mail prior to delivering it to him/her. This affected RI #15, one of one sampled resident whose mail was received opened by the facility. Findings Include: A review of the facility's policy titled, RESIDENT RIGHT TO ACCESS AND VISITATION ,without a date, revealed the following: .Policy Explanation and Compliance Guidelines . 4. The resident will have the right to access mail . to receive letters .The resident has the right to privacy in these communications . A review of the facility's form titled, Resident Rights revealed the following: .The resident has the right to . receive mail .the resident has the right to have reasonable . [...]

Inspectors wroteBased on interview, record review and a review of the facility's policy titled, Abuse Prevention, the facility failed to ensure Resident Identifier (RI) #107 was free from physical abuse that involved RI #31. This affected RI #107, one of two residents identified for abuse. Findings Include: A review of the facility's policy titled, Abuse Prevention with a revised date of 12/20/18, revealed the following: . III. PREVENTION . 3. residents' rights which include the right to be free of abuse . A review of the State Agency Intake Information, dated 12/06/18, regarding resident on resident physical abuse revealed the following: . Review of a FRI (Facility Reported Incident) received on 12/6/18 revealed that (RI #31) punched (RI #107) in the shoulder and leg . 1. [...]

Inspectors wroteBased on observation, record review, interviews, and a review of the facility's policy titled, CAREPLANS, the facility failed to ensure Resident Identifier (RI) #27's care plan was followed for wound care to the tracheostomy site . This affected one out of 46 residents whose care plans were reviewed. Findings Include: A review of the facility's policy titled, CAREPLANS without a date, revealed the following: .Procedure 1. A care plan will be developed and implemented . RI #27 was readmitted to the facility on [DATE], with diagnoses including Quadriplegia Unspecified and Adjustment Disorder With Depressed Mood. A review of the RI #27's current Quarterly Minimum Data Set (MDS), dated [DATE], revealed RI #27's Brief Interview for Mental Status (BIMS) score of 15, indicating cognition was intact. [...]

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy titled Comprehensive Care Plans, the facility failed to ensure: 1) Resident Identifier (RI) #87 had a fall mat placed at bedside on two of seven days of survey; and 2) RI #s 48, 69, and 87 had person-centered care plan interventions in place addressing their toileting and/or incontinence needs. These failures affected three of 32 residents for whom care plans were reviewed.

Inspectors wroteBased on a test tray, meal observations and resident interviews, the facility failed to consistently serve food palatable in taste and temperature to the residents. This affected RI #s 18, 56, 35, 170, 78, 88, 103, 54, and 173, nine of 29 sampled residents.

Inspectors wroteBased on observations of incontinence care and medication administration, review of the facility's policies titled: Oral Inhalers, Eye Drops, Hand Hygiene, Standard Precautions Infection Control, and Handling Linen, as well as a review of medical records, and staff interviews, the facility failed to ensure staff utilized good infection control practices .as follows: 1) Staff provided no barrier prior to placing supplies (for catheter and perineal care) on the bedside tables of Resident Identifier (RI) #17 and RI #170. 2) Licensed and unlicensed staff placed bags of soiled and/or clean linen directly on the floors of RI #17 and RI #69's rooms. 3) Staff failed to wash hands after changing gloves and before donning clean gloves during the care of RI #69 and RI #367. 4) Licensed staff handled clean linen and the brief of RI #69 with dirty gloves. [...]

Inspectors wroteBased on record review, interviews, and review of the facility's Voiding Pattern Rosters for Resident Identifier (RI) #76, the facility failed to ensure RI #76's 10/05/17 quarterly Minimum Data Set (MDS) assessment and 12/25/17 annual MDS assessment, accurately reflected RI #76's incontinence status. This affected one of 32 residents for whom MDS assessments were reviewed:

Inspectors wroteBased on record review, interviews, and review of the facility policy titled Comprehensive Care Plans, the facility failed to ensure: 1) Resident Identifier (RI) #48's care plans were updated to reflect his/her catheter had been discontinued; and 2) RI #78's care plans and/or FYI (for your information) Smart Charting tasks were revised to ensure incontinence interventions were consistent. These failures affected two of 32 residents for whom care plans were reviewed.

Inspectors wroteBased on an observation of catheter care, interviews with staff, and review of the facility policies related to Perineal and and Urinary Catheter Care, the facility failed to clean the perineal area of Resident Identifier (RI) #170 on 01/31/18. This affected one of one resident observed for the provision of catheter care.

Inspectors wroteBased on observations, review of the facility policy Proper Use of Side Rails, side rail consent forms signed by the sponsor, the Siderail Assessment and interviews with staff, the facility failed to ensure: 1) the consent form signed by the sponsor detailed the potential risks associated with the use of side rails; 2) the side rail assessment addressed prior alternatives attempted before installation; and 3) the side rail assessment included an assessment for the risk of entrapment. This affected Resident Identifier (RI) #87, one of two residents reviewed for the use of side rails.

Inspectors wroteBased on observation, resident and staff interviews and a review of the planned menus, the facility staff failed to follow each menu as planned, including the provision of the planned dessert at the 01/31/18 lunch meal for Resident Identifier (RI) #169 and the planned alternate to RI #173 at the 02/01/18 supper meal. Three other residents likewise reported similar complaints of staff not following the menus, including RI#s 88, 56 and 35. This affected five of 116 residents for whom food of a solid consistency (non-pureed) were prepared and served.

Inspectors wroteBased on observations, interviews, review of the facility's Census List dated 01/30/2018, review of the facility's policies titled Comfortable and Homelike Environment and Preventative / PRN (as needed) Maintenance Schedule, and review of Job Descriptions for the Maintenance Director and Maintenance Technician, the facility failed to ensure resident rooms and common areas were maintained to provide a safe, clean, comfortable, and/or homelike environment for the residents. Walls, door frames, doors, baseboards, and furniture throughout the facility were observed chipped, scraped, scratched, and with missing paint. Furniture was missing knobs and/or handles, sinks and/or showers did not have faucet fixtures, leaving unfinished exposed pipe, ceiling tiles were stained brown, floor tiles were missing and/or stained. Tube feeding and/or Intravenous (IV) poles were wobbly. [...]

Inspectors wroteBased on interviews and review of a facility document titled Hillview Terrace Facility Assessment, the facility failed to evaluate and identify areas of the environment needing to be maintained. This had the potential to affect all 137 of 137 residents residing in the facility at the time of the survey.