Medical Hill Healthcare Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, for Residents 2-4, the scheduled (controlled medication, narcotic) medication record system was complete (all documents available) and accurate (numbers match). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility did not have complete records. The facility did not have accurate records. These failures resulted in the potential for undetected loss and diversion. In addition, these failures resulted in the potential for avoidable medication errors.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide pharmaceutical services and procedures to six of six sampled residents (Residents 58, 93, 24, 121, 29, and 69) that ensured acquiring, dispensing, administration, and maintaining accurate controlled drug records when:Resident 93 and Resident 58's routine medications were not available during medication administration. The Controlled Drug Records (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) for four out of four sampled residents (Residents 29, 121, 69, and 24) did not reconcile with the Medication Administration Records (MAR). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices with census of 119 when: 1) A box of Resident 59's discontinued and unlabeled oral prescribed medication was stored in an active storage area in medication cart #3.2) Resident 65's discontinued as needed prescription medication was stored in medication cart #2.3) Multiple medications with different routes of administration (a way by which a drug is taken into the body) were stored together in medication carts #2 and #3.4) An unopened insulin vial with pharmacy label of refrigerate until opened was stored at room temperature in medication cart #2. These failed practices could contribute to unsafe use of medications and potential for medication error.

Inspectors wroteBased on interview and record review the facility failed to ensure accuracy of medical record for four of four sampled residents (Residents 24, 121, 29, and 69) when:1. Resident 24 had a physician's order to give an as needed lorazepam (a controlled substance used by calming the nervous system and reducing feelings of anxiety, fear, and worry) was created on 8/5/25 with a start date of 8/1/25, resulting in a four-day backdate (put an earlier date to a document than the actual one) without verification.2. Residents 24, 121, 29, and 69's controlled drug records (CDR) and medication administration record (MAR) did not match, and licensed nursing staff subsequently created late entry and back dated notes. [...]

Inspectors wroteBased on observation, interview and record review, for two of 27 sampled residents (Resident 40 and Resident 94), the facility failed to ensure their call lights were within reach. This failure had the potential to result in their inability to call for help. During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was admitted to the facility in September 2003 with diagnoses that included paraplegia (paralysis of the lower half of the body) and epilepsy (characterized by unprovoked seizures, loss of consciousness and sensory disturbances). [...]

Inspectors wroteBased on interview and record review, for one of three sampled residents for closed record review (Resident 132), the facility failed to ensure an effective discharge process when caregiver training and discharge notice were not provided in a timely manner. This failure had the potential to result in avoidable accidents and unsafe discharge. During a review of Resident 132's admission Record (AR), the AR indicated Resident 132 was admitted to the facility on [DATE] with diagnoses that included dislocation of the left knee, difficulty walking, dislocation of left hip prosthesis and the need for assistance with personal care. [...]

Inspectors wroteBased on observation, interview, and record review the skilled nursing facility's licensed nursing staff did not perform a complete assessment of 2 of 17 sampled residents (Residents 81 and 129) when:Assigned nursing staff were unable to explain why Resident 81 was grinding her teeth. Assigned nursing staff could not explain the necessity for a 1:1 sitter (aide with a resident around-the-clock) for Resident 129. This deficient practice had the potential to result in residents receiving inappropriate care or being unable to achieve established health care goals. Record review of the document admission Record showed the facility admitted Resident 81 on 12/8/2010. Diagnoses included Major Depressive Disorder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an environment free of accident hazards when one of three (Resident 67) sampled residents, Resident 67, who was on pureed diet, did not receive adequate supervision during meals. Resident 67 received and ate regular consistency food. This failure had the potential to result in choking and aspiration. During a review of Resident 67's admission Record (AR), the AR indicated Resident 67 was admitted to the facility in March 2025 with diagnoses that included dementia (decline in cognitive function, impaired memory, thinking and decision-making abilities severe enough to interfere with daily life) and dysphagia (difficulty swallowing). During a review of Resident 67's Order Summary Report (OSR) as of 8/7/25, the OSR indicated an order dated 6/3/25 for Resident 67 to have pureed texture with honey thick liquid, 1: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sample resident (Resident 24) was free from significant medication error when Resident 24 was given a psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication called lorazepam (drugs that helps calm the brain and reduce symptoms of anxiety) without a physician's order. This failure had the potential to result in unnecessary use of psychotropic medication, placing Resident 24 at risk for adverse consequences such as impairment or decline in Resident 24's mental or physical condition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control and prevention measures when Certified Nursing Assistant (CNA) 1 provided direct resident care inside an Enhanced Barrier Precaution room without adequate Personal Protective Equipment (PPE). This failure had the potential to spread infections. Definitions: Enhanced Barrier Precaution (EBP, refers to the use of gown and gloves during high-contact care activities that provide opportunities for transfer of Multi-Drug-Resistant Organisms/ MDRO.) MDROs are microorganisms, usually bacteria, that have developed resistance to one or more classes of antimicrobial agents (antibiotics and antifungals) to staff hands and clothing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse were reported to officials that included the State Survey Agency, Office of the Long-Term Care Ombudsman and law enforcement officials within the required timeframe for one of one sampled resident (Resident 1). This failure had the potential to result in the lack of protection for residents alleging abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of sexual assault was reported to officials that included the State Survey Agency, Office of the Long-Term Care Ombudsman and law enforcement officials within the required timeframe for one of two sampled residents (Resident 1). This failure had the potential to result in the lack of protection for residents alleging abuse.

Inspectors wroteBased on interviews and record review, the facility failed to provide account statement of residents ' spending, including transaction receipts, timely information on account access and available account balances for 4 out of 4 residents when facility did not notify residents or their conservators of the amount of funds in their personal accounts, track spending or submit quarterly report statements on time. This failure undermined Residents ' Rights to have informed and easy access to their funds for personal purchases they wish to make.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure staff prepared and served foods for residents in a sanitary manner. Specifically, staff failed to implement proper hand hygiene practices during meal service to prevent potential cross-contamination. This failure had the potential to affect 115 of 115 residents who received meals from the dietary department.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 2 (Resident #2 and Resident #86) of 24 sampled residents. Specifically, the facility failed to ensure Resident #2's visual status and Resident #86's nutritional status was accurately reflected on each resident's MDS assessment.

Inspectors wroteBased on interviews, record review, and facility document and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for 1 (Resident #45) of 5 sampled residents reviewed for PASRR requirements. Specifically, the facility failed to ensure a Level I PASRR Screening was resubmitted when Resident #45 remained in the facility longer than 30 days.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to monitor the implementation of physician prescribed fluid restrictions for 1 (Resident #178) of 3 sampled residents reviewed for nutrition. Specifically, Resident #178, who received renal dialysis, had a physician's order for a 1200 milliliter (mL) fluid restriction each day, and the facility failed to ensure the resident did not routinely exceed 1200 mL of fluids per day.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure an order for oxygen use was transcribed into the electronic health record (EHR) for 1 (Resident #178) of 1 sampled resident reviewed for respiratory care.

Inspectors wroteBased on observation, record review and interview, the facility failed to post nurse staffing data. This deficient practice prevented residents and visitors from receiving information about the number of nursing personnel available to provide direct care to residents.

Inspectors wrote3. A review of Resident 4's admission Record dated 5/20/21, indicated he was admitted to the facility in January 2021 with an included diagnosis of chronic obstructive pulmonary disease (a chronic respiratory disease which results in progressive difficulty breathing). During a review of the Minimum Data Set (MDS, an assessment tool used to guide care), dated 2/2/21, the MDS indicated Resident 4 required physical assistance from one person for toilet use and personal hygiene. During an observation on 5/17/21, at 12:17 p.m., Certified Nurse Assistant 2 (CNA 2) donned gloves outside Resident 4's room without performing hand hygiene, and immediately entered Resident 4's room and proceeded to provide direct care to Resident 4. During an interview on 5/17/21, at 12:20 p.m., with CNA 2, CNA 2 stated she had helped Resident 4 change clothes after toilet use. During an interview on 5/19/21, at 9: [...]

Inspectors wroteBased on interview and record review the facility failed to inform and provide information for one of three sampled residents (Resident 35) regarding the option to prepare an advance directive (a written statement of a person's wishes regarding medical treatment to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This deficient practice had the potential to result in Resident 35's wishes regarding medical treatment not being followed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one (Resident 217) of three sampled residents when the facility failed to have a physician-ordered bag mask valve (A bag mask valve, commonly called an Ambu bag, is a handheld tool that is used to deliver positive pressure ventilation to a person with insufficient or ineffective breathing.) available at Resident 217's bedside for emergency use. This failure had the potential to result in staff being unable to deliver necessary respiratory support to Resident 217 in the event of a respiratory emergency, potentially resulting in physical injury and/or death.