Miracle Hill Nursing & Rehabilitation Center, Inc

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to fully inform the residents of the risks and benefits and alternate treatment options for 1 of 3 residents sampled for the use of psychotropic medications (Resident #4).

Inspectors wroteBased on interviews and record review, the facility failed to ensure that staff administered medications ordered to treat a urinary tract infection for 2 of 3 residents reviewed after their return to the facility following hospitalization.(Residents #1 and #3)

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement the plan of care for 1 of 4 residents sampled for medication administration (Resident #3).

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that a resident was free from harm and neglect when it failed ensure that residents with diabetes mellitus receive their insulin and/or blood glucose monitoring as ordered for 1 of 16 residents diagnosed with diabetes mellitus. (Resident #90)

Inspectors wroteResident #50 On 6/02/25 at 1:17 PM, an interview was conducted with Resident #50. The resident looked disheveled and had her hair was unbrushed and oily. She stated she had only two showers since she was admitted to the facility. She further stated that both showers happened with Occupational Therapy (OT) staff members. A review of Resident #50's medical record was conducted. This resident was admitted on [DATE] with diagnoses that included needing assistance with Activities of Daily Living (ADL). The plan of care included ADL self-care deficit related to decreased functional mobility and activity tolerance and generalized weakness. Interventions included nursing staff providing ADL care to ensure daily needs. A review of documentation related to bathing indicated Resident #50 was scheduled for showers on Tuesdays, Thursdays, and Saturdays. [...]

Inspectors wroteroom [ROOM NUMBER] On 06/02/2025 during the tour of the facility, it was noted that the floor in room [ROOM NUMBER] was sticky and a dried brown substance was noted on the floor and wall of the room in the corner left side of the doorway facing the hallway. (Photographic evidence obtained) On 6/3/26 a follow up observation was made of room [ROOM NUMBER] at approximately 12:00 PM, which revealed the dried brown substance in the left corner of the doorway had been removed from the floor, however remained on the wall. On 6/4/25 at approximately 2:45 PM, another observation was made of room [ROOM NUMBER]. The wall remained with a dried brown substance and the floor remained sticky. An interview was conducted with Nurse B, a Licensed Practical Nurse (LPN), who was responsible for the residents on this hallway. [...]

Inspectors wroteBased upon record review and interviews, the facility failed to identify and properly code an assessment correctly upon admission to facility. (Resident #27)

Inspectors wroteBased on record reviews and interviews, the facility failed to forward a resident for a level 2 Preadmission Screening and Resident review (PASARR) for 1 of 2 residents residents sampled for PASARR. (Resident #51)

Inspectors wroteBased on record reviews and interviews, the facility failed to update the Preadmission Screening and Resident Review (PASARR) for 1 of 2 residents sampled for PASARR. (Resident #51)

Inspectors wroteResident #27 Resident #27 was admitted to facility on 04/22/25 with admitting diagnoses of End stage renal disease, dependence on renal dialysis, Type 2 diabetes with neuropathy, Atherosclerotic Heart disease, Chronic ischemic heart disease, Hypertension, Cardiac pacemaker, Cirrhosis of the liver, Heart Failure, AFIB, Osteoarthritis, and Pneumonia. Resident 27's plan of care revealed he has a risk for falls, complications of anticoagulant medication use, activity involvement, ADL self-care performance, potential for complications related to dialysis, potential for complications related to diabetes, and the potential for complications related to cardiovascular disease with a pacemaker. No goals or interventions are documented for each focus problem identified. An interview with Staff Member Q was conducted on 06/04/25 at 10:26 AM. [...]

Inspectors wroteBased upon interview, observation, and record review, the facility failed to consistently perform services to prevent pressure ulcers for 1 of 1 residents observed for pressure ulcers. (Resident #50)

Inspectors wroteBased upon record reviews, observations, and interviews, the facility failed to properly assess and provide services for 1 of 1 residents reviewed for range of mobility care. (Resident #40)

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide care and services for 2 out 2 residents receiving hemodialysis. (Resident #27 and #82)

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide medications as ordered for 2 of 5 residents observed during medication administration observations. (Resident #79 and #21)

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to store medications in accordance with currently accepted professional principles and include the appropriate expiration date when applicable for 2 of 2 medication carts reviewed for medication storage.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the Quality Assurance and Program Improvement Program (QAPI) identified and prioritized problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information and corrective actions addressed gaps in systems, and were evaluated for effectiveness. Specifically the facility failed to provide medications to meet the needs for 2 of 5 residents observed during medication administration observations. (Resident #79, and #21).

Inspectors wroteBased on record review and staff interview, the facility failed to provide documentation that 2 of 5 residents received education and were offered a Influenza immunizations. (Residents #41 and #83)

Inspectors wroteBased on record review and staff interview, the facility failed to provide documentation that 2 of 5 residents received education and were offered a COVID immunization. (Resident #83 and #44)

Inspectors wroteBased on observations, staff interview, document review, and policy review, the facility failed to maintain a fully functional resident call system in 4 of 8 sampled facility bedrooms. (Rooms 11, 36, 18, and 48)

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to follow pharmacy documentation procedures for administration of medications for 2 of 4 sampled residents receiving thyroid medications. (Resident #2 and #3)

Inspectors wroteOn 3/14/24, Resident # 68's Quarterly MDS, dated [DATE], showed in progress, to be completed by 1/1/24, resulting in the plan being 73 days overdue at the time of review. On 3/14/24, Resident # 53's Quarterly MDS, dated [DATE] showed in progress, to be completed by 2/27/24, resulting in the plan being 16 days overdue. An interview was conducted with the MDS Licensed Practical Nurse on 3/13/24 at 4:05 PM concerning all of the above issues. She confirmed the quarterly MDS reviews were not completed. She stated she was the only full-time employee completing MDS and care plans. A review of the undated facility policy for Care Plans revealed the resident assessment must be reviewed no less than once every 3 months. Resident #20 had a quarterly assessment initiated on 12/16/23 that was not completed by survey exit date on 3/14/24. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure comprehensive assessments (minimum data sets) were completed within 14 days of admission or within 14 days of a significant change of resident status for 3 of 29 sampled residents. (Resident #84, #148, and #150)

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure each resident assessment (minimum data set) accurately reflected the resident's status for 2 of 29 sampled residents. (resident numbers 30 and 55)

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan for 2 of 23 residents sampled. (Resident #32 and #49)

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to develop and implement an effective discharge plan that includes care giver support and referrals to local contact agencies in a timely manner for 1 of 1 residents sampled for discharge planning. (Resident #20)

Inspectors wroteBased on observation, interview, and policy review, the facility failed to store all drugs and biologicals in locked compartments for 2 of 27 observations of medication pass and storage conducted during the survey.