The Hills Nursing & Rehabilitation

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 residents (Resident #1) reviewed for change of condition. The facility staff failed to notify the NP or Physician when Resident #1 began to have a change of condition on [DATE] when he experienced lethargy, clammy skin, was unable to verbally talk to staff, and did not appear to be himself. Resident #1 continued to have a change of condition until [DATE] when he was sent to the hospital and passed away. The noncompliance was identified as past non-compliance. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered- care plan, and the resident's choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to assess and follow-up on Resident #1's change of condition which began on [DATE] when he experienced lethargy, clammy skin, was unable to verbally talk to staff, and did not appear to be himself. Resident #1 was found on [DATE] around 4 PM by staff to have shortness of breath and appeared to be in distress where he was sent to the hospital and passed away. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal care for 2 of 8 residents (Residents #13, and 55) reviewed for ADL care. The facility failed to ensure nail care, to include trimming and cleaning, was provided to Residents #13, and #55. The failure placed the residents at risk of hygiene and safety risks such as nail tearing, injury, and functional difficulties.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #86) and 1 of 3 staff (HA C) reviewed for infection control. 1. A medical equipment provider failed to put on PPE prior to entering Resident #86's room, while the resident was on isolation for COVID-19. 2. The facility failed to ensure HA C performed hand hygiene between residents while passing meal trays on E Hall. This failure could place residents at risk of being infected by staff/providers in contact with other residents with infections.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #12) reviewed for care plans. The facility failed to ensure Resident #12's comprehensive care plan was updated to reflect his G-tube was changed in-house, as required. This failure could place the residents at risk of not receiving the necessary care and services needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #61) of three residents reviewed for pressure ulcers. The Wound Care Nurse failed to re-clean the wound to Resident #61's right heel after she put his foot down on the bed with the wound exposed to the drawsheet under the resident. This failure could place residents at risk for deterioration of existing wounds/skin injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for three of six residents (Residents #1, #3 and #2) reviewed for abuse.1. The facility failed to ensure Resident #3 did not kiss Resident #1 without her consent on 05/23/25.2. The facility failed to ensure LVN G did not yell at Resident #2. These failures could place residents at risk for injury or psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (Residents #1 and #2) reviewed for accidents. 1. Driver A failed to secure Resident#1's wheelchair properly in the van, resulting in the resident hitting her head when the wheelchair tipped backwards during transport on 03/18/25. The resident was sent to the hospital but did not have any injuries. 2. Driver B failed to secure the safety strap on the lift when Resident #2 was being lowered. Driver B fell onto Resident #2 causing him to tip backwards in his wheelchair and hitting his head on the ground on 04/07/25. The resident was sent to the hospital where he was found to have an abrasion on his scalp but no serious injury. The noncompliance was identified as past noncompliance. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 10 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a care plan for Resident #1 to address him being at risk for constipation which he was at increased risk for due to his diagnosis of cerebral palsy. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that received residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the comprehensive assessment of a resident for 1 of 10 residents (Resident #1) reviewed for quality of care. The facility failed ensure Resident #1, who was at increased risk for constipation due to having cerebral palsy, had measures in place to monitor his bowel activity and to ensure physician ordered interventions were implemented when the resident did not have a bowel movement within 72 hours. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents are free of any significant medication errors for 1 of 10 residents (Resident #1) reviewed for medications. The facility failed ensure Resident #1, who was at increased risk for constipation due to having cerebral palsy, was administered his physician-ordered Bisacodyl Rectal Suppository when he had only one bowel movement between 02/11/25 and 02/26/25. This failure resulted in the resident being diagnosed in the hospital with fecal impaction of the rectum with associated stercoral colitis, which is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually hardened stool formation. Prior to the hospitilization, the resident had only had one bowel movement between 02/11/25 and 02/26/25. An Immediate Jeopardy was identified on 03/13/25 at 10:00 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative when there was a need to alter treatment for 1 of 3 residents (Resident #1) reviewed for notification of change. The facility failed to notify Resident #1's representative when the medication, Pramipexole (Mirapex), was added to her drug regimen on 01/01/25 to treat restless leg syndrome. This failure could place residents at risk for a delay in treatment and not receiving proper care due to failure to notify resident representative.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare, store, distribute, and serve foods in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure pork chops stored in the facility freezer were covered to prevent contamination. This failure placed residents, who received food from the kitchen, at risk for food contamination and food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #3) reviewed for dignity. The facility failed to allow Residents #31 to keep his electric wheelchair when he admitted to the facility. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #47) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #47 after they returned from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care resulting in harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 4 medication carts (Hall C Medication Cart) reviewed for storage, in that: MA A failed to ensure the Hall C Medication cart was locked when she left it unattended for approximately two minutes. This deficient practice placed residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents comprehensive care plan was reviewed and revised after each assessment, including both the comprehensive and quarterly review assessments for 3 of 14 residents (Residents #5, #7 and #104) reviewed for care plans, in that: The facility failed to ensure Residents #5, #7, #104's selected resuscitaiton statuses were updated on their care plans. This deficient practice could affect residents at the facility and place them at-risk of their advanced directives not being honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #121 and #122) of ten residents observed during medication pass. Reviewed for infection control, in that: 1. Medication Aide C failed to clean the blood pressure wrist cuff after checking vitals of Residents #121 and #122. 2. Medication Aide C failed to disinfect the medication cart prior to it being used. These failures could affect the 4 residents on the Quarantine Hall who received medications by Medication Aide C by placing them at risk for spread of infection through cross-contamination of pathogens and illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 2 residents (Resident #12) reviewed for tube feeding. The facility failed to follow physician order's for Resident #12 when cleaning the resident's enteral stoma site by not applying a gauze dressing. This deficient practice could place residents who require enteral feedings at risk for weight loss, dehydration, metabolic abnormalities, and hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were provided with respiratory care consistent with professional standards for 1 of 6 residents (Residents #5) reviewed for respiratory care in that: Resident #5's humidifier bottle attached to the oxygen concentrator was empty and had not been changed since 09/17/23. These deficient practices could affect residents who received oxygen with inadequate oxygen support, infections and could result in a decline in health.