The Springs of Hillcrest

Inspectors wroteBased on interviews, record review, facility policy review, and documents it was determined the facility failed to ensure written notification provided to the resident, and or the residents representative of transfer/discharge to the hospital included all the required information when a resident was transferred to the hospital for two (2) (Resident #86, # 81) of three (3) sampled residents, reviewed for hospitalization. Based on record review, interview, and facility policy review, it was determined the facility failed to ensure written notification was provided to the resident and/or the resident's representative of transfer or discharge to the hospital. The facility also failed to ensure that the notification included all the required information for two (Residents #86 and # 81) of three residents reviewed. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, it was determined the facility failed to ensure wound care supplies available for use were not expired in 2 of 2 medication rooms. Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure wound care supplies available for use were not expired in two (Station #1, Station #2) of two medication rooms observed.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure serving items were properly covered; unused food items were kept away from used food items; the kitchen was free from buildup of unknown substances that had the potential to fall into food items to be served; equipment was in safe and useable condition; open food items were properly closed/sealed and had an open date; food items were not expired; food containers were put away without the contents being on the outside container; and the walls, floors, and door were in good repair without holes and or missing or chipped paint.

Inspectors wroteBased on observation, record review and interview, the facility to ensure the dignity and privacy of 2 (Residents #187 and #438) residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the rear casters/wheels were kept in the unlocked position when lifting and lowering residents when using a patient lift for 3 (Residents #11, #17, and #36) residents to prevent accidental falls and injury; failed to ensure damaged, or frayed lift pads were removed from service for 1 (Resident 17) resident who had an order for mechanical lift assistance; and failed to ensure chemicals were safely stored to prevent potential harm to 8 (Residents #5, #7, #8, #20, #26, #36, #56, #58) residents who ambulated or self-propelled in the facility.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that staff displayed competency in caring for residents on Enhanced Barrier Precautions (EBP), and how to use hygiene supplies according to the manufacturer ' s directions for 1 (Resident #41) sampled resident. This failed practice had the potential to affect any resident on EBP and/or dependent on staff for baths.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nebulizer treatments were not left at the bedside for the resident to self-administer for 2 (Resident #8 and #188) residents who were not assessed to be safe to self-administer nebulizer treatments; an unattended medication cart on the South Hall was locked on 1 of 1 observation to prevent misappropriation of resident medications; and a narcotic box containing controlled substances was kept and maintained securely behind two locks.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure respiratory mask tubing/nasal cannula tubing was stored in a manner to prevent infection and cross contamination for 2 (Residents #50 and #17) resident; denture brush was stored in a secure and sanitary manner for 1 (Resident #438) resident to prevent infections and cross contamination; staff wore proper Personal Protective Equipment (PPE) prior to providing care for 1 (Resident #41) resident on Enhanced Barrier Precautions (EBP); hand hygiene was performed during perineal care for 2 (Residents #11 and #36) to prevent cross contamination, and the facility failed to ensure dirty laundry was bagged and returned to the laundry room in a manner to prevent the spread of germs to all 85 residents who resided in the facility.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to protect the privacy and dignity of 1 (Resident 41) sampled resident when providing wound care.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the care plan included oxygen therapy and Continuous Positive Airway Pressure (CPAP) as ordered by a physician.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a leg strap was in place to prevent trauma from an indwelling catheter for 1 (Resident #438) of 8 sampled residents who were dependent on staff for indwelling catheter care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an altercation between two residents on the Secure Special Needs Unit. This failed practice resulted in actual harm for Resident #229 who received a laceration to her forehead requiring steri-strips and had the potential to cause more than minimal harm to 12 residents who resided on the Secure Special Needs Unit as documented on the Midnight Census Report provided by the Administrator on 07/03/23 at 9:31 AM.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was placed in the freezer per manufacturer instructions when received to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; kitchen vents were cleaned to provide a sanitary environment for food preparation, a storage shelf paint was peeling exposing the wood and the floor was chipped and dirty and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 79 residents who received meals from the kitchen (total census: 79), as documented on a list provided by the Dietary Supervisor on 07/05/23 at 12:30 PM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents seated at the same dining table received their meals at the same time to allow the residents to eat together and promote dignity and respect for 1 (Resident #47) resident who shared a meal table during lunch on 07/03/24. The failed practice had the potential to affect 10 residents who received dietary trays in the Dining Room as documented on a list provided by the Director of Nursing (DON) on 07/07/23 at 11:02 AM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 3 (Residents #3, #11 and #21); oxygen tubing was changed and labeled for 2 (Residents #3 and #11) and humidifier bottles were monitored and changed as needed for 1 (Resident #3) of 8 (Residents #3, #7, #11, #,19, #21, #25, #44 and #72) sampled residents who had Physician Orders for oxygen therapy. These failed practices had the potential to affect 27 residents who had Physician Orders for oxygen therapy as documented on a list provided by the Director of Nursing (DON) on 07/07/23 at 11:02 AM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 7 residents who received pureed diets, 12 residents who received mechanical soft diets and 60 residents who received regular diets from 1 of 1 kitchen (total census: 79) according to a list provided by the Dietary Supervisor on 07/05/23 at 12:30 PM.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 3 of 3 meals observed. The failed practice had the potential to affect 7 residents who received pureed diets as documented on a list provided by the Dietary Supervisor on 07/05/23.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure food storage, preparation and service areas were free of pests. This failed practice had the potential to affect 79 residents who received a meal tray from the kitchen as documented on a list provided by the Dietary Supervisor on 07/05/23 at 12:30 PM.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed to ensure a resident with mental health diagnoses received the necessary care and services in the most appropriate setting for 1 (Resident #75) of 2 (Residents #49 and #75) sampled residents who were screened for a Level II mental disorder or intellectual disability prior to admission.