Tower Hill Healthcare Center

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents that were cognitively impaired were free from physical abuse. This applies to 2 of 10 residents (R2 and R4) reviewed for physical abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve a resident with multiple sclerosis and dementia hot coffee in a safe manner for 1 of 6 residents (R1) reviewed for safety in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident, who was at risk for skin breakdown, was kept clean and dry, and did not develop a pressure ulcer. This failure resulted in the development of a stage 2 pressure ulcer to the resident's buttock. This applies to 1 or 3 residents (R1) reviewed for improper nursing care in the sample of 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident, who was at risk for skin breakdown, was kept clean and dry. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to ensure a grievance was reported and resolved for a resident's missing items. This applies to 1 of 10 residents (R5) reviewed for grievances in the sample of 10.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from physical abuse for 2 of 8 residents (R1, R3) reviewed for abuse in the sample of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from physical abuse. This applies to 3 of 4 residents (R2, R4, R5) reviewed for abuse in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was transported via wheelchair in a manner to prevent a resident fall for 1 (R5) of 3 residents reviewed for safety and supervision in the sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to ensure antidepressant medication was obtained from the pharmacy in a timely manner to prevent a resident from missing medication doses as ordered by the physician. This applies to 1 of 3 residents (R1) reviewed for quality of care in the area of missing antidepressant medications in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse between two residents. This applies to 2 of 4 residents (R1, R2) reviewed for abuse in a sample of 5.

Inspectors wroteBased on interview and record review the facility failed to complete neurological assessments following a fall. This applies to 1 of 3 (R1) resident reviewed for falls.

Inspectors wroteBased on interview and record review the facility failed to maintain a residents dignity by not answering a call light in a timely manner for 1 of 3 residents (R1) reviewed for dignity and resident rights in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were prevented from having access to a room where medical equipment in need of repair was being stored. This applies to 1 of 3 residents (R4) reviewed for accidents in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to have protocols in place to utilize an assessment tool or management algorithm for residents who may receive antibiotics. This applies to all 166 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare mechanical soft consistency diets for residents that had a diet order for the same. This applies to 4 of 4 residents (R27, R108, R111, R136) reviewed for dining in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide grooming assistance for residents that needed extensive assistance from staff. This applies to 2 of 5 residents (R3, R58) reviewed for ADLs (activities of daily living) in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to change residents' central venous catheter dressing in a timely manner to prevent the spread of infection. This applies to 2 of 2 residents (R310 and R309) reviewed for intravenous catheter dressing changes in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage a resident's complaint of severe pain. This applies to 1 of 3 residents (R41) reviewed for pain in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain central venous catheter dialysis access site in accordance with infection control standards and their policy. This applies to 1 of 4 residents (R119) reviewed for dialysis in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to follow their policy to have the physician respond in a timely manner to the pharmacist's monthly Medication Regimen Review recommendations. The facility also failed to follow their policy to conduct monthly Medication Regimen Reviews for a resident. This applies to 3 of 5 residents (R39, R122, and R128) reviewed for unnecessary medications in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to attempt gradual dose reductions for residents receiving psychotropic medications. This applies to 3 of 5 residents (R73, R91, and R128) reviewed for unnecessary medications in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to use scoop size as shown for pureed diets as shown on menu. This applies to 3 of 3 residents (R14, R65, R90) reviewed for dining in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with a pureed diet per physician orders. This applies to 1 of 3 residents (R14) reviewed for pureed diets in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies for norovirus, contact precautions, and enhanced barrier precautions. This applies to 3 of 33 residents (R7, R14, and R124) reviewed for infection control in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse between two residents. This applies to 2 of 4 residents (R1, R2) reviewed for abuse in a sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to safely transfer a resident through a mechanical lift from her wheelchair to her bed. This resulted in R1 having a fall. This applies to 1 of 3 residents (R1) reviewed for transfers in a sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow current standards of infection control during a pressure dressing change. This applies to 2 of 2 residents (R6, R7) reviewed for infection control in a sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse of a resident residing at the facility. This applies to 1 of 6 residents (R3) reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to prevent the physical abuse of a resident residing at the facility per facility policy. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve lunch palatable and at a safe and appetizing temperature. This applies to all 154 residents consuming food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with a clean, comfortable, home-like interior. This applies to 2 of 6 residents (R1 and R2) reviewed for the sanitary, comfortable, home-like environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect residents from abuse per their facility abuse prevention program. This applies to 3 of 4 residents (R1, R3 and R4) reviewed for abuse in the sample of 6. The failure resulted in R1 experiencing ongoing head, neck and shoulder pain as a result of R2 hitting R1.

Inspectors wroteBased on interview and record review, the facility failed to have physician document the necessity of immediate transfer. This applies to 1 of 5 residents (R4) reviewed for transfer/discharge in a sample of 5. The Findings Include: R4 was a [AGE] year-old male admitted on [DATE], with an admitting diagnosis, including dementia, anxiety, mental disorder, depression, and Alzheimer's. A record review of the clinical progress note, dated 3/14/24, documents R4 was involuntarily discharged to the hospital due to aggressive behavior towards another resident. A record review of the clinical documentation indicates there is no evidence of any physician documentation to reflect the necessity of the transfer on 3/13/24. On 4/5/24 at 12:10 PM, V17 (Nurse Practitioner/Attending) stated, The Psychiatrist is supposed to document the necessity of the immediate transfer. [...]

Inspectors wroteB. Based on observation, interview, and record review, the facility failed to ensure a resident was free from sexual abuse (R61), and failed to ensure residents were free from verbal abuse (R80 and R52), for 3 of 32 resident reviewed for abuse in the sample of 32. 1. The Facility Reported Incident (FRI) as Final Report, dated 3/5/24 with date of incident as 3/1/24, shows (R61) was observed to have his hand on (R132's) breast. Both residents were on 2nd floor. (R132) was up and about, while (R61) was sitting in his wheelchair able to wheel himself around. Both were in the nurse station on 2nd floor, several staff were behind the nurses station documenting. Upon looking, it was observed that (R61) had his hand on (R132's) left breast. Upon observation, staff immediately intervened and separated the two residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their abuse policy and procedure by not protecting R102 from abuse by not removing a staff members who's observed actions were suspected to be abusive, and not performing a full body assessment of a resident who was suspected of being abused for 1 of 36 residents (R102) reviewed for abuse in the sample of 36. The Immediate Jeopardy began on 03/09/2024 at 12:30AM, when V38, CNA-Certified Nursing Assistant, failed to report her suspicion of abuse when she observed V37, CNA, becoming aggressive, grabbing R102's hands and pinning them down to R102's chest, resulting in R102 being abused by V37, CNA, at 5:30AM. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately report a suspicion of physical abuse for 1 of 36 residents (R102), and failed to ensure and allegation of verbal abuse was immediately reported for 1 of 32 residents (R80) reviewed for abuse in the sample of 36. The Immediate Jeopardy began on 03/09/2024 at 12:30AM, when V38, CNA-Certified Nursing Assistant, failed to report her suspicion of abuse when she observed V37, CNA, becoming aggressive, grabbing R102's hands and pinning them down to R102's chest, resulting in R102 being abused by V37, CNA, at 5:30AM. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and identify a sacral pressure injury for R13, failed to assess and identify a pressure injury to left heel and left elbow for R73,and failed to ensure a wound did not get worse to 3 of 7 residents (R13, R73 and R31) reviewed for pressure injury in the sample of 32. This failure resulted in R13 having a stage 3 acquired pressure injury, and R73 having a deep tissue injury (DTI).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's menu for pureed diets and failed to served the correct serving size for the lunch meal. This failure has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a three compartment sink was maintained at the correct concentration and failed to ensure hair restraints were worn. This failure has the potential to affect all residents residing in the facility. The facility's Application for Medicare and Medicaid dated March 11, 2024 shows the facility census was 141. 1. On 3/11/24 at 9:48 AM, V51 was washing pots, pans, and other various dishes via a three compartment sink. At 10:11 AM, V51 used a test strip to test the sanitation level in the third compartment. The sanitizing solution measure 50 PPM. V51 said it should read 200 PPM. V51 said the water was too cold. V51 said the sanitizing solution won't read properly if the water is too cold. On 3/12/24 at 1:33 PM, V4, Dietary Manager, said the sanitizing solution should ready between 100-200 PPM. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide oral care to a resident requiring extensive assistance with activities of daily living (ADLs). This applies to 1 of 32 (R31) reviewed for ADLs in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to assess, notify the physician, and implement treatment interventions for a resident with a new skin alteration for 1 of 27 residents (R392) reviewed for quality of care in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a device was applied to a contracted hand to 1 of 5 residents (R73) reviewed for range of motion in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to safely transfer a resident resulting in a fall. This applies to 1 of 4 residents (R75) reviewed for safety in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to ensure dietary interventions were initiated for 1 of 5 residents (R243) reviewed for significant weight loss in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a residents medication was received from pharmacy for 1 of 27 residents (R136) reviewed for pharmacy services in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident food preferences and provide an alternative based on their preferences for 3 of 27 residents (R50, R11 and R242) reviewed for food preferences in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to complete an ordered speech therapy evaluation, and failed to offer therapy services to a newly admitted resident. This applies to 2 of 3 (R75, R242) reviewed for speech therapy services in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to follow podiatry recommendations for routine podiatry care for a resident. This applies to 1 of 3 residents (R1) reviewed for foot care in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to a resident who requires assistance, and failed to provide two showers a week as ordered. This applies to 2 of 3 residents (R13,R84) in the sample of 26 reviewed for ADL's.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a pressure injury prior to becoming a stage 2, failed to perform weekly assessments for a pressure injury, and failed to reposition residents with pressure injuries for 2 of 6 residents (R125, R23) reviewed for pressure injuries in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement restorative therapy interventions. This applies to 1 of 3 (R83) residents reviewed for restorative services in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to, following a resident's 40 pound weight loss, notify the resident's physician of the registered Dietitians recommendation to increase her tube feeding rate; and failed to re-weigh a resident per the Dietitian's request. This applies to 1 of 8 residents (R27) reviewed for weight loss in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered before being signed out, and failed observe a resident to ensure medications were taken for 2 of 6 residents (R53, R13) reviewed for medication administration in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinence care was provided in a manner to prevent cross contamination for 2 of 26 residents (R53, R5) reviewed for infection control in the sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to address the pneumonia vaccine for 1 of 5 residents (R28) reviewed for vaccines in the sample of 26.