Hildebrand Care Center

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Have properly sized and located compartments to protect residents from smoke.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Resident Rights Deficiencies

Ensure residents have reasonable access to and privacy in their use of communication methods.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Smoke Deficiencies

Provide properly protected cooking facilities.

A complaint survey, prompted by #CO35592 was conducted from 4/16/24 - 4/17/24. One deficiency was cited. Based on record review and interviews, the facility failed to ensure one (#1) out of three sample residents received the care and services necessary to maintain her highest practicable level of well-being. Specifically, the facility failed to serve Resident #1 the correct physician-ordered mechanical soft texture diet which contributed to her mental and physical decline. Resident #1, who had a history of dysphagia (difficulty swallowing) and dementia, had a physician-ordered texture diet of mechanical soft. On 3/3/24, Resident #1 was served large pieces of steak, mashed potatoes, and a bread roll for dinner. The resident began choking in the dining room, the Heimlich maneuver (a first aid procedure utilized to dislodge an obstruction from the throat) was performed and emergency services were called. In the emergency room, a "large" piece of meat was dislodged from her trachea (the airway that leads from the vocal box to the lungs).The resident was admitted to the hospital for acute hypoxic (low levels of oxygen in the body' s tissues) respiratory failure due to choking. The resident' s mental status did not recover and she was unresponsive to verbal stimuli. She was diagnosed with severe acute hypoxic encephalopathy (a type of brain damage from lack of oxygen in the brain). Resident #1 returned to the facility under hospice care on 3/7/24 and passed away on 3/10/24 at the facility, seven days after the choking incident.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/16/24 to 4/17/24, resulting in the deficiency being cited as past noncompliance with a correction date of 3/6/24.I. Situation of serious harmThe facility failed to ensure Resident #1, who had a history of swallowing difficulties, was served the appropriate physician-ordered mechanical soft texture diet, which included ensuring food was chopped in small pieces and soft. This resulted in Resident #1 experiencing a choking episode in the dining room on 3/3/24.The facility' s failure to serv..

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:A complete written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was available during surveyNFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms.6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is one story, Type V (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1973 and is licensed for 80 beds. This re-certification survey conducted on December 11, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

A recertification survey was conducted from 11/13/23 - 11/16/23. Six deficiencies were cited. An Emergency Preparedness survey was conducted from 11/13/23 - 11/16/23. No deficiencies were cited. Based on interviews and record review, the facility failed to ensure one (#6) out of 31 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to document and provide a resolution to Resident #6' s missing item. Findings include: I. Facility policy and procedureThe Resident Grievance Policy, revised April 2018, was provided by the director of nursing (DON) on 11/16/23 at 2:00 p.m. It reve.. Based on observations and interviews the facility failed to ensure two out of two medication refrigerators stored narcotic medications in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications.Specifically, the facility failed to:-Ensure the treatment cart and medication cart was locked when left unattended; and -Ensure controlled medications were in a locked storage container that was perma.. Based on observations, record review and interviews, the facility failed to ensure one (#121) of three out of 31 sample residents received adequate supervision to prevent accidents.Specifically, the facility failed to agency staff were aware of Resident #121 ' s history and risk of elopement.Findings include:I. Facility policy and procedureThe Wandering and Elopement policy and procedure, reviewed May 2019, was provided by the director of nursing (DON) o.. Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#121) of one resident reviewed for visual problems out of 31 sample residents.Specifically, the facility failed to ensure Resident #121 was assisted to wear his glasses.Findings include:I. Resident #121 status Resident #121, age 53, was admitted on 10/26/23. According to the November 2023 computeriz.. Based on observations, record review and interviews, the facility failed to honor resident choices for one (#37) of one out of 31 sample residents.Specifically, the facility failed to ensure Resident #37 received anti-nausea medication in a timely manner upon request.Findings include:I. Facility policy and procedureThe Resident Self Determination and Participation policy and procedure, revised August 2022, was provided by the director of nursing (DON) on 11/16/22 .. Based on resident observations, record review, and staff interviews, the facility failed to ensure residents received respiratory treatment as ordered for two (#20 and #64) of two residents reviewed for supplemental oxygen use out of 31 sample residents. Specifically, the facility failed to ensure Resident #20 and Resident #64 received oxygen at the liter flow prescribed by the physician. Findings include: I. Facility policy and procedure The O..

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/23/2023 and 10/29/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/16/2023 and 10/22/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.