Hillcrest Care Center

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Have an externally vented heating system.

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.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Quality of Life and Care Deficiencies

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

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Emergency Preparedness Deficiencies

Establish an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

Emergency Preparedness Deficiencies

Include a process for Emergency Preparedness collaboration.

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

Emergency Preparedness Deficiencies

Establish policies and procedures for medical documentation.

Emergency Preparedness Deficiencies

Establish policies and procedures for volunteers.

Emergency Preparedness Deficiencies

Establish roles under a Waiver declared by secretary.

Emergency Preparedness Deficiencies

Develop a communication plan.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

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.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

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

Environmental Deficiencies

Keep all essential equipment working safely.

Quality of Life and Care Deficiencies

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

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Assessment and Care Planning Deficiencies

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

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 a one-story, Type V (111) wood-framed structure. The facility is protected throughout the first floor by a wet fire sprinkler system and a dry-pipe system in the attic space and is classified as Fully Sprinkled. The facility was constructed in 2000 and is licensed for 45 beds. This re-certification survey conducted on October 16, 2024, was for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Ch.. STANDARD not met: Based on record review and documentation of inspection and testing of the non-hospital grade electrical outlets in patient care areas as required by sections 6.3.4.1.3 and 6.3.4.2.1.1 of NFPA 99, Health Care Facilities Code. This deficient practice could affect all residents, staff, and visitors throughout the facility if the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade were to fail due to lack of testing. No written test records of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care areas were condu.. STANDARD not met: Based on observation and staff interviews during the survey, it was determined that the facility needed to maintain the trans-filling of oxygen storage room ventilation per NFPA 99 - Health Care Facilities, 11.5.2.3. This deficient practice could affect all residents and staff within the facility should a fire emergency occur.The oxygen trans-filling room is not mechanically ventilated correctly per NFPA 99.9.3.7.5.3.1Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction.9.3.7.5.3.2Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 c.. The facility did not meet the standard as it failed to maintain emergency power systems according to section 19.2.9.1 of the Life Safety Code and the referenced 2010 NFPA 110, Section 8.3.7.1 Maintenance and Operational Testing. This failure could potentially impact all residents, staff, and visitors in the event of a power loss.At the time of the survey, no records were available to verify the monthly testing and recording of battery conductance testing in connection with the emergency power supply system (emergency generator).NFPA 110, Section 8.3.7. Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing .. The standard was not met. During the record review, it was determined that the facility did not comply with the corridor door requirements as outlined by NFPA 101 and NFPA 80 (2010). This deficiency could potentially impact occupants, including residents, staff, and visitors within the affected smoke compartments in the event of a fire emergency.No record of the fire door inspection, testing, or maintenance report being conducted annually.NFPA 101 4.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment,.. This standard is not met: Based on observations and staff interviews, it was determined that the facility failed to provide an adequate source of input ratings for appliances operating at elevations above 2,000 feet, in accordance with the National Fire Protection Association (NFPA) Life Safety Code and NFPA 54 Natural Gas Code. This deficiency could impact all residents and staff in the core smoke compartment if the natural gas-fueled heating equipment malfunctions due to improper settings.The orifices for cloth dryers are not sized correctly. According to the dryer data plate, they are currently set for 0-2000 feet at a rate of 4 percent for each 1000 ft. (300 m) above sea level.11.1.2 H..

A recertification survey was conducted from 9/30/24 to 10/3/24. Five deficiencies were cited. An Emergency Preparedness survey was conducted from 9/30/24 to 10/3/24. No deficiencies were cited. Based on observation, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services to prevent complications for one (#26) of one resident reviewed for tube feeding out of 23 sample residents.Specifically, the facility failed to ensure Resident #26' s physician' s orders were updated and accurate; and,-Ensure Resident #26' s feeding tube was flushed to maintain patency (prevent clogging). Findings include:I. Facility policy and procedureThe Appropriate Use of Feeding Tubes policy, revise.. Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen.Specifically, the facility failed to develop a maintenance program to ensure environmental concerns in the dish room, kitchen and serving area were identified and corrected in a timely manner.Findings include:I. Facility policy and procedureThe Maintenance Inspection policy, reviewed on 4/13/23, was provided by the nursing home administrator (NHA) on 10/2/24 at 12:21 p.m. The policy re.. Based on observations, record review and interviews, the facility failed to ensure residents were provided services that meet professional standards for one (#1) of five residents out of 23 sample residents.Specifically, the facility failed to ensure Resident #1' s insulin was administered according to the physician' s orders.Findings include:I. Facility policy and procedureThe Insulin Administration policy, revised September 2014, was provided by the nursing home administratior (NHA) on 10/2/24 at 12:32 p.m. The policy provided guidelines for the safe administration of insulin t.. Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.Specifically the facility failed to ensure residents were offered hand hygiene before meals in both the dining room and during the delivery of room trays.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention' s (CDC) Hand Hygiene in Healthcare settings, r.. Based on record review and interviews, the facility failed to ensure a Level II preadmission screening and resident review (PASRR) was completed for one (#27) of two residents out of 23 sample residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being.Specifically, the facility failed to ensure a Level II PASRR was in place for Resident #1.Findings include:I. Facility policy and procedureThe preadmission screening and resident review (PASRR) policy, reviewed in March 2018, was provided by the nursing home administrat..

A complaint survey, prompted by #CO36256, #CO36344 and #CO36345 was conducted on 7/16/24. One deficiency was cited. Based on observations, record review and interviews, the facility failed to address and/or act promptly upon the grievances and recommendations during resident council on issues of resident care and quality of life in the facility that were important to the residents.Specifically, the facility failed to ensure resident council grievances were addressed to resolve resident concerns related to residents being left in the dining room for up to an hour after meals, lack of staff in the dining room, inappropriate staff conversations, rude staff members and call light response times. Findings include:I. Facility policy The Resident and Family Grievance policy, dated 4/23/23, was received from the nursing home administrator (NHA) on 7/16/24 at 2:00 p.m. The policy documented in pertinent part,"Grievances may be voiced in the following forums: Verbal complaint during resident council meetings.All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgment of complaint grievances and actively working toward a resolution of that complaint grievance."In accordance with the residents' right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include, at a minimum, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident' s concern(s),any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued."II. Resident interviewResident #4 was interviewed on 7/16/24 at 9:27 a.m. Resident #4 said she attended the resident council meetings each month. Resident #4 said concerns brought up in the resident council meeting were not addressed by the facility. She said she had not received any follow up on the concerns rais..

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 08/28/2023 and 09/03/2023, 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 08/21/2023 and 08/27/2023, 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.