Hunter Hill Assisted Living

The facility failed to ensure physician orders for thrombo-embolic deterrent (TED) hose were properly implemented for 3 of 5 sampled residents. Specifically, for Resident #1, documentation showed periods where the hose were not worn, and physical observations revealed the hose were improperly applied or not worn at all during breakfast. Interviews with the resident confirmed that staff often failed to apply the hose correctly or consistently as ordered.

The facility failed to ensure physician orders were implemented for 3 of 5 sampled residents regarding the use of thrombo-embolic deterrent (TED) hose. Specifically, for Resident #1, documentation showed TED hose were not applied correctly, were documented as being off without explanation, and the resident was observed without them during breakfast.

The facility failed to ensure a proper referral and follow-up for a resident following a fall. This failure resulted in a delay of care for a resident who sustained a right femoral neck subcapital impaction fracture requiring a full hip replacement.

The facility failed to ensure a proper referral and follow-up for a resident following a fall, which resulted in a delay of care and a subsequent hip fracture. Although the resident refused hospital transport, the facility failed to call EMS to make a professional medical determination regarding the need for emergency treatment.

The facility failed to ensure proper contact and implementation of medication orders from the resident's physician. The Resident Care Director was unaware of a specific order for warm compresses, and there was a breakdown in the process of ensuring orders were communicated to the pharmacy and updated in the eMAR.

The facility failed to ensure physician orders were implemented for a resident, specifically regarding the use of warm compresses for an eye condition. There was no documentation of the treatment in the electronic medication administration record (eMAR), and the resident had not received the ordered treatment.

The facility failed to ensure physician orders were implemented and documented for a resident. Specifically, an order for warm compresses to be applied to a resident's left eye four times daily was not entered into the electronic medication administration record (eMAR) or performed.

The facility failed to ensure that one of three sampled medication aides had completed required training on the care of diabetic residents prior to administering insulin. Personnel records showed no documentation of this specific training, despite the staff member performing fingerstick blood sugars and insulin administration multiple times in April and May 2022.

The facility failed to complete a national criminal background check for one sampled staff member (Staff C). While a state check was performed, the administrator failed to realize a national check was required because the employee had recently moved from another state.

The facility failed to ensure that two of five sampled residents were properly tested for tuberculosis disease upon admission. Specifically, one resident lacked documentation of a second step TB skin test, and another resident's records showed no documentation of two skin tests administered within 12 months of each other.