The Hills Nursing & Rehabilitation

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.

Penalty

Inspection fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents during transportation, resulting in two separate incidents involving two residents. In the first incident, a female resident with diabetes, heart failure, and vision loss, who was cognitively intact and independent in her activities of daily living, was being transported in the facility van. The driver did not properly secure the resident's wheelchair, causing it to tip backward when the van accelerated. The resident reported hitting her head on the ramp and experiencing a headache, though she had a headache prior to the incident. The driver admitted to not fully securing the wheelchair and did not immediately report the incident to the Administrator, instead informing the nurse upon return to the facility. In the second incident, a male resident with kidney failure, diabetes, heart failure, and Parkinson's disease, who required minimal assistance with activities of daily living and used a wheelchair, was being unloaded from the facility van. The driver failed to secure the safety strap on the lift and lost her balance, falling onto the resident. This caused the resident's wheelchair to roll backward off the lift and tip over, resulting in the resident hitting his head on the ground and sustaining a scalp abrasion. The driver had previously received in-service training on transport procedures but did not follow the required protocols during this incident. Both incidents were attributed to staff failing to follow established procedures for securing residents and their wheelchairs during transport. In both cases, the drivers had received prior training on transport safety but did not adhere to the protocols, leading to the residents being placed at risk for injury. The facility did not have a specific policy for transporting residents and relied on the company's driver training manual.

Penalty

Inspection fine: $20,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The resident, who had a diagnosis of cerebral palsy, was at increased risk for constipation. However, the facility did not address this risk in the resident's care plan, leading to a lack of awareness among staff about the resident's risk factors for constipation. As a result of this oversight, the resident experienced a fecal impaction of the rectum with associated stercoral colitis, a rare inflammatory condition caused by impacted fecal material. The resident's medical records indicated that he had not had a bowel movement for several days, and the facility staff did not administer the prescribed medication for constipation during this period. The resident was eventually transferred to the hospital due to a change in condition, where he was diagnosed with severe constipation and fecal impaction. Interviews with facility staff revealed that the resident's risk factors for constipation were not adequately communicated or addressed in the care plan. The Medical Director had provided standing orders for the treatment of constipation, but there was no evidence that these interventions were implemented or that the Medical Director was notified of the resident's change in condition. The facility's failure to develop and implement an appropriate care plan placed the resident at risk of serious harm.

Removal Plan

• All residents in the facility were assessed for risk of constipation or other bowel issues, comprehensive care plans updated to include interventions and monitoring by the DON and/or the ADON and/or the Regional Compliance Nurse.
• The Compliance Nurse in-serviced the Administrator, the DON, and ADON 1:1 on the following topics: all residents who are at risk of constipation will have an active care plan with interventions and monitoring; upon admission all residents will be assessed by a nurse on risk of constipation, history of constipation/fecal impaction, or other bowel related issues; upon admission the nurse will be responsible for developing and implementing the care plan of risk of constipation based upon their assessment; the DON and/or the ADON/and/or the Designee will monitor care plans to ensure all resident care plans reflect their risk of constipation or other bowel issues; the DON and/or the ADON/and/or the Designee will monitor admission assessment to ensure all resident care plans reflect their risk of constipation or other bowel issues; upon admission, and as needed, all residents will be assessed for risk of constipation or other bowel issues. The care plan will reflect findings, interventions, and monitoring; in-service on care plan location and how to access the care plan in software.
• The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the following topics: all residents who are at risk of constipation will have an active care plan with interventions and monitoring; upon admission all residents will be assessed by a nurse on risk of constipation, history of constipation/fecal impaction, or other bowel related issues; the DON and/or the ADON and/or the Designee will monitor care plans to ensure all resident care plans reflect their risk of constipation or other bowel issues; ensure all resident care plans reflect their risk of constipation or other bowel issues; upon admission, and as needed, all residents will be assessed for risk of constipation or other bowel issues. The care plan will reflect findings, interventions, and monitoring; in-service on care plan location and how to access the care plan in facility software.
• The DON, the ADON, and the Regional Compliance Nurse in-serviced the non-licensed staff on the following: in-service on care plan location and how to access the care plan in facility software; all residents who are at risk of constipation will have an active care plan with interventions and monitoring.
• AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse.
• The QAPI committee will review findings and make changes as needed.
• Admitting nurse will assess all new residents for risk of constipation and/or bowel complications.
• All residents at risk of bowel complications will have a care plan with interventions and goals developed upon admission.
• The MDS Coordinator will review care plans with the interdisciplinary team at the resident's quarter care plan meetings and make necessary changes to the care plan.
• Care Plans will be monitored by the DON and/or the ADON to ensure that changes are updated quarterly and as needed.
• Licensed and Non-licensed staff know how to review residents' care plans in the facility software and will review resident's care plans for risk of constipation and monitor for risk of constipation.

Penalty

Inspection fine: $20,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, who was at increased risk for constipation due to cerebral palsy, received appropriate monitoring and interventions for bowel activity. Despite having a comprehensive care plan, the resident did not have measures in place to monitor bowel movements, and physician-ordered interventions were not implemented when the resident did not have a bowel movement within 72 hours. This oversight resulted in the resident being diagnosed with fecal impaction and stercoral colitis after being transferred to the hospital. Interviews and record reviews revealed that the facility's software system, which was supposed to flag when a resident had not had a bowel movement in 72 hours, did not alert staff. Consequently, the aides and nurses did not report or address the resident's lack of bowel movements. The resident's care plan did not include a bowel toileting program, and the resident was always incontinent of bowel, which contributed to the oversight. Staff interviews indicated a reliance on the software system to trigger alerts, and there was a lack of communication and follow-up among staff regarding the resident's bowel movements. The facility's policies required that if a resident did not have a bowel movement within 72 hours, the aides were to report it to the charge nurse, and an as-needed medication for constipation should be administered. However, this protocol was not followed, and the resident's condition went unaddressed until the family requested a hospital transfer. The failure to monitor and implement physician-ordered interventions placed the resident at risk of serious harm, leading to the identification of an Immediate Jeopardy situation.

Removal Plan

• The Compliance Nurse in-serviced the Administrator, the DON, and the ADON on the use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements, Nurses will document Interventions in the facility software.
• Promptly and correctly assessing a resident when a change of condition has been identified or reported using a SBAR tool so that all necessary information is communicated to the physician or nurse practitioner.
• In-service on Abuse and Neglect Policy.
• Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards.
• Residents who have not had a bowel movement will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported.
• In-service on potential complications of Bowel constipation.
• All residents who are at risk of constipation will have an active care plan with interventions and monitoring.
• If the nurse does not assess timely, the DON is to be notified.
• Accurate and timely documentation in the facility software, including resident bowel movement.
• The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements, Nurses will document Interventions in the facility software.
• The DON, the ADON, and Regional Compliance Nurse in-serviced the non-licensed staff on reporting changes in a resident's condition to a nurse immediately, including when a resident has not had a bowel movement.
• AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse.
• The QAPI committee will review findings and make changes as needed.
• Nursing Administration will monitor all residents at risk for bowel complications.
• CNAs will monitor residents for no bowel movements and notify nurses and document it in the facility software.
• Nurses will monitor the software dashboard for clinical alerts.
• Nurses will contact the physician when a resident has a change in condition.
• Nurses will provide a resident with an intervention medication if the resident has not had a bowel movement.

Penalty

Inspection fine: $20,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, who was at increased risk for constipation due to cerebral palsy, was administered the physician-ordered Bisacodyl Rectal Suppository. The resident had only one bowel movement between February 11 and February 26, leading to a diagnosis of fecal impaction with associated stercoral colitis at the hospital. This condition is a rare inflammatory colitis caused by impacted fecal material leading to colon distention and hardened stool formation. Interviews and record reviews revealed that the facility's software system was supposed to flag a warning if a resident went 72 hours without a bowel movement. However, the system did not alert the staff, and the aides did not report the lack of bowel movements to the charge nurse. The resident's aides and nurses did not recall seeing any warning or being informed about the resident's lack of bowel movements, despite the facility's policy requiring notification to the charge nurse if a resident did not have a bowel movement within 72 hours. The resident's condition was not adequately monitored, and the necessary interventions were not provided, resulting in the resident being transferred to the hospital due to a change in condition. The facility's failure to monitor and address the resident's bowel movements placed the resident at risk of serious harm, as evidenced by the hospital diagnosis of severe constipation and fecal impaction.

Removal Plan

• The Compliance Nurse in-serviced the Administrator, the DON, and the ADON 1:1 on the use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements, Nurses will document Interventions in the facility software.
• Promptly and correctly assessing a resident when a change of condition has been identified or reported using a SBAR (Situation, Background, Assessment, Recommendations tool) so that all necessary information is communicated to the physician or nurse practitioner.
• Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards.
• Residents who have not had a bowel movement will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported.
• All residents who are at risk of constipation will have an active care plan with interventions and monitoring.
• If the nurse does not assess timely, the DON is to be notified.
• Accurate and timely documentation in the facility software, including resident bowel movement.
• The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the following topics: Abuse/Neglect Policy, the use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements, Nurses will document Interventions in the facility software, promptly and correctly assessing a resident when a change of condition has been identified or reported using a SBAR, reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards, residents who have not had a bowel movement will be assessed for constipation and offered PRN interventions, potential complications of Bowel constipation, all residents who are at risk of constipation will have an active care plan.
• The DON, ADON, and Regional Compliance Nurse in-serviced the non-licensed staff on the following: Abuse/Neglect Policy, reporting changes in a resident's condition to a nurse immediately, including when a resident has not had a bowel movement, if the nurse does not assess timely, the DON is to be notified, accurate and timely documentation in the facility software, including resident bowel movements.
• AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse.
• The QAPI committee will review findings and make changes as needed.
• Nursing Administration will monitor all residents at risk for bowel complications.
• CNAs will monitor residents for no bowel movements and notify nurses and document it in the facility software.
• Nurses will monitor the software dashboard for clinical alerts.
• Nurses will contact the physician when a resident has a change in condition.
• Nurses will provide a resident with an intervention medication if the resident has not had a bowel movement.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately notify a resident's representative when there was a need to alter treatment. Specifically, the facility did not inform the representative of a resident when the medication Pramipexole was added to the resident's drug regimen to treat restless leg syndrome. The resident, a female with a moderately impaired cognition, was on multiple medications for various conditions, including coronary artery disease, high blood pressure, hemiplegia, anxiety disorder, depression, and pain. Despite the addition of Pramipexole to her treatment plan, there was no documented evidence that the resident's responsible party was informed of this change. Interviews with facility staff revealed a lack of communication and documentation regarding the notification of the resident's family about the new medication. The LVN who entered the medication order did not contact the family, citing the late hour as a reason, and expected the morning shift nurse to do so. However, the morning shift nurse did not recall being instructed to notify the family and did not document any such communication. The Assistant Director of Nursing (ADON) was unaware that the family had not been contacted and emphasized the importance of documenting such notifications as part of compliance. The facility's policy required timely notification of any resident change to the family, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety in its only kitchen, specifically in the storage of pork chops in the facility freezer. During an observation, it was noted that the pork chops were stored uncovered in a labeled metal pan, which is against the facility's policy. This oversight was confirmed through interviews with staff members, who acknowledged the importance of covering food to prevent contamination and the potential risk of foodborne illness to residents. Interviews with the staff, including a dietary manager, revealed that all items in the facility's refrigerators and freezers should be covered, labeled, and dated to prevent contamination. The dietary manager confirmed that the pork chops should have been covered according to facility policy, which mandates that open packages of food be stored in closed containers or sealed bags and dated. The dietary department had been in-serviced on food storage about a month and a half prior to the observation, indicating a lapse in adherence to the established procedures.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was treated with respect and dignity by not allowing him to keep his electric wheelchair upon admission. The resident, who had a history of heart disease, end-stage renal disease, and stroke, was admitted with an electric wheelchair but was provided with a manual wheelchair instead. The resident expressed that he was told it was against the rules to have an electric wheelchair unless he passed a test, which he was never given. The facility's records indicated that the electric wheelchair was deemed unnecessary, and the resident was able to use a manual wheelchair with his legs. Interviews with the resident's family member and facility staff revealed that the resident was not assessed for the use of his electric wheelchair, despite the facility's usual practice of assessing residents for safety. The Director of Rehabilitation, who was new to the facility, was unaware of the resident's previous use of an electric wheelchair and confirmed that no assessment had been conducted. The Assistant Director of Nursing also could not recall the circumstances surrounding the decision but acknowledged that residents are typically assessed for electric wheelchair use. The facility's Resident Rights policy emphasizes treating residents with respect and dignity, which was not upheld in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident requiring dialysis received appropriate post-dialysis assessments, consistent with professional standards of practice. Specifically, the facility did not complete post-dialysis assessments for a resident, identified as Resident #47, after returning from dialysis treatments. The resident, a female with a history of encephalopathy, end-stage renal disease, acute kidney failure, fluid overload, and difficulty in walking, was admitted to the facility and required hemodialysis three times a week. The care plan for the resident included monitoring for complications from dialysis, obtaining vital signs, and documenting weights before and after dialysis sessions. However, record reviews revealed that the facility failed to document pre-dialysis weights on multiple occasions and post-dialysis weights on another occasion. Interviews with facility staff, including an LVN, the ADON, and the Regional Clinical Consultant, confirmed that it was the responsibility of the charge nurse to ensure that vital signs and weights were documented before and after dialysis. The staff acknowledged the importance of these assessments in determining the amount of fluid removed during dialysis and the potential health risks if not properly monitored. The facility's current dialysis policy also required documentation of vital signs and other relevant data upon the resident's return from dialysis, which was not consistently followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with the Hall C Medication Cart. On the morning of November 19, 2024, the medication cart was left unlocked and unattended for approximately two minutes outside the dining room. This cart contained around 100 different types of medications, including antihypertensives, anticonvulsants, and anticoagulants, which were accessible to anyone passing by. Although the narcotics were secured in a separately locked drawer, the rest of the medications were not properly secured, posing a risk of misappropriation or accidental ingestion. The incident occurred when MA A, a medication aide who had been working at the facility for about a year, left the cart unlocked while administering medications to a resident in the dining room. MA A acknowledged the oversight, stating that she typically locks the cart to prevent unauthorized access, especially considering the presence of dementia patients who might inadvertently take medications. The Director of Nursing (DON) was informed of the incident and confirmed that the facility's policy requires medication carts to be locked when not in view to ensure the security of medications.