Inspection Reports for
Hill Haven Nursing Home

Multiple deficiencies were cited including failure to conduct required fingerprint background checks prior to employment for two employees, failure to timely report and thoroughly investigate an allegation of sexual abuse involving a resident, failure to develop comprehensive care plans for respiratory treatments for two residents, unsafe water temperatures in resident rooms, lack of an established water management plan, and improper labeling and storage of food items in the kitchen.

Multiple complaint intake numbers were investigated in conjunction with the recertification survey, including allegations of sexual abuse involving one resident (R59). The facility failed to timely report the allegation and conduct a thorough investigation.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to timely report and thoroughly investigate an allegation of sexual abuse, incomplete care plans for respiratory treatments, unsafe water temperatures in resident rooms, improper storage of respiratory equipment, unlabeled and improperly stored food items, and lack of a water management program.

The facility was found not in substantial compliance with emergency preparedness and life safety code requirements. Deficiencies included lack of documentation for emergency preparedness exercises, failure to update emergency plans annually, improperly maintained means of egress, non-functioning exit signs, hazardous storage conditions, fire alarm and sprinkler system maintenance issues, missing smoke detection in corridors, improperly maintained fire extinguishers, resident room door latch issues, electrical hazards, obstructed ventilation, incomplete fire drill documentation, and malfunctioning emergency lighting.

The facility failed to report an injury of unknown origin involving a resident with a closed fracture of the right distal femur within the required two-hour timeframe and did not investigate the allegation of injury of unknown origin, potentially risking other residents' safety.

The complaint investigation found multiple complaint intake numbers unsubstantiated. Complaint Intake Numbers GA00238318 and GA00235907 were substantiated with no deficiencies cited. Complaint Intake Number GA00231422 was substantiated with regulatory deficiencies cited related to failure to report and investigate an injury of unknown origin for Resident R12.

The investigation found several complaints unsubstantiated, two substantiated with no deficiencies cited, and one substantiated with regulatory deficiencies cited. The facility failed to report an injury of unknown origin for one resident (R12) and failed to investigate the allegation of injury of unknown origin properly.

The facility failed to report complete COVID-19 information to the CDC's NHSN between 08/07/2023 and 08/13/2023 as required by regulation, which has the potential to cause more than minimal harm to residents.

The facility did not report complete COVID-19 data to the NHSN between 07/31/2023 and 08/06/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.

The facility failed to report complete COVID-19 information to the CDC's NHSN between 07/24/2023 and 07/30/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.

All previously cited survey tags have been corrected except for the failure to have a copy of the five year fire sprinkler system internal inspection documentation on site, which affects the probability of sprinkler system malfunction in case of fire.

The facility failed to employ a certified Dietary Manager and did not document temperatures for all foods on the steam table or dish machine temperatures, which could negatively impact food quality and cleanliness for all 60 residents.

Complaint Intake Number GA00226149 was investigated in conjunction with the standard survey.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide written transfer/discharge notices and bed hold policy notices to residents and representatives, inappropriate use and documentation of PRN psychotropic medications, lack of certified dietary manager, incomplete food temperature documentation, and incomplete staff training on abuse, neglect, and dementia.

The facility was found not in substantial compliance with emergency preparedness requirements and life safety codes. Deficiencies included failure to update emergency preparedness policies annually, obstructed egress corridors due to wheelchairs and lifts, lack of documentation for fire alarm sensitivity testing, missing five-year internal inspection/testing records for the sprinkler system, incomplete fire drill documentation, and a missing smoke/fire blanket in the designated smoking area.

Complaint Intake Numbers GA00201921 and GA00201951 were investigated in conjunction with the licensure survey.

The facility failed to ensure all components of the nurse call system were fully functional in eight of 63 resident shared rooms, and lacked an effective monitoring system to identify call light issues. Multiple call light logs showed ongoing unresolved issues, and residents affected were not consistently provided secondary means to call for assistance.

Complaint Intake Numbers GA00201921 and GA00201951 were investigated in conjunction with the standard survey.

The facility failed to ensure that all components of the nurse call system in eight of 63 resident shared rooms were fully functional and lacked an effective monitoring system to identify call light issues. Multiple call lights were not working over several months, and secondary means of alerting staff were inconsistently provided.

The facility was found not in substantial compliance due to failure to follow adopted smoking regulations, including lack of approved ashtrays and improper disposal of cigarette butts in combustible trash containers.

The facility was found not in substantial compliance with life safety requirements, including improper locking mechanisms on egress doors, non-functioning emergency lighting, missing fire alarm strobes in certain restrooms, and inadequate smoking area fire safety equipment.

The facility was found not in substantial compliance with fire safety requirements, including improper maintenance of the fire alarm system, fire sprinkler system, portable fire extinguishers, rated walls and ceilings, electrical systems, and emergency lighting. Specific issues included pull stations mounted at incorrect heights, missing smoke detectors, lack of sensitivity testing, painted sprinkler heads, missing escutcheons, missing outlet covers, use of prohibited space heaters, and absence of emergency lighting in medication rooms.