Deficiencies (last 4 years)
Deficiencies (over 4 years)
30.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
663% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Routine
Deficiencies: 14
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, medication management, dietary services, and facility environment.
Findings
The facility was found deficient in multiple areas including environmental maintenance, care planning, personal hygiene, medication administration, IV care, respiratory care, dialysis care, pharmaceutical services, dietary services, medical record accuracy, infection control practices, and sanitation in the kitchen. Several residents were affected by these deficiencies, which posed risks for resident safety, health, and well-being.
Deficiencies (14)
Facility failed to maintain a comfortable and homelike environment including noise control and room repairs.
Failed to develop and revise comprehensive care plans for residents, including oxygen use and psychotropic medication changes.
Failed to provide adequate personal hygiene care, including nail care, resulting in self-inflicted scratches.
Failed to provide prescribed amount of fluids with meals for a resident with fluid restrictions.
Failed to provide proper IV care including dressing changes, measurements, physician orders, and care plans for multiple residents.
Failed to provide safe and sanitary respiratory care including oxygen tubing labeling and maintenance.
Failed to provide safe and appropriate dialysis care including holding blood pressure medications on dialysis days and monitoring dialysis access site.
Failed to ensure proper accounting and safeguarding of controlled medications and proper administration of eye drop medication.
Failed to ensure proper storage, labeling, and disposal of medications including missing documentation for emergency kit medication and expired ointments.
Failed to honor food preferences for a resident, serving disliked foods which impacted psychosocial well-being.
Failed to provide special eating equipment (sippy cup) as ordered for a resident.
Failed to maintain sanitary conditions in the kitchen including hood cleaning, utensil condition, cutting boards, freezer thermometers, and beverage temperatures.
Failed to maintain complete and accurate medical records including medication administration records, POLST forms, and fluid intake documentation.
Failed to implement infection prevention and control practices including proper placement of urinals, hand hygiene before gastrostomy tube care, and use of evidence-based precautions.
Report Facts
Residents sampled: 33
Fluid intake documented: 1200
Fluid intake documented: 1400
Fluid intake documented: 1500
Dialysis schedule: 3
Oxygen rate: 2
Medication cart log missing signatures: 7
Expired ointment: 2
Residents affected: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Verified Resident 123 oxygen therapy orders and sanitation issues |
| LVN 3 | Licensed Vocational Nurse | Verified missing signatures in Controlled Substance Log |
| LVN 4 | Licensed Vocational Nurse | Verified missing signatures in Controlled Substance Log |
| LVN 5 | Licensed Vocational Nurse | Observed improper eye drop administration and hand hygiene |
| LVN 8 | Licensed Vocational Nurse | Verified expired ointments and missing sippy cup for Resident 27 |
| LVN 9 | Licensed Vocational Nurse | Observed medication administration and verified fingernail care issues |
| LVN 10 | Licensed Vocational Nurse | Verified dialysis access site assessments |
| RN 1 | Registered Nurse | Verified dialysis access site assessments and PICC line care |
| RN 2 | Registered Nurse | Observed PICC line dressing and IV care |
| RN 4 | Registered Nurse | Observed failure to don PPE for EBP resident care |
| RD | Registered Dietitian | Verified kitchen sanitation issues and dietary care plan discrepancies |
| DON | Director of Nursing | Acknowledged multiple findings including documentation and care issues |
| IP | Infection Preventionist | Verified oxygen tubing sanitation and emergency kit medication documentation |
| MDS Coordinator | MDS Coordinator | Verified late care plans and IV care documentation issues |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide the appropriate dietary texture as ordered by the physician for Resident 1.
Complaint Details
The complaint investigation found that Resident 1 was given regular texture peanut butter and jelly sandwiches despite a physician's order for a fortified, pureed texture diet with nectar thick liquids. The resident choked on the food and expired. Interviews revealed staff were unaware of the diet order and continued to provide regular sandwiches.
Findings
The facility failed to ensure Resident 1 was provided with the appropriate pureed food texture as per physician's orders, which put the resident at risk for choking. Resident 1 was given regular texture peanut butter and jelly sandwiches instead of pureed food, leading to a choking episode and subsequent death.
Deficiencies (1)
Failure to ensure Resident 1 was provided with the appropriate food texture as per physician's diet orders, putting the resident at risk for choking.
Report Facts
Residents Affected: 4
Residents Affected: 1
Date of resident's death: Feb 5, 2025
Date of inspection: Feb 14, 2025
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding missing controlled medications at the facility.
Complaint Details
The visit was complaint-related due to allegations of missing controlled medications. The complaint was substantiated as the facility investigation confirmed diversion of medications for Residents 3, 4, 5, 6, 7, 8, 9, 10, and 11.
Findings
The facility failed to provide necessary pharmaceutical services to safeguard controlled medications for nine of 11 sampled residents, resulting in diversion of medications such as tramadol, hydrocodone-acetaminophen, and oxycodone. The diversion went unnoticed due to forged signatures and improper documentation in the controlled medication logs.
Deficiencies (1)
Failure to safeguard controlled medications resulting in missing tablets of tramadol, hydrocodone-acetaminophen, and oxycodone for multiple residents.
Report Facts
Missing tablets: 116
Missing tablets: 39
Missing tablets: 60
Missing tablets: 15
Missing tablets: 87
Missing tablets: 60
Missing tablets: 24
Missing tablets: 48
Missing tablets: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Attempted to obtain tramadol medication from Resident 3's bubble pack and noted missing medication |
| DON | Director of Nursing | Responsible for controlled medication logs and confirmed forged signatures and missing medications |
| Administrator | Participated in interview and facility document review regarding medication diversion |
Inspection Report
Deficiencies: 1
Date: Jul 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care standards following an incident involving Resident 3 who had an unwitnessed fall with injury to his head.
Findings
The facility failed to ensure Resident 3 received appropriate care and documentation after his fall, specifically lacking detailed skin/wound documentation and follow-up assessment of the hematoma. The Director of Nursing acknowledged the documentation deficiencies.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders and resident's preferences, specifically lack of detailed skin documentation after Resident 3's fall.
Report Facts
Hematoma size: 2.5
Hematoma size: 2.5
Emergency Department hematoma size: 2
Emergency Department hematoma size: 1
Pain level: 8
Vital sign - Blood Pressure: 119
Vital sign - Blood Pressure: 82
Vital sign - Pulse: 114
Vital sign - Respiratory Rate: 15
Vital sign - Temperature: 98
Oxygen saturation: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Acknowledged staff should document the description of the hematoma |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 25, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards regarding the accuracy and completeness of medical records and medication administration documentation.
Findings
The facility failed to ensure licensed nurses documented blood sugar levels, medication administration, and nurses' initials in the Medication Administration Records (MAR) for three sampled residents, potentially compromising accurate and complete medical information.
Deficiencies (3)
Failure to document blood sugar levels and medications administered to Resident 2 in the MAR.
Failure to document blood sugar levels and insulin medication administered to Resident 3 in the MAR.
Failure to document licensed nurses' initials in the MAR when medications were administered to Resident 8.
Report Facts
Medication administration dates missing documentation: 2
Medication administration dates missing documentation: 2
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding missing oxycodone medications for Resident 1 and concerns about the facility's pharmaceutical services and medication management.
Complaint Details
The investigation was triggered by a suspected drug discrepancy reported on 4/29/24 involving missing oxycodone medications for Resident 1. The complaint was substantiated by interviews and document reviews confirming missing medications and documentation discrepancies.
Findings
The facility failed to properly store Resident 1's oxycodone medications, resulting in missing medications. The Controlled Drug record and MAR documentation did not match, and there were multiple missing licensed nurses' signatures on narcotic shift count sheets for Medication Carts 1, 2, 3, and 5, indicating failures in inventory control and documentation.
Deficiencies (3)
Failed to ensure Resident 1's oxycodone medications were stored properly, resulting in missing medications.
Failed to ensure Resident 1's Controlled Drug record and MAR documentation for oxycodone matched.
Failed to ensure proper inventory of all narcotics during shift changes for licensed nurses assigned to Medication Carts 1, 2, 3, and 5, with multiple missing signatures on shift count sheets.
Report Facts
Tablets of oxycodone received: 30
Dates with missing licensed nurses' signatures on Medication Cart 3 shift count sheets: 17
Dates with missing licensed nurses' signatures on Medication Cart 1 shift count sheets: 14
Dates with missing licensed nurses' signatures on Medication Cart 5 shift count sheets: 8
Dates with missing licensed nurses' signatures on Medication Cart 2 shift count sheets: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Signed and received Resident 1's oxycodone medications on 4/17/24; did not inform others about medication placement |
| LVN 2 | Licensed Vocational Nurse | Followed up on Resident 1's oxycodone medication on 4/22/24 and communicated with pharmacy |
| LVN 3 | Licensed Vocational Nurse | Verified discrepancies between Controlled Drug Records and MARs for Resident 1 |
| LVN 6 | Licensed Vocational Nurse | Verified missing licensed nurses' signatures on narcotic shift count sheets and explained shift count process |
| LVN 7 | Licensed Vocational Nurse | Verified missing signatures on narcotics Shift Count sheets and explained the reconciliation process |
| DON | Director of Nursing | Acknowledged findings, verified missing signatures, and confirmed monitoring responsibilities |
| Administrator | Acknowledged RN 1 signing and receiving oxycodone medications for Resident 1 | |
| Clinical Resource nurse | Verified missing oxycodone medications and informed DON |
Inspection Report
Routine
Deficiencies: 32
Date: Feb 8, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with health and safety regulations, including resident care, medication administration, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for medications, incomplete care planning and resident participation, inadequate medication administration and documentation, privacy violations, environmental cleanliness issues, failure to provide grievance process information, bed hold notification failures, incomplete PASARR follow-up, incomplete baseline and comprehensive care plans, inadequate respiratory and dialysis care, medication storage and labeling issues, infection control lapses, and failure to monitor antibiotic use and psychotropic medication appropriately.
Deficiencies (32)
Failure to obtain informed consent for psychotropic medications for multiple residents.
Failure to provide residents opportunity to participate in care planning.
Failure to assess resident ability to self-administer medications safely.
Failure to maintain privacy during medication administration and wound care.
Failure to provide dignity bags for residents with indwelling urinary catheters.
Failure to safeguard resident personal and medical records from public view.
Failure to maintain a clean, sanitary, and homelike environment including missing blinds, paint peeling, rusty bathtub, and inadequate linens.
Failure to provide grievance process information and anonymous grievance filing options to residents.
Failure to provide bed hold notification to residents or representatives upon hospital transfer.
Failure to follow PASARR recommendations and incorporate into care plans.
Failure to develop baseline care plan within 48 hours of admission including nutritional and activity goals.
Failure to develop comprehensive care plans for oxygen therapy and pain management medications.
Failure to revise care plans to reflect current treatments including CPAP and pain medications.
Failure to monitor medication administration including blood pressure and heart rate prior to antihypertensive medications, rotate insulin injection sites, complete change of condition reports for COVID-19 diagnoses, and assess residents after falls.
Failure to provide bilateral heel protectors as ordered for residents with skin integrity risks.
Failure to ensure safe environment including unplugged portable heater near resident bed and failure to use and educate on tab alarms.
Failure to label and date enteral feeding syringes and change daily as per policy.
Failure to assess and document midline catheter site weekly, and dressing was unlabeled and undated.
Failure to flush IV catheter as ordered before medication administration.
Failure to provide oxygen therapy as ordered including lack of physician order, improper storage of BiPap and CPAP equipment, and incorrect oxygen flow rates.
Failure to provide timely medication administration, accurate controlled substance documentation, and safe medication storage including unlocked medication cart and expired or unlabeled medications.
Failure to provide appropriate respiratory care including cleaning and storage of nebulizer and BiPap equipment, and proper administration of inhaled medications.
Medication errors by licensed nurses including failure to administer ordered medications and improper eye drop administration.
Failure to provide food according to resident preferences and diet orders including serving disliked foods and missing preferred items.
Failure to maintain proper sanitation in food preparation and storage areas including failure to perform hand hygiene and uncovered food items.
Failure to maintain infection control practices including incomplete infection surveillance, improper PPE use, failure to close isolation room doors, improper handling of soiled and clean linens, and improper disposal of drainage system.
Failure to provide antibiotic stewardship including lack of monitoring antibiotic use and failure to notify physicians when antibiotics did not meet McGeer's criteria.
Failure to provide timely and appropriate pain management including failure to administer pain medication after a fall.
Failure to provide appropriate dialysis care including incomplete pre and post dialysis assessments and communication.
Failure to provide accurate and complete medical records including inconsistent physician orders and incomplete treatment administration records.
Failure to coordinate hospice services including lack of visitation calendar and care plan coordination.
Failure to ensure safe use of bed rails including lack of entrapment assessment and inconsistent documentation of bed type and safety checks.
Report Facts
Medication error rate: 12.82
Residents with COVID-19: 23
Residents ordered antibiotics: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 8 | Licensed Vocational Nurse | Named in medication administration errors and interview regarding medication administration |
| LVN 12 | Licensed Vocational Nurse | Named in medication administration errors and interview regarding medication administration |
| LVN 17 | Licensed Vocational Nurse | Named in medication administration errors and interview regarding medication administration |
| DON | Director of Nursing | Interviewed multiple times regarding findings, medication errors, infection control, and care plan issues |
| MDS Coordinator | Interviewed regarding care plan and infection control findings | |
| DSD/IP | Infection preventionist interviewed regarding COVID-19 outbreak and antibiotic stewardship | |
| Assistant DDS/Cook 2 | Assistant Director of Dietary Services/Cook | Observed failing hand hygiene during food preparation |
| LVN 13 | Licensed Vocational Nurse | Observed failing infection control practices |
| CNA 14 | Certified Nursing Assistant | Observed failing infection control practices |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 8, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care planning, bed hold notification, care plan development for oxygen therapy, accident hazards, medication storage, and labeling.
Findings
The facility was found deficient in multiple areas including failure to involve a resident in care planning, failure to notify residents or representatives about bed hold policies upon hospital transfer, incomplete care plans for oxygen therapy, unsafe environmental hazards such as a portable space heater and improper use of tab alarms, and multiple medication storage and labeling violations including unlocked medication carts, unlabeled or expired medications, and improper disposal of medications.
Deficiencies (5)
Failed to ensure Resident 812 was provided opportunity to participate in care plan meeting and informed of plan of care.
Failed to notify residents or representatives in writing about bed hold policy upon transfer to acute care hospital for Residents 29 and 152.
Failed to develop comprehensive care plans reflecting oxygen therapy use for Residents 128 and 662.
Failed to provide adequate supervision and accident hazard prevention including portable space heater plugged in Resident 49's room and improper use of tab alarm for Resident 122.
Failed to ensure safe storage, labeling, and disposal of medications including unlocked medication cart, unlabeled chest vapor rub ointments at bedside, expired and undated medications, and improper disposal of insulin pens and wound care treatments.
Report Facts
Residents sampled: 33
Residents affected: 2
Residents affected: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Verified medication cart was left unlocked and acknowledged care plan deficiency for oxygen therapy |
| LVN 17 | Licensed Vocational Nurse | Verified portable space heater in Resident 49's room and administered medications to Resident 12 |
| DON | Director of Nursing | Acknowledged multiple deficiencies including care plan, bed hold notification, and medication storage |
| SSD | Social Services Director | Verified baseline care plan meeting not conducted for Resident 812 and bed hold notification process |
| MDS Coordinator | Minimum Data Set Coordinator | Verified care plan deficiencies and medication room thermometer issue |
| LVN 6 | Licensed Vocational Nurse | Interviewed regarding bed hold notification for Resident 152 |
| RNA 1 | Registered Nurse Assistant | Observed tab alarm not attached to Resident 122 |
| LVN 1 | Licensed Vocational Nurse | Verified unlabeled wound care supplies and medication storage issues |
| LVN 4 | Licensed Vocational Nurse | Observed medication pill cutter with residue |
| LVN 10 | Licensed Vocational Nurse | Observed insulin pens with missing or expired open dates |
| LVN 14 | Licensed Vocational Nurse | Interviewed about medication open date policy |
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 19
Date: Jan 23, 2024
Visit Reason
The inspection was conducted based on complaints and observations regarding inadequate call light response times, insufficient staffing, improper medication administration, and other care deficiencies at the nursing facility.
Complaint Details
The complaint investigation revealed multiple deficiencies including inadequate call light response, insufficient staffing, medication errors, improper wound care, unsafe discharge practices, and environmental hazards.
Findings
The facility failed to ensure timely response to call lights for multiple residents, adequate staffing to meet resident needs, proper medication administration, accurate care planning, appropriate wound care, safe discharge planning, and proper urinary catheter care. Several residents reported long wait times for assistance, missed medications, and inadequate care. The facility also failed to maintain comfortable room temperatures and proper garbage disposal.
Deficiencies (19)
Failure to ensure call lights for 10 of 29 sampled residents were answered promptly and within reach.
Failure to provide Resident 3 with right to self-determination and communication regarding changes to Social Security Income payments.
Failure to ensure accurate Physician Orders for Life Sustaining Treatment (POLST) and advance directives for multiple residents.
Failure to maintain comfortable room temperatures in six resident rooms, with temperatures below the facility's policy minimum.
Failure to ensure safe and appropriate discharge of Resident 1 to another skilled nursing facility without documented criteria, notification, or discharge planning.
Failure to revise care plans to reflect current needs for Residents 1 and 17, including fall interventions and psychotropic medication monitoring.
Failure to provide appropriate nursing services for wound care and admission assessments for Residents 13 and B, and failure to administer enoxaparin as ordered for Resident 1.
Failure to administer scheduled medications at 2100 hours on 1/9/24 for Residents 6, 8, 9, 10, and 22.
Failure to provide and explain California Standard admission Agreement to Residents 3 and 22 or their responsible parties.
Failure to provide daily wound treatments as ordered for Residents 14 and 15, and failure to provide Resident 24 with ordered low air loss mattress.
Failure to update care plans and conduct interdisciplinary team meetings after falls for Residents 19, 20, and 21.
Failure to ensure proper urinary catheter care for Resident 17, with catheter bag observed on floor or trash can, increasing infection risk.
Failure to provide appropriate pain management for Residents 10 and 23, including failure to notify physician of high pain levels and missed medication doses.
Failure to maintain adequate nursing staffing to meet resident care needs, resulting in missed medications and delayed care.
Failure to ensure accurate physical inventory of controlled medications during shift change for Medication Cart A.
Failure to ensure accurate medication administration documentation for Residents 9 and D to prevent medication errors.
Failure to monitor and manage psychotropic medication use for Resident 17, including lack of behavior and side effect monitoring.
Failure to ensure Residents 8 and 9 were free from significant medication errors due to missed scheduled medications.
Failure to dispose of garbage properly with dumpsters overflowing and lids unable to close, posing pest contamination risk.
Report Facts
Residents affected by call light deficiency: 10
Residents requiring wound care treatments: 36
Resident census: 168
Residents assigned per LVN: 26
Medication Cart A shift count missing signatures: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 7 | Licensed Vocational Nurse | Reported residents not medicated timely and sometimes signed MAR without giving medications |
| RN 5 | Registered Nurse | Verified missed medication administrations and lack of physician notification |
| LVN 1 | Licensed Vocational Nurse | Verified missing controlled medication shift count signatures |
| RN 2 | Registered Nurse | Reported understaffing and overwhelming workload on 1/9/24 night shift |
| RN 3 | Registered Nurse | Reported arriving late and overwhelmed with over 50 residents on 1/9/24 night shift |
| LVN 5 | Licensed Vocational Nurse | Verified missed wound treatments due to staffing and prioritization |
| LVN 12 | Licensed Vocational Nurse | Observed improper urinary catheter bag placement for Resident 17 |
| RN 1 | Registered Nurse | Verified urinary catheter bag placement and call light response issues |
| ADON | Assistant Director of Nursing | Verified multiple findings including lack of discharge planning and IDT meetings |
| Administrator | Facility Administrator | Acknowledged staffing and temperature control deficiencies |
Inspection Report
Routine
Deficiencies: 5
Date: Dec 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, food safety, medical record accuracy, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide ordered restorative nursing services to maintain residents' range of motion, inadequate monitoring of residents on blood thinner medications and hemodialysis, improper food storage and freezer maintenance, incomplete and inconsistent medical record documentation regarding safety devices, and failure to enforce infection control practices for visitors in contact isolation rooms.
Deficiencies (5)
Failure to provide restorative nursing services for range of motion exercises as ordered for Resident 3, and delay in addressing physician's order for hand surgeon consultation.
Failure to monitor for bleeding or bruising in residents on blood thinner medications and failure to monitor hemodialysis for Resident GG.
Failure to maintain freezer at proper temperature, lack of thermometer, undated foods, and unsanitary conditions in food storage.
Inconsistent and incomplete documentation on medical records for monitoring placement and functionality of WanderGuards for Residents 1 and 2.
Failure to maintain infection control practices when a family member was observed not wearing required PPE inside a contact isolation room.
Report Facts
Deficiencies cited: 5
Date of survey completion: Dec 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNA 1 | Restorative Nursing Assistant | Named in deficiency related to failure to provide ordered ROM exercises for Resident 3 |
| ADOR | Assistant Director of Rehabilitation | Named in deficiency related to failure to communicate RNA orders and follow up on hand surgeon consultation for Resident 3 |
| LVN 12 | Licensed Vocational Nurse | Named in deficiency related to verification of blood thinner medications and hemodialysis monitoring for Residents 8 and GG |
| LVN 2 | Licensed Vocational Nurse | Named in deficiency related to documentation of WanderGuard monitoring for Residents 1 and 2 |
| LVN 3 | Licensed Vocational Nurse | Named in deficiency related to documentation of WanderGuard monitoring for Resident 1 |
| LVN 6 | Licensed Vocational Nurse | Named in deficiency related to infection control failure observation with Resident 9's family member |
| Administrator | Acknowledged findings related to multiple deficiencies | |
| DON | Director of Nursing | Acknowledged findings related to multiple deficiencies |
Inspection Report
Deficiencies: 2
Date: Nov 30, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care accommodations and medical record accuracy at The Hills Post Acute facility.
Findings
The facility failed to ensure Resident 1's call light was kept within sight and reach, potentially impacting psychosocial well-being and timely care. Additionally, the facility failed to maintain accurate and complete medical records for Resident 5, lacking documentation of change of condition events and transfer details to an acute care hospital.
Deficiencies (2)
Failure to ensure Resident 1's call light was kept within sight and reach.
Failure to document a summarization of Resident 5's change of condition event, interventions after signs of unresponsiveness, and reporting to the receiving acute care hospital.
Report Facts
Residents sampled: 5
Date of facility tour: Nov 29, 2023
Date of survey completion: Nov 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Verified Resident 1's call light was on the floor and should be within reach |
| LVN 1 | Licensed Vocational Nurse | Stated Resident 1's call lights should be within reach |
| LVN 5 | Licensed Vocational Nurse | Verified failure to complete eInteract Transfer Form and document Resident 5's change of condition |
| ADON | Assistant Director of Nursing | Verified findings regarding Resident 5's medical record documentation deficiencies |
| DON | Director of Nursing | Verified and acknowledged findings related to Resident 5's medical record deficiencies |
Inspection Report
Deficiencies: 4
Date: Oct 18, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident discharge notifications, bed hold policies, medication administration, employee identification, and overall facility compliance with applicable laws and standards.
Findings
The facility failed to notify the Long-Term Care Ombudsman of resident discharges for four sampled residents, did not provide written or verbal notice of the bed hold policy to one resident, failed to administer medications as ordered for three residents, and had four employees not wearing identification badges while on duty. These deficiencies had the potential for minimal harm or actual harm to residents.
Deficiencies (4)
Failure to ensure the Long-Term Care Ombudsman was notified of the discharge for four residents.
Failure to notify resident or representative in writing about the facility's bed hold policy upon transfer to hospital for one resident.
Failure to administer medications as ordered by the physician for three residents, including missed and late doses.
Failure to ensure four employees wore identification badges while on duty.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 3
Employees affected: 4
Missed gabapentin doses: 3
Late medication administration: 1
Missed insulin doses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Acknowledged medication administration findings for Residents 1 and 3 | |
| LVN 1 | Observed administering medication to Resident 1 and acknowledged medication findings | |
| MDS Coordinator | Acknowledged medication administration documentation issues for Resident 1 | |
| DON | Director of Nursing | Acknowledged findings related to discharge notification, medication administration, and employee identification badge deficiencies |
| LVN 3 | Reported gabapentin medication not administered due to unavailability | |
| LVN 4 | Verified and acknowledged medication administration findings for Resident 3 | |
| SSD | Social Services Director interviewed regarding Ombudsman notification | |
| ADON | Assistant Director of Nursing | Interviewed regarding discharge notifications and responsibilities |
| LVN 5 | Observed not wearing identification badge | |
| LVN 6 | Observed not wearing identification badge | |
| Housekeeping Staff 1 | Observed not wearing identification badge | |
| Housekeeping Staff 2 | Observed not wearing identification badge |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 13, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate personal hygiene care for residents and failure to provide appropriate respiratory care to a resident with COPD and hypoxemia.
Complaint Details
The complaint investigation was substantiated based on findings that the facility failed to provide scheduled showers to residents who did not refuse care and failed to provide appropriate respiratory care and medication administration to a resident with COPD and hypoxemia.
Findings
The facility failed to provide scheduled showers to two residents who were dependent on staff for bathing, resulting in potential physical and emotional harm. Additionally, the facility failed to properly assess and oxygenate a resident with respiratory distress, placing her on a CPAP machine instead of a high-flow oxygen mask, and failed to administer ordered inhalation medications. Competency deficiencies were identified in a licensed vocational nurse related to respiratory care and medication administration.
Deficiencies (3)
Failure to provide necessary care and services to ensure two residents maintained good grooming and personal hygiene, missing scheduled showers.
Failure to provide safe and appropriate respiratory care for one resident, including inadequate assessment, monitoring, and oxygenation during respiratory distress.
Failure to ensure one licensed vocational nurse had the competencies and skills necessary for medication administration via inhalation and respiratory care.
Report Facts
Oxygen saturation level: 63
Scheduled showers missed: 2
Date of survey completion: Sep 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Named in findings related to failure to administer breathing treatment and lack of competency in respiratory care and medication administration. |
| RN 1 | Registered Nurse | Interviewed regarding proper respiratory care procedures and verification of findings. |
| ADON | Assistant Director of Nursing | Verified shower schedules and competency assessments. |
| DON | Director of Nursing | Verified nursing responsibilities and competency requirements. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to properly investigate and assess fall risks for a resident, maintain vascular access devices, accurately document medication removal from the emergency kit, and ensure proper administration of medications.
Complaint Details
The complaint investigation focused on Resident 1's fall risk assessment failures and Resident 7's medication administration and vascular access device maintenance issues. The facility was found to have failed in these areas, putting residents at risk for further accidents and infections.
Findings
The facility failed to ensure Resident 1 was free from accidents by not assessing fall risk after falls and not documenting IDT recommendations. The facility also failed to maintain PICC line dressings for Resident 7, failed to document medication removal from the emergency kit, and failed to administer Resident 7's full prescribed doses of cefazolin, resulting in potential risks for further injury and infection.
Deficiencies (4)
Failure to investigate and assess Resident 1's fall risk after fall incidents and failure to document IDT recommendations after falls on 5/17 and 6/23/23.
Failure to perform PICC line dressing changes every seven days for Resident 7 as per facility policy, risking device-associated infection.
Failure to accurately document removal of cefazolin medication from the emergency E-Kit.
Failure to administer Resident 7's full dose of cefazolin sodium as ordered and failure to ensure three doses were administered as prescribed.
Report Facts
Fall incidents: 4
PICC dressing change interval: 7
Missed medication doses: 3
Medication administration frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding fall risk assessment process and medication administration. |
| LVN 2 | Licensed Vocational Nurse | Interviewed regarding fall risk assessment process. |
| ADON | Assistant Director of Nursing | Interviewed and acknowledged findings related to fall risk assessments, PICC line maintenance, medication administration, and documentation. |
| RN 2 | Registered Nurse | Interviewed regarding IV medication preparation and administration. |
Inspection Report
Deficiencies: 3
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with medical record documentation standards and to ensure accurate and complete medical records for residents.
Findings
The facility failed to ensure accurate and complete medical record documentation for one sampled resident, including incomplete entries for turning, repositioning, dietary intake, eating assistance, and treatment administration on multiple dates across April and May 2023. The Assistant Director of Nursing (ADON) verified the findings and acknowledged the documentation deficiencies.
Deficiencies (3)
Incomplete documentation for turning, repositioning, dietary intake, and eating assistance in the Documentation Survey Reports and TAR for Resident 1.
No entries in TAR to show treatments for coccyx fragile skin and left first metatarsal head ulcer Stage 2 PI were completed on multiple specified dates.
No entries to show monitoring of alternating pressure mattress and application of BLE heel protectors on multiple specified dates and shifts.
Report Facts
Dates with missing documentation: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Interviewed and verified the documentation deficiencies; explained staff responsibilities for documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 14, 2023
Visit Reason
The inspection was conducted based on complaints regarding delayed responses to call lights and failure to provide restorative nursing assistant (RNA) services as ordered.
Complaint Details
The complaint investigation found substantiated issues with delayed call light responses ranging from 30 minutes to over an hour, especially during night shifts, and missed RNA services due to staff shortages and RNAs performing CNA duties.
Findings
The facility failed to ensure timely response to residents' call lights, affecting five of six sampled residents, and failed to provide RNA services to one resident as ordered. Staffing shortages and RNAs being pulled to CNA duties contributed to these issues.
Deficiencies (2)
Failure to reasonably accommodate residents' needs and preferences when call lights were not answered in a timely manner.
Failure to provide restorative nursing assistant (RNA) services as ordered for one resident.
Report Facts
Residents affected: 5
Call light response time: 30
Call light response time: 45
Call light response time: 60
RNA program frequency: 5
RNA program frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNA 1 | Restorative Nursing Assistant | Verified RNA services were not provided due to working as CNA |
| RN 1 | Registered Nurse | Stated CNAs could be busy with many residents and unable to attend all at once |
| ADON | Assistant Director of Nursing | Reported staffing shortages and use of registry staff |
| Activities Director | Activities Director | Acknowledged ongoing call light response issues during night shifts |
| CNA 2 | Certified Nursing Assistant | Reported stress due to multiple residents pressing call lights simultaneously |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 3, 2023
Visit Reason
The inspection was conducted following a complaint regarding the failure to obtain informed consents for psychotropic medications for Resident 1 and concerns about the room temperature due to a covered air vent.
Complaint Details
The complaint involved Family Member 1 reporting that Resident 1 was prescribed psychotropic medications without authorization or consent, and that Resident 1's room was hot due to the air vent being taped over. The complaint was substantiated by interviews and medical record reviews.
Findings
The facility failed to obtain informed consents from Resident 1's responsible party for the use of Lexapro and risperidone, and failed to maintain safe and comfortable temperature levels in Resident 1's room due to a taped-over HVAC air vent and lack of routine temperature checks.
Deficiencies (3)
Failure to ensure informed consents were obtained from Resident 1's responsible party for the use of Lexapro and risperidone.
HVAC ceiling air vent in Resident 1's room was completely covered with plastic and taped off, preventing air circulation and hindering temperature regulation.
Failure to conduct routine temperature checks to ensure a comfortable and safe temperature level throughout the building.
Report Facts
Date of psychotropic drug orders: Mar 28, 2022
Date of psychotropic drug orders: Apr 11, 2023
Date of last documented ambient air temperature check: Mar 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON | Interviewed and verified that informed consents were required and not obtained | |
| Medical Records Director | Interviewed and verified that informed consents were not obtained | |
| DON | Interviewed regarding room temperature concerns and air vent coverage | |
| Maintenance Supervisor | Interviewed regarding temperature checks and air vent coverage |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 14, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care planning and medication storage regulations at The Hills Post Acute facility.
Findings
The facility failed to revise the care plan for a resident after a change in condition, placing the resident at risk for unmet care needs. Additionally, the facility failed to ensure proper storage of medications for another resident, potentially causing unsafe handling and storage.
Deficiencies (2)
Failure to revise the care plan problem for a resident after a change in condition, resulting in risk for unmet care needs.
Failure to ensure proper storage of medications, with medications found unattended in bedside drawer and clothing closet.
Report Facts
Date of inspection: Apr 14, 2023
Expiration date of medication: 202409
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 4 | Licensed Vocational Nurse | Verified medication storage findings |
| ADON | Assistant Director of Nursing | Interviewed regarding care plan revision and IDT meeting |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding medication storage |
Inspection Report
Deficiencies: 1
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding monitoring of residents on blood thinner medications, specifically to ensure proper side effect monitoring and prevention of unnecessary drug use.
Findings
The facility failed to ensure proper monitoring for bleeding or bruising in a resident on blood thinner medications, which had the potential to cause negative outcomes. Interviews with nursing staff confirmed the lack of monitoring orders and documentation for anticoagulant side effects.
Deficiencies (1)
Failure to ensure proper side effect monitoring of blood thinner medications for one resident, including lack of documented evidence of monitoring for bleeding or bruising.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON | Verified monitoring requirements for residents on blood thinners and responsibility of admitting nurses | |
| LVN 4 | Verified Resident 1 was on blood thinners without monitoring orders since admission | |
| RN 1 | Verified importance of monitoring residents on blood thinners for bleeding and bruising |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 9, 2023
Visit Reason
The inspection was conducted due to allegations of misappropriation of property involving two residents who reported financial abuse by maintenance staff.
Complaint Details
The complaint was substantiated based on interviews, medical record reviews, and facility investigation showing financial abuse by maintenance staff involving unauthorized bank withdrawals and failure to return money.
Findings
The facility substantiated the allegations that maintenance staff wrongfully withdrew money from Resident 1's bank account without consent and failed to return money given by Resident 2 to purchase items. These actions had the potential to negatively impact the well-being of the residents.
Deficiencies (1)
Failure to protect residents from misappropriation of property by maintenance staff.
Report Facts
Residents affected: 2
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 2, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a discrepancy and missing controlled medications for Resident 1 at the facility.
Complaint Details
The complaint investigation was substantiated by findings that controlled medications were missing for Resident 1. The facility was unable to account for the missing medications despite multiple interviews and review of medication records.
Findings
The facility failed to have a system in place to ensure safeguarding and accurate accountability of controlled medications, resulting in missing hydrocodone-acetaminophen tablets for Resident 1. Despite investigation and interviews with nursing staff, the facility was unable to determine who was responsible for the missing medications or the exact date they went missing.
Deficiencies (1)
Failure to have a system in place to ensure safeguarding and accurate accountability of controlled medications for Resident 1, resulting in missing controlled medications.
Report Facts
Tablets delivered: 42
Tablets delivered: 42
Date of physician order: Dec 28, 2022
Date of admission: Admission date for Resident 1 not specified
Date of discharge: Dec 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Interviewed regarding controlled medication count and missing medication on 1/24/23 |
| LN 2 | Licensed Nurse | Interviewed regarding controlled medication count and missing medication on 1/24/23 |
| LN 3 | Licensed Nurse | Interviewed about signing for Resident 1's medications on 12/29/22 |
| LN 4 | Licensed Nurse | Interviewed about documentation of controlled medications received on 12/29/22 |
| RN Clinical Resource | Registered Nurse Clinical Resource | Conducted multiple interviews and acknowledged missing medications and investigation details |
| RN Supervisor | Registered Nurse Supervisor | Reported discrepancy and notified DON about missing medications |
| DON | Director of Nursing | Reported to be unavailable at times; involved in investigation of missing medications |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Oct 18, 2021
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident assessments, care planning, safety, therapeutic diets, dialysis care, and medical record completeness.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments related to tobacco use, incomplete care plans for oxygen therapy and medication changes, unsafe smoking practices, failure to monitor fluid restrictions for a dialysis resident, improper competency checks for Wanderguard devices, failure to provide prescribed therapeutic diets, improper food storage, and incomplete medical records.
Deficiencies (12)
Failed to complete accurate Minimum Data Set (MDS) assessments for tobacco use for multiple residents.
Failed to develop and implement a comprehensive care plan addressing oxygen therapy needs for Resident 48.
Failed to revise care plan to reflect increased trazodone dose for Resident 10.
Failed to ensure safe smoking practices and supervision for residents who smoke, including safe storage of smoking materials.
Failed to initiate plan of action and reassessment for Resident 514 after multiple attempts to leave the building.
Resident 75 had an unlabeled, unattended disposable razor at bedside posing safety risk.
Failed to provide safe and appropriate respiratory care; oxygen therapy administered without physician's order for Resident 48.
Failed to complete weekly Intake and Output evaluations and notify physician of fluid intake exceeding restriction for Resident 84 on dialysis.
Failed to ensure staff competency in proper use and functionality checks of Wanderguard devices.
Failed to provide Resident 58 with the prescribed therapeutic diet; meal served did not match physician's order.
Failed to ensure proper labeling and dating of opened food items in kitchen and resident food storage areas.
Incomplete medical record for Resident 115; physician's history and physical examination not included.
Report Facts
Residents sampled: 25
Residents nonsampled: 12
Fluid restriction: 1200
Average fluid intake: 1694
Average fluid intake: 1882
Fluid intake: 2200
Residents with Wanderguard orders: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Verified care plan problem not revised for Resident 10's trazodone dose |
| DON | Director of Nursing | Verified multiple deficiencies including oxygen therapy order missing and fluid restriction monitoring |
| MDS Coordinator Assistant | Verified inaccurate MDS tobacco use coding for multiple residents | |
| Social Services Assistant | Responsible for smoking assessments, stated no IDT meeting was held | |
| LVN 5 | Licensed Vocational Nurse | Verified fluid restriction monitoring for Resident 84 |
| RN 3 | Registered Nurse | Verified fluid intake exceeding restriction and incomplete weekly evaluations for Resident 84 |
| RD | Registered Dietitian | Reviewed Resident 84 records, unaware of fluid intake exceeding restriction |
| LVN 4 | Licensed Vocational Nurse | Described incorrect Wanderguard functionality check method |
| RN 2 | Registered Nurse | Described incorrect Wanderguard functionality check method |
| DSD | Director of Social Services | Confirmed staff incorrectly checked Wanderguard by taking residents to door |
| RN 3 | Registered Nurse | Verified Resident 58 diet order discrepancy |
| Medical Records Director | Verified missing physician H&P in Resident 115's record |
Viewing
Loading inspection reports...
