Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillcrest Center during CMS and state inspections, most recent first.
Failure to Notify Resident Representative of Hospital Transfer: A resident was sent from scheduled HD to the hospital for evaluation of an AV fistula complication, but the facility did not notify the resident’s POA of the transfer as required by policy. The record showed staff confirmed the hospital admission, yet the representative only learned of the transfer when visiting the facility later, and the NHA confirmed no prior notification occurred.
A resident with ESRD on hemodialysis had a physician order directing staff not to obtain BP readings in the left arm, but the clinical record showed repeated BP measurements documented in that arm. The NHA and DON confirmed staff documented left-arm BP readings despite the order.
Incomplete dialysis communication and recordkeeping were identified for a resident with ESRD receiving HD. Required pre- and post-dialysis documentation was missing or inconsistent, including absent post-HD assessments, vital signs, and weights, and the EMR did not consistently match the dialysis communication binder. An LPN confirmed the binder was incomplete.
A resident with HTN, stroke, renal insufficiency, anemia, and hemiplegia had repeated critically elevated BP readings documented on the MAR. The resident had orders for BP checks every 6 hours and PRN clonidine for BP above ordered parameters, but the MAR did not show the medication was given when criteria were met. The DON confirmed the physician was not notified of the repeated elevated readings, and the resident was later transferred to the ER and admitted with hypertensive urgency.
Failure to provide ordered 1:1 supervision and safe hot beverage temperatures. A resident with dementia, impulse disorder, and an unsteady gait had an order for continuous 1:1 supervision, but was observed alone in the room without assigned staff and later found attempting to get out of bed while no 1:1 staff were present. In addition, coffee served in the dining room was distributed without being checked for temperature, steam was visible, and a later measurement showed the coffee at 165 degrees F despite log entries that did not clearly identify the floor served.
Inadequate Colostomy Care Competency for Nursing Staff: The facility failed to ensure that all licensed nursing staff were competent in colostomy care. Agency LPNs and a newly hired nurse had no documented hands-on competency checks, and the Nurse Practice Educator confirmed there was no process to verify agency staff skills. A resident with a prolapsed, herniated colostomy and limited hand function required frequent colostomy and peri-stomal care, but staff gave inconsistent accounts of their ability to manage the stoma, and the Nurse Practice Educator was unable to demonstrate care for the resident’s unusual stoma without first reviewing the record and consulting additional resources.
Improper Medication Storage and Temperature Monitoring: Medication storage was not maintained according to policy on the 1st and 3rd floors. An LPN observed an outdated refrigerator temperature log, an employee lunch bag stored in the med refrigerator, insulin and other meds without proper dating, expired Vitamin B12, and no temperature record for the 1st floor refrigerator despite an observed temp of 39 F.
A resident with hemiplegia/hemiparesis and left-side flaccidity was supposed to wear a left-hand splint daily with skin checks and complete daily UE/LE AROM, but staff did not implement the restorative nursing plan. Observations found the resident not wearing the splint, the resident reported staff do not apply it, and the assigned LPN confirmed it was not being worn and that no MD order was in the chart. The rehab director confirmed therapy had recommended the splint and that it had never been discontinued, and the record lacked documentation that the restorative program was carried out.
Improper Handling of Blood Specimen Transport: A lab tech placed a biohazard specimen pouch containing a vial of blood into a cooler of ice at the nurses station and used the ice scoop to add ice to the pouch. The lab tech stated this was normal practice, and an RN later said the cooler was intended for resident drinking water and should not be used for blood specimens.
Unsanitary conditions were observed on the 2nd floor, including a strong feces odor in the back hallway, a resident’s toilet covered in feces, breakfast meal trays left on the nourishment room counter, and a hole in the wall behind the sink. An aide confirmed the toilet remained soiled at the start of the shift.
A resident reported repeated mouse sightings in her room and provided photos showing rodents in the living area. Another resident stated that mice were frequently seen throughout the unit for several months and reported seeing a mouse under the PTAC unit in the 3rd floor dining room.
The facility failed to maintain an effective pest control program, as evidenced by repeated pest control service reports documenting mouse activity in staff areas, multiple resident rooms, therapy areas, and common spaces, along with ongoing use of traps and glue boards. Several residents and a resident’s family reported seeing mice in resident rooms and noted structural gaps in baseboards and near heating/air conditioning units that could allow rodent entry. During a tour, surveyors observed mouse droppings in specific resident rooms on the first floor and a hole in a baseboard, while staff from various departments, including kitchen staff, NAs, and licensed staff, confirmed rodent sightings on multiple floors and near the kitchen hallway, even though no droppings were seen in the kitchen or dry storage at the time of observation.
A resident with severe cognitive impairment was verbally abused by a nursing assistant, as witnessed by a cognitively intact roommate. The incident was reported to an LPN, but the LPN failed to immediately notify a supervisor as required by facility policy. Documentation later confirmed both the abuse and the failure to report it promptly.
The facility failed to meet the required minimum nurse aide staffing ratios on several occasions due to call outs from inclement weather and illness, resulting in unfilled slots. This deficiency was observed on multiple days, with the facility not maintaining the mandated staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the night shift.
The facility did not meet the required 3.2 hours of direct resident care per resident on nine days, with staffing hours ranging from 2.94 to 3.16. This was confirmed by facility administration.
The facility failed to ensure nursing staff had the necessary competencies for PICC line care, as evidenced by missing documentation of required dressing changes and assessments for a resident. Two registered nurses lacked documented competencies for PICC line management, and the Director of Nursing could not provide this documentation during the survey.
The facility failed to maintain an effective infection control program, as evidenced by a nurse aide entering a COVID-19 positive resident's room without proper PPE and improper catheter care for a resident. Additionally, infection surveillance logs were incomplete, lacking essential details such as infection type and symptoms.
The facility failed to maintain an effective antibiotic stewardship program, lacking protocols and a monitoring system for antibiotic use over five months. Documentation from March to June 2024 showed missing symptom records, stop dates, and reviews for antibiotic appropriateness. The Infection Preventionist confirmed these deficiencies, violating facility policies and CDC guidelines.
The facility did not provide mandatory training on its QAPI program to four staff members, including LPNs and Nurse Aides, as required. This deficiency was confirmed with the DON, highlighting a failure in staff development and management responsibilities.
A resident in an LTC facility missed doses of Oxycodone and Ciprofloxacin due to errors in medication administration. The resident, who was cognitively intact and had a recent urinary tract infection, reported missing Oxycodone doses after the order was discontinued. The Director of Nursing confirmed the error. Additionally, the resident missed three doses of Ciprofloxacin, confirmed by the Regional RN, as the pills were still in the medication bubble pack.
A facility failed to provide adequate care for a resident with a PICC line, as required by professional standards. The facility's policy mandated regular measurements of the upper arm circumference and external catheter length, but these were not documented on several occasions. The DON confirmed that the necessary dressing changes and assessments were not completed as ordered by the physician, indicating a breach in the facility's protocols.
A resident with multiple health conditions did not receive a prescribed K2 Plus D3 oral tablet consistently due to the facility's failure to ensure timely availability of the medication. The medication was not administered on several occasions due to it being on back order or on hold, with no documented reason for some dates. The Director of Nursing was unaware of the reasons for the medication's unavailability.
The facility failed to adequately monitor the use of psychotropic medications for two residents, leading to a deficiency in ensuring drug regimens were free from unnecessary drugs. Despite having care plans that required monitoring for side effects and efficacy, there was no evidence of ongoing monitoring for the prescribed medications. An interview with the Infection Preventionist confirmed the need for such monitoring, highlighting the facility's failure to adhere to its medication management policy.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify Resident R1’s representative of a transfer to the hospital after the resident was sent from a scheduled outpatient dialysis treatment for further evaluation of a left AV fistula complication. The facility policy titled Discharge and Transfer required the resident and resident representative to be informed immediately when a transfer decision was made, or as soon as practicable for urgent transfers, but the clinical record contained no documented evidence that the resident’s POA was notified of the hospital transfer. Resident R1 was transported by medical transport to scheduled hemodialysis, and during treatment the dialysis center notified the facility that the resident had been transferred to the hospital due to the AV fistula complication. A nursing progress note documented that facility staff confirmed the resident had been admitted for evaluation and treatment, but the resident’s representative did not learn of the transfer until arriving at the facility approximately two days later, when staff informed the representative that the resident had been transferred on the prior date. The Nursing Home Administrator confirmed in interview that the representative was not notified before that visit.
Failure to Follow Blood Pressure Order
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with physician orders for one resident with end stage renal disease who received hemodialysis. The resident had a physician order dated October 21, 2025 directing staff not to obtain blood pressure measurements in the left arm. Review of the clinical record showed repeated blood pressure readings documented in the resident’s left arm on multiple dates in June 2026, including 6/4, 6/6, 6/11, 6/14, 6/16, 6/18, 6/26, and 6/27. The resident’s discharge MDS dated June 19, 2026 indicated the resident was discharged to a short-term acute care hospital. During an interview on June 30, 2026, the Nursing Home Administrator and DON confirmed that staff documented blood pressure readings from the resident’s left arm despite the physician order not to do so.
Incomplete Dialysis Communication and Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate dialysis communication and medical record documentation for one resident with end stage renal disease who received hemodialysis. Facility policy required a licensed nurse to complete the pre-dialysis evaluation before the resident left for dialysis, the dialysis facility to return the communication form after treatment, and the facility nurse to complete the post-dialysis treatment evaluation upon the resident’s return. The dialysis service agreement also required ongoing communication and coordination of care, including the exchange of pertinent medical information and dialysis treatment reports for inclusion in the resident’s record. Review of the resident’s dialysis communication records showed incomplete and inconsistent documentation, including missing post-dialysis vital signs, post-dialysis weights, and post-treatment assessments. The facility did not consistently complete the required post-dialysis nursing assessment on multiple dates, and on one date neither the dialysis nurse section nor the facility’s post-hemodialysis section was completed. Review of the clinical record also found that vital signs documented in the electronic medical record did not consistently match the vital signs recorded in the dialysis communication binder, with discrepancies and missing documentation in both records. A licensed nurse confirmed that the dialysis communication binder was incomplete.
Failure to Administer PRN Antihypertensive and Notify Physician for Repeated Elevated Blood Pressures
Penalty
Summary
The facility failed to appropriately monitor and notify the physician about repeated critically elevated blood pressure readings for Resident R12 and failed to ensure the resident received Clonidine HCl 0.1 mg as ordered. Resident R12 had diagnoses including stroke, anemia, hypertension, renal insufficiency, and hemiplegia. The care plan identified cardiovascular risk related to hypertension and included interventions to administer medications as ordered, assess effectiveness and side effects, monitor vital signs as ordered, and report abnormalities to the physician. Resident R12 had a physician order to check blood pressure every six hours and a PRN order for Clonidine HCl 0.1 mg every six hours for systolic blood pressure greater than 150 mmHg and/or diastolic blood pressure greater than 90 mmHg. The December 2025 MAR documented multiple elevated blood pressure readings, including several readings above the ordered parameters and one reading of 246/121. The MAR did not show that Clonidine HCl was administered during those times when the readings met the criteria for use. Practitioner notes did not show evaluation of the PRN Clonidine order or adjustments to antihypertensive medications in response to the elevated readings. Nursing notes documented that the resident was transferred to the hospital emergency room on December 16, 2025, and the hospital confirmed admission with hypertensive urgency. The DON confirmed that Clonidine HCl was not administered as ordered and that the physician was not notified of the repeated elevated blood pressure readings.
Failure to Provide Ordered 1:1 Supervision and Safe Hot Beverage Temperatures
Penalty
Summary
The facility failed to ensure continuous 1:1 supervision for a resident with Impulse Disorder, dementia with progressive cognitive decline, and abnormal gait/mobility who had a physician order dated March 1, 2026 for one-to-one supervision at all times every shift. The resident’s care plan dated March 3, 2026, also indicated 1:1 supervision was initiated at the time of escalation on February 27, 2026. On April 13, 2026, at 10:45 a.m., the resident was observed alone in the room without any nursing staff present providing the ordered supervision. When asked about the lack of supervision, a nurse aide stated there was no staff coverage available at that time. On April 16, 2026, at 9:46 a.m., the resident was again observed in the room attempting to get out of bed with both legs dangling off the left side of the bed, and an occupational therapist who was not assigned as the 1:1 staff attempted to assist the resident because she did not want the resident to fall. The unit manager confirmed the resident required continuous 1:1 supervision and confirmed there was no staff present in the room during the earlier observation. The facility also failed to ensure safe temperatures for hot beverages on the third floor. Facility instructions required hot beverages to be measured immediately after preparation and held until they reached 120 to 150 degrees Fahrenheit before delivery, with the delivery temperature, time, and signature documented on the log. On April 15, 2026, during lunch service in the third-floor dining room, an activities assistant distributed coffee to residents and told one resident, "Careful, it's hot," while steam was visible rising from the cup. The assistant stated, "We don't take the temperature of the coffee." Later that day, the regional dietary manager poured coffee from the third-floor beverage dispenser and measured it at 165 degrees Fahrenheit. The hot beverage log documented a lunch coffee delivery temperature of 145 degrees at 11:30 a.m., but it did not specify which floor the entry applied to. A dietary aide stated he/she did not check the temperature of the coffee delivered to the third-floor dining room before delivery and reported the insulated coffee dispenser was prepared pretty fresh before delivery.
Inadequate Colostomy Care Competency for Nursing Staff
Penalty
Summary
The facility failed to ensure that four of four licensed nursing staff were knowledgeable in stoma/colostomy care. Survey review found no evidence that agency nurses E5 and E10 or newly hired nurse E6 had hands-on skills competency evaluations for colostomy care, and the Nurse Practice Educator confirmed that no such evaluations were available for review. The Nurse Practice Educator also stated there was no process for confirming hands-on skills evaluations for agency nursing staff. Resident R106 had a colostomy and was assessed as cognitively intact with a BIMS score of 15. The resident also had polyneuropathy and required supervision or touching assistance with ADLs. Physician orders included colostomy care every shift and as needed, monitoring the stoma for changes and notifying the physician, and peri-stomal wound care with cleansing, ointment, dressing changes, and clindamycin treatment. The resident reported having a complex colostomy that was herniated and prolapsed, measuring approximately 6 to 8 inches, and stated that care was difficult because of limited hand function and that assistance from staff was typically needed. During interview and observation, staff demonstrated inconsistent knowledge of the resident’s colostomy care needs. E6 stated she was competent in changing a colostomy bag but was unsure of the technique and additional care required for this resident. E7, who was responsible for staff education, stated that all nursing assistants and licensed nurses had been educated and were competent to provide colostomy care, but when asked to demonstrate care for R106’s unusual stoma appearance, she was unable to proceed and said she needed to review the record and consult additional resources before providing care. She later stated that this specific type of colostomy would require additional staff education to ensure proper care and assessment.
Improper Medication Storage and Temperature Monitoring
Penalty
Summary
Medication storage was not maintained according to the facility’s policy on two nursing units, the 1st floor and 3rd floor. The policy reviewed stated that medications and biologicals must be stored according to manufacturer or pharmacy guidance, that refrigerated medications must be kept between 36 F and 46 F with temperature monitoring, and that medications must be properly labeled and separated from food items. During observation of the 3rd floor medication room with an LPN, the refrigerator temperature log was found to be dated July 2025, and an employee lunch bag was inside the medication refrigerator along with Novolin insulin dated January 2026, Lanzapizole dated February 2026, and a multi-use insulin bottle with no date. The observation showed that the refrigerator was being used to store both medications and food items, and that the temperature log was not current. In the 1st floor medication storage room, two bottles of Vitamin B12 500 mcg were observed with an expiration date of January 2026. Observation of the 1st floor medication refrigerator also revealed no temperature record for the refrigerator, although the temperature at the time of observation was 39 F. The LPN present during the observation confirmed these findings. The cited deficiency was based on failure to properly store and document medications and refrigerated supplies on the two units.
Failure to Implement Restorative Splinting and ROM Program
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received treatment and services to maintain or improve ROM and mobility. Resident R93 had diagnoses including hemiplegia or hemiparesis and malnutrition, and the care plan identified the resident as at risk for alterations in comfort related to left-side flaccidity and immobility, with interventions to assist the resident to a position of comfort using positioning devices. Occupational therapy discharge documentation and restorative nursing goals indicated that the resident was to wear a left-hand splint daily for 4 to 6 hours with skin checks before and after use, and to perform daily upper and lower extremity active ROM. The restorative nursing program goals were acknowledged by RN E13, who was trained in the procedures for the program. Observations showed Resident R93 had a contracture to the left hand, and a splint instruction picture was posted at the bedside directing staff to apply the splint daily and complete skin checks before and after application. The resident stated staff do not apply the splint, and later observation again found the resident not wearing it. The assigned LPN confirmed the resident was not wearing the splint and reported there was no physician order in the clinical record for it. The Director of Rehabilitation confirmed the splint should be applied daily and stated therapy recommended the left-hand splint in December 2025 and that it had never been discontinued. Review of the clinical record found no documented evidence that the restorative nursing recommendations were implemented, including no documentation that the splint was applied daily with skin checks from December 3, 2025 through April 16, 2026.
Improper Handling of Blood Specimen Transport
Penalty
Summary
The facility failed to maintain infection control practices related to the collection and transport of biohazard specimens on the 2nd floor nursing unit. Facility policy for Collection and Transport of Specimens, revised March 20, 2026, stated that specimen collection items are to be kept in a separate area away from food, medications, and other items. During observation on April 13, 2026, at 10:20 a.m., consultant lab tech Employee E19 was holding a biohazard specimen transport pouch containing a vial of blood and placed the pouch inside a cooler filled with ice at the 2nd floor nurses station, then used the ice scoop to pour ice into the pouch. When asked about the process, Employee E19 stated this was normal practice. In a later interview, Registered Nurse Employee E7 stated the cooler of ice was intended for resident drinking water and should not be used for blood specimen samples.
Unsanitary Conditions on 2nd Floor
Penalty
Summary
The facility failed to ensure a sanitary and homelike environment for one of three nursing units, the 2nd floor. During an initial tour of the 2nd floor on April 13, 2026, surveyors noted a strong feces odor in the back hallway. Later that morning, Resident R93's toilet was observed to be covered in feces. R93 reported accidentally making a mess on the toilet overnight, and a nurse aide confirmed that the toilet was still covered in feces at the start of the 7:00 a.m. shift. On April 16, 2026, surveyors also observed breakfast meal trays left on the counter in the nourishment room and a hole in the wall behind the sink on the 2nd floor.
Pest Activity Observed in 3rd Floor Dining Room
Penalty
Summary
The facility failed to ensure that the environment remained free of pests in one of three dining rooms, specifically the 3rd floor dining room. During an interview on April 13, 2026, Resident 1 reported repeatedly seeing mice in her room and provided photographs documenting rodents in the living environment. During an interview on April 15, 2026, Resident 154 stated that mice were frequently observed throughout the unit and that the issue had been ongoing for several months without resolution. The resident also reported seeing a mouse earlier that day in the third-floor dining room under the PTAC unit.
Failure to Maintain Effective Rodent Control Throughout Facility
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of rodents, despite having a policy that assigns responsibility for a pest-free environment through contracted pest control services on a periodic basis. Review of pest control service reports showed ongoing and repeated interventions for rodent activity throughout the facility, including placement of snap traps in a staff bathroom, identification of rodent feces near vending machines, and capture of a mouse in the maintenance office. Documentation also showed rodent activity in multiple resident rooms, the third-floor therapy area, and other common areas, with repeated replacement of glue boards and snap traps, indicating persistent rodent concerns across various locations. Interviews and observations further confirmed active rodent presence in resident care areas. Two of eight alert and oriented residents reported seeing mice in their rooms, and family members of a resident reported observing mice in that resident’s room, providing photographs and identifying structural deficiencies such as holes in baseboards and near the heating/air conditioning unit that could allow rodent entry. During a facility tour, mouse droppings were observed in specific first-floor resident rooms, including on the floor near windows, on top of heating/air conditioning units, and behind a headboard, along with a visible hole in a baseboard along a bathroom wall. Staff interviews across multiple floors, including first-floor staff, kitchen staff, nurse aides, and licensed staff, confirmed sightings of mice in resident areas and in the hallway adjacent to the kitchen, demonstrating that rodent activity was occurring in multiple parts of the facility.
Failure to Immediately Report Resident Abuse Allegation
Penalty
Summary
Facility staff failed to immediately report an allegation of verbal and physical abuse involving a resident with severe cognitive impairment. According to the facility's abuse prohibition policy, all allegations of abuse must be reported immediately, investigated, and documented, with the administrator responsible for reporting to local authorities within 24 hours. On the date in question, a cognitively intact resident, who shared a room with the affected resident, witnessed a nursing assistant using foul and racially abusive language toward the resident with memory problems. The witness reported the incident to the licensed nurse responsible for their care during the shift. Despite this report, the licensed nurse did not immediately notify the supervisor on duty about the alleged abuse. Documentation later submitted to the Department of Health confirmed that the nursing assistant verbally abused the resident and that the nurse neglected to report the incident as required by policy. The resident who was the subject of the abuse was noted to have severe cognitive impairment but no physical limitations, and was ambulatory with supervision and a walker.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios on several occasions, as evidenced by document review and staff interviews. Specifically, the facility did not maintain the mandated staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the night shift. This deficiency was observed on multiple days across December 2024, January 2025, and February 2025. For instance, on December 27, 2024, the day shift had 15 NAs for 169 residents, falling short of the required 16.9 NAs. Similarly, on January 18, 2025, the night shift had only 6 NAs for 171 residents, whereas the minimum required was 11.27 NAs. During an interview with the Nursing Home Administrator and Director of Nursing on February 12, 2025, it was revealed that the facility did not intentionally staff below the minimum requirements. However, they experienced challenges in maintaining staffing levels due to call outs caused by inclement weather and illness, which resulted in unfilled open slots. This situation led to the facility's inability to meet the regulatory staffing requirements on the specified dates.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Deficiency in Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on nine out of twenty-one sampled days. This deficiency was identified through a review of the facility's nursing staffing sheets for specific weeks between December 2024 and February 2025. On the identified days, the facility's staffing hours fell below the required threshold, with recorded hours ranging from 2.94 to 3.16. The facility administration confirmed the failure to meet the nursing hour requirements during an interview conducted on February 12, 2025.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Deficiency in PICC Line Care Competency
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with PICC lines. Specifically, two employees, identified as E8 and E9, did not have documented competencies for PICC line care and management. This deficiency was identified during a review of clinical records, facility documentation, and staff interviews. The Director of Nursing was unable to provide the requested competency documentation for these employees during the survey. The deficiency was further evidenced by the case of Resident R137, who had a PICC line in the right upper extremity. The resident's treatment administration record (TAR) showed no documented evidence of required dressing changes and assessments on multiple dates in June and July 2024, as ordered by the physician. The lack of documentation indicated that the necessary PICC line care, including dressing changes and assessments of external catheter length and arm circumference, was not completed as required.
Inadequate Infection Control and Surveillance in LTC Facility
Penalty
Summary
The facility failed to establish an effective infection control program, particularly in infection surveillance, catheter care, and the use of personal protective equipment (PPE) with transmission-based precautions. Observations revealed that a nurse aide, Employee E4, entered a room of a resident with confirmed COVID-19 without wearing the required PPE, which included a gown, face shield, and gloves, despite signage indicating the need for such precautions. This lapse in protocol was confirmed by a licensed nurse, Employee E5, who acknowledged the necessity of full PPE for entering the room of a COVID-19 positive resident. Additionally, the facility's catheter care practices were found to be inadequate. Observations showed that Resident R163's catheter bag was placed directly on the floor, contrary to the facility's policy that requires catheter bags to be kept off the floor to prevent infection. This improper placement was confirmed by Employee E5, who acknowledged the deviation from the established protocol. The facility's infection surveillance logs from March to June 2024 were incomplete, lacking critical information such as infection type, organism identification, and signs and symptoms for numerous cases. This deficiency in documentation was confirmed by the Infection Preventionist, Employee E7, who admitted the logs were incomplete. The lack of comprehensive infection surveillance data indicates a failure to effectively monitor and manage infections within the facility.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program over a five-month period, as evidenced by a lack of antibiotic use protocols and a system to effectively monitor antibiotic usage. The facility's policy, dated August 7, 2024, required the implementation of an Antibiotic Stewardship Program (ASP) that included antibiotic use protocols and systems for monitoring antibiotic use. However, the facility did not adhere to these requirements, as confirmed by the Infection Preventionist during an interview. Throughout the months of March to June 2024, the facility's documentation revealed significant gaps in the monitoring and documentation of antibiotic use. In March, all 11 antibiotic orders lacked documented symptoms on the infection surveillance tool, and there was no record of stop dates, total days of therapy, outcomes, or adverse events. Similar deficiencies were noted in April, May, and June, with a consistent absence of symptom documentation and no antibiotic review to determine the appropriateness of usage. The facility's failure to document and review antibiotic use was further corroborated by the Infection Preventionist, who confirmed the absence of use protocols and an effective monitoring system. This lack of compliance with the facility's own policies and CDC guidelines for antibiotic stewardship resulted in a deficiency under 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(d)(1)(5).
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program included mandatory training for staff on the elements and goals of the program. This deficiency was identified through a review of the education records of four employees, including two Licensed Practical Nurses and two Nurse Aides, which revealed no evidence of training related to the facility's QAPI program. The findings were confirmed with the Director of Nursing, indicating a lack of compliance with the required staff development and management responsibilities as outlined in the relevant Pennsylvania Code sections.
Medication Administration Errors for Resident
Penalty
Summary
The facility failed to ensure medications were administered per physician orders for a resident, identified as R68. The resident, who was cognitively intact and had a recent diagnosis of a urinary tract infection, reported missing doses of Oxycodone, an opioid medication prescribed for chronic pain. The medication was discontinued on July 23, 2024, and the resident did not receive it on July 24 and the morning of July 25, 2024. The medication was re-ordered on July 25, 2024, and the resident received the evening dose that day. The Director of Nursing confirmed there was an error in the medication ordering process, resulting in the missed doses. Additionally, the resident had a physician order for Ciprofloxacin, an antibiotic for treating urinary tract infections, to be administered twice daily for 14 days starting July 14, 2024. The medication administration record showed that the evening doses on July 19, 21, and 25, 2024, were not signed out as administered. This was confirmed by the Regional Registered Nurse, who observed that the pills were still in the medication bubble pack, indicating the doses were missed.
Failure to Adhere to PICC Line Care Protocols
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident with a Peripherally Inserted Central Line Catheter (PICC) in accordance with professional standards of practice. The facility's policy required the measurement of the upper arm circumference and the external length of the PICC catheter at insertion, with each dressing change, and when clinically indicated. However, observations and reviews of clinical records revealed that the dressing change and necessary assessments were not completed as ordered by the physician for Resident R137. Specifically, there was no documented evidence of dressing changes or assessments on several dates in June and July 2024. The Director of Nursing confirmed that the PICC line dressing change, assessment, and monitoring were not completed for the resident as ordered by the physician and according to the facility protocol. This deficiency was identified through observations, clinical record reviews, and interviews with staff, highlighting a failure to adhere to the facility's policies and procedures for PICC line care. The report cites specific Pennsylvania Code regulations related to resident care policies and nursing services that were not followed.
Medication Availability Deficiency for Resident
Penalty
Summary
The facility failed to ensure timely availability of a prescribed medication for a resident, identified as Resident R135, who has multiple health conditions including diabetes, obesity, chronic kidney disease, hypertension, and vitamin D deficiency. The resident was prescribed a K2 Plus D3 oral tablet to be administered once weekly on Saturdays. However, the medication was not consistently available, leading to missed doses on several occasions. Specifically, the medication was not administered on March 2, March 23, March 30, April 6, and April 13, 2024, due to it being on back order or on hold, with no documented reason for some of these dates. Interviews and record reviews revealed that the resident reported not receiving the vitamin supplement regularly because the facility frequently ran out of it. The Director of Nursing was unaware of the reasons for the medication's unavailability from the pharmacy. The medication was eventually discontinued for the remaining dates in April 2024 due to its unavailability. This deficiency was identified under the Pennsylvania Code sections related to pharmacy services, resident care policies, and nursing services.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens of two residents were free from unnecessary drugs, specifically related to the use of antipsychotic medications without adequate monitoring. The facility's policy on medication management requires that each resident's drug regimen be reviewed to ensure it is free from unnecessary drugs, including those without adequate monitoring. However, the clinical records for Resident R45 and Resident R29 revealed a lack of evidence that the facility conducted ongoing monitoring of the side effects, adverse consequences, and efficacy of the psychotropic medications prescribed to them. Resident R45 had orders for Clonazepam for anxiety and Trazodone for depression and insomnia. Despite having a care plan that included monitoring for changes in mental status and functional level, there was no evidence of ongoing monitoring for the side effects and efficacy of these medications. Similarly, Resident R29 was prescribed multiple medications, including Divalproex Sodium for substance abuse disorder, Lorazepam for anxiety, Mirtazapine for poor appetite and depression, Quetiapine Fumarate for schizophrenia, and Trazodone for anxiety and schizoaffective disorder. The care plan for Resident R29 also included interventions for behavior monitoring and side effects, but the clinical record lacked evidence of ongoing monitoring. An interview with Employee E7, the Infection Preventionist, confirmed that residents on psychotropic drugs should have orders to monitor side effects and adverse effects, with staff documenting findings on an ongoing basis. The facility's failure to adhere to its medication management policy and ensure adequate monitoring of psychotropic medications resulted in a deficiency related to the unnecessary use of drugs for these two residents.
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Nursing homes near Wyncote
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hopkins Center | 0.3 mi | ★★★★★ | 1 | 0 |
| Wyncote Care Center | 0.4 mi | ★★★★★ | 11 | 0 |
| York Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 17 | 1 |
| Ivy Hill Post Acute Nursing & Rehabilitation Llc | 1.8 mi | ★★★★★ | 19 | 0 |
| Edgehill Nursing And Rehab Cen | 1.9 mi | ★★★★★ | 0 | 0 |
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