Inspection Results » Hillcrest Manor

Health Inspection on October 2, 2018 ^[1]

1. Pattern: Actual harm that is not immediate jeopardy

   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-11-07)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Implement a program that monitors antibiotic use. (Corrected 2018-11-24)
   • Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. (Corrected 2018-11-24)
   • Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. (Corrected 2018-11-07)
   • Ensure the activities program is directed by a qualified professional. (Corrected 2018-10-04)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2019-01-25)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-11-07)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2019-01-25)
   • Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne (Corrected 2018-11-24)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2019-01-25)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-11-24)
   • Provide and implement an infection prevention and control program. (Corrected 2019-01-25)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2018-11-24)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2019-01-25)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-11-24)
   • Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (Corrected 2018-11-24)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-11-24)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2019-01-25)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-11-07)
   • Honor the resident's right to choose his or her attending physician. (Corrected 2018-11-07)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-01-25)
   • Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. (Corrected 2018-11-07)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-11-07)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-11-24)