Hildebrand Care Center

In the surveyor’s words

From the most serious findings on record at Hildebrand Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 17, 2024

  Based on record review and interviews, the facility failed to ensure one (#1) out of three sample residents received the care and services necessary to maintain her highest practicable level of well-being. Specifically, the facility failed to serve Resident #1 the correct physician-ordered mechanical soft texture diet which contributed to her mental and physical decline. Resident #1, who had a history of dysphagia (difficulty swallowing) and dementia, had a physician-ordered texture diet of mechanical soft. On [DATE], Resident #1 was served large pieces of steak, mashed potatoes, and a bread roll for dinner. […]

• Actual harm, isolatedF689Jul 6, 2023

  Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents remained as free from accident hazards as possible. The facility failed to ensure interventions were implemented to prevent major injury from falls for Resident #1. Interviews during the survey revealed the facility still was not implementing interventions for toileting per the care plan. Furthermore, interviews and documentation revealed the staff did not provide transfer assistance to the resident with two person assistance as ordered. Due to the facility's failures to implement effective interventions, Resident #1 sustained a fracture of the left hip from a fall on 2/1/23. […]

• Actual harm, isolatedF697Jul 6, 2023

  Based on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#1) of three residents reviewed out of three sample residents. Resident #1 fell on [DATE] in the bathroom. He had increased pain, at the facility, for two days until 2/3/23, when an x-ray confirmed he had a fracture of the left hip. Two resident representatives were interviewed. Both representatives said Resident #1 had called them all night long on 2/1/23 and 2/2/23 complaining of being in pain and being unable to move his left leg. […]

• Actual harm, isolatedF692May 11, 2021

  Based on observations, record review, and interviews; the facility failed to maintain acceptable parameters of nutritional status for one (#52) of three residents reviewed for nutrition out of 22 total sample residents. Resident #52 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to document, track and monitor weight records consistently. The facility failed to provide the appropriate level of assistance with eating. The facility failed to update the resident's care plan with nutritional risks and interventions. Due to the facility failures, Resident #52 sustained a 13 pound avoidable weight loss considered significant in six months. Findings include: I. […]

• Actual harm, isolatedF742May 11, 2021

  Based on observation, record review and interviews the facility failed to provide appropriate treatment and services to a resident with depression to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one (#16) of four out of 22 sampled residents. Resident #16, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On several occasions, it was documented and staff interviews revealed the resident was persistently depressed and had feelings of anxiety. The facility failed to provide the appropriate treatment and services to the resident to attain the highest practical mental and psychosocial well-being. Cross-reference F745 provision of social services. Findings include: I. […]