Hill Crest Manor

In the surveyor’s words

From the most serious findings on record at Hill Crest Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 31, 2023

  Based on record review and interview, the facility staff failed to keep one resident (Resident #1) free from abuse when Nurse Aide (NA) A provided the resident with a green leafy plant material that appeared to be marijuana/cannabis (a psychoactive drug from the cannabis plant) on 1/12/23 and the resident ingested it on 1/12/23 and 1/13/23. The resident was prescribed medications noted to have both major and moderate interactions with cannabis. The resident experienced a change in condition that included, vomiting, decreased oxygen saturation (measurement of the amount of oxygen in the blood with a normal reading of 100%) of 65% requiring use of oxygen, gray skin tone, an increased heart rate of 115, and decreased cognition. […]

• Actual harm, isolatedF600Mar 28, 2023

  Please refer to Event ID: Y8C912 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 1/31/23. Based on interview and record review, the facility failed to keep two residents (Resident #1 and #2) free from abuse when Certified Medication Technician (CMT) A grabbed Resident #1's arm during a struggle over a magazine. CMT A caused a bruise and swelling to the resident's right arm. CMT A called Resident #2 a Needy little bitch when he/she activated his/her call light, because he/she had spilled his/her medications on his/her chest. The Director of Nursing (DON) was aware of both allegations and did not follow facility policy to protect residents pending the investigation findings. CMT A was allowed to continue to provide care to residents. […]

• Actual harm, isolatedF580Jan 31, 2023

  Based on interview and record review, the facility failed to notify Resident #1's physician in a timely manner when staff discovered the resident ingested a green leafy plant material that appeared to be marijuana/cannabis (a psychoactive drug from the cannabis plant) and experienced a change in condition that included, vomiting, decreased oxygen saturation (measurement of the amount of oxygen in the blood with a normal reading of 100%) of 65% requiring use of oxygen, gray skin tone, an increased heart rate of 115, and decreased cognition at 11:00 A.M. on 1/13/23. Licensed Practical Nurse (LPN) A placed the resident on five liters of oxygen, but did not call the physician. The facility Administrator and Director of Nursing (DON) assessed the resident at 1:30 P.M. […]

• No harm, potential for more than minimal, widespreadF725Sep 13, 2023

  Based on interview, observation, and record review, the facility failed to ensure adequate nursing department staffing was in place to meet the needs for 4 of 14 sampled residents (Resident #5, #29, #14, #205); related to adequate grooming, providing showers, and prevention of pressure ulcers and skin breakdown for dependent residents. The facility census was 53. Review of the facility's Payroll Based Journal, dated fiscal year quarter one 1/1/23 to 3/31/23, showed: -One star rating for staffing -Excessively low weekend staffing Review of the facility provided policy, Staffing, Sufficient and Competent Nursing, dated August 2022 showed in part: -Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related… […]

• No harm, potential for more than minimal, widespreadF727Sep 13, 2023

  Based on record review and interview, the facility failed to maintain Registered Nurse (RN) coverage for eight consecutive hours, seven days per week. The facility census was 53. Review of the Staffing, Sufficient and Competent Nursing Policy, dated August 2022, showed: - A RN provides services at least eight consecutive hours every 24 hours, seven days per week; - The Director of Nursing (DON) may serve as the charge nurse only when the daily occupancy of the facility is 60 or fewer residents. […]