Hillview Health Care CTR

In the surveyor’s words

From the most serious findings on record at Hillview Health Care CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 4, 2023

  Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed for fall concerns, out of a total sample of 3 (R1). On [DATE], a Certified Nursing Assistant (CNA) attempted to provide care to R1 without waiting for a second person to assist as directed in R1's care plan. R1 rolled off the bed and fell approximately 4 feet to the floor. R1 suffered multiple fractures and a secondary fat emboli secondary to multiple fractures. This created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator) was informed of the Immediate Jeopardy on [DATE] at 1:50 PM. […]

• Actual harm, isolatedF689Jul 14, 2022

  Based on interview, and record review, the facility did not ensure each resident received staff assistance to prevent accidents for 1 of 4 residents (R48) reviewed for incidents/accidents out of a total sample of 19. R48 has severe cognitive impairment, left sided paralysis due to stroke, and requires extensive assist of two staff with bed mobility and transfers. Staff determined that R48 was a 1 assist vs. a 2 assist without a nursing assessment and attempted to perform cares on R48 with 1 staff member rather than with the assistance of 2 staff members per R48's MDS (minimum data set) assessment. […]

• Actual harm, isolatedF563May 6, 2021

  Based on interviews and record review, the facility did not ensure the right of a resident to receive visitors at the time of their choosing for 1 Resident (R128) of 2 residents reviewed for end of life visitation. The facility restricted R128's spouse, 6 children, and her Priest access to R128 when she was showing signs of decline and then actively dying. R128, a lifelong Catholic, did not receive her last rites due to the facility's visiting restrictions. Using reasonable person concept, the facility's restricted visitation policy caused R128 actual harm when her family was put in a position to choose between the two things that brought R128 comfort, her faith (receiving last rites) or her family. […]

• No harm, potential for more than minimal, widespreadF880Dec 1, 2025

  Based on interviews, record reviews, and facility policy reviews, the facility failed to follow infection control and prevention guidelines for environmental cleaning of floors in resident areas for 34 sampled residents. Findings include:Review of the Centers for Disease Control (CDC) Environmental Cleaning Procedures dated 03/19/24 revealed, spills of bodily fluids. Regardless of an area's risk level, spills or contamination from blood or body fluids (e.g., vomitus) must be cleaned and disinfected immediately using a two-step process. She said she expected staff to use detergent and then sanitize the floors after cleaning. Review of the Centers for Disease Control (CDC) Environmental Cleaning Procedures dated 03/19/24 revealed, spills of bodily fluids. […]

• No harm, potential for more than minimal, widespreadF812Nov 13, 2024

  Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 51 residents who reside in the facility. Facility staff did not conduct appropriate hand hygiene and were observed touching ready to eat foods with contaminated gloved hands. This is evidenced by: Facility's policy Hand Hygiene-Kitchen with the revised date of 08/31/22 read in part, 2. How to wash hands: .c. Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Pay close attention to the fingernails using a brush as needed. Scrub for a minimum of 10 to 15 seconds within the 20 second hand washing procedure. […]