Medical Hill Healthcare Center

In the surveyor’s words

From the most serious findings on record at Medical Hill Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF755Jul 6, 2026

  Based on observation, interview and record review, the facility failed to ensure, for Residents 2-4, the scheduled (controlled medication, narcotic) medication record system was complete (all documents available) and accurate (numbers match). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility did not have complete records. The facility did not have accurate records. These failures resulted in the potential for undetected loss and diversion. In addition, these failures resulted in the potential for avoidable medication errors. […]

• No harm, potential for more than minimal, widespreadF812Mar 14, 2024

  Based on observations, interviews, and facility policy review, the facility failed to ensure staff prepared and served foods for residents in a sanitary manner. Specifically, staff failed to implement proper hand hygiene practices during meal service to prevent potential cross-contamination. This failure had the potential to affect 115 of 115 residents who received meals from the dietary department. Findings included: Review of a facility policy titled, Food Preparation, dated 2023 (no month specified), revealed, Employees will prepare food in a clean and safe manner to protect residents and staff from foodborne illness. The policy specified, 1. Hands should be properly washed prior to food preparation. Plastic gloves should be worn to avoid direct contact with food, i.e. […]

• No harm, potential for more than minimal, patternF755Aug 8, 2025

  Based on observation, interviews, and record review, the facility failed to provide pharmaceutical services and procedures to six of six sampled residents (Residents 58, 93, 24, 121, 29, and 69) that ensured acquiring, dispensing, administration, and maintaining accurate controlled drug records when:Resident 93 and Resident 58's routine medications were not available during medication administration.The Controlled Drug Records (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) for four out of four sampled residents (Residents 29, 121, 69, and 24) did not reconcile with the Medication Administration Records (MAR). […]

• No harm, potential for more than minimal, patternF761Aug 8, 2025

  Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices with census of 119 when: 1) A box of Resident 59's discontinued and unlabeled oral prescribed medication was stored in an active storage area in medication cart #3.2) Resident 65's discontinued as needed prescription medication was stored in medication cart #2.3) Multiple medications with different routes of administration (a way by which a drug is taken into the body) were stored together in medication carts #2 and #3.4) An unopened insulin vial with pharmacy label of refrigerate until opened was stored at room temperature in medication cart #2.These failed practices could contribute to unsafe use of medications and potential for medication error. […]

• No harm, potential for more than minimal, patternF842Aug 8, 2025

  Based on interview and record review the facility failed to ensure accuracy of medical record for four of four sampled residents (Residents 24, 121, 29, and 69) when:1. Resident 24 had a physician's order to give an as needed lorazepam (a controlled substance used by calming the nervous system and reducing feelings of anxiety, fear, and worry) was created on 8/5/25 with a start date of 8/1/25, resulting in a four-day backdate (put an earlier date to a document than the actual one) without verification.2. […]