Miracle Hill Nursing & Rehabilitation Center, Inc

In the surveyor’s words

From the most serious findings on record at Miracle Hill Nursing & Rehabilitation Center, Inc, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 5, 2025

  Based on observation, interviews, and record reviews, the facility failed to ensure that a resident was free from harm and neglect when it failed ensure that residents with diabetes mellitus receive their insulin and/or blood glucose monitoring as ordered for 1 of 16 residents diagnosed with diabetes mellitus. (Resident #90) The findings include: A medical record review was conducted on Resident# 90, who was admitted in the facility on 11/10/2024. Resident #90 was noted to have an elevated blood glucose of 583 mg/dl and elevated A1C of 11.4% on 12/23/2024. There was no documented intervention or orders to address the elevated blood glucose level and elevated A1C. Record review showed no nursing actions and no medical orders had taken place on these laboratory results. […]

• No harm, potential for more than minimal, patternF677Jun 5, 2025

  Resident #50 On 6/02/25 at 1:17 PM, an interview was conducted with Resident #50. The resident looked disheveled and had her hair was unbrushed and oily. She stated she had only two showers since she was admitted to the facility. She further stated that both showers happened with Occupational Therapy (OT) staff members. A review of Resident #50's medical record was conducted. This resident was admitted on [DATE] with diagnoses that included needing assistance with Activities of Daily Living (ADL). The plan of care included ADL self-care deficit related to decreased functional mobility and activity tolerance and generalized weakness. […]

• No harm, potential for more than minimal, patternF919Apr 15, 2025

  Based on observations, staff interview, document review, and policy review, the facility failed to maintain a fully functional resident call system in 4 of 8 sampled facility bedrooms. (Rooms 11, 36, 18, and 48) The findings include: An observation of bedroom [ROOM NUMBER] (A and B beds) was conducted on 4/14/25 at 1:24 PM. The bedroom call light system was tested for both A and B bed and found to be not functional. An observation of bedroom [ROOM NUMBER] (A and B beds) was conducted on 4/14/25 at 1:50 PM. The bedroom call light system was tested and found to be not functional. An observation of unoccupied resident bedroom [ROOM NUMBER] was conducted on 4/15/25 at 9:18 AM. Resident bedroom [ROOM NUMBER]'s call light system was not functional. […]

• No harm, potential for more than minimal, patternF638Mar 14, 2024

  Based on record review, staff interview, and policy review, the facility failed to ensure quarterly review assessments (minimum data sets) were completed at least once every 3 months for 9 of 29 sampled residents. (Resident #18, #20, #26, #37, #53, #55, #68, #75, and #94) The findings include: A review of Resident #55's electronic medical record revealed a quarterly minimum data set (MDS) dated [DATE] as in progress but not complete. 30584 A record review of the electronic medical record for Resident #18 revealed the resident was admitted on [DATE]. A review of the MDS list for Resident #18 revealed the last quarterly MDS assessment was completed on 10/16/23. As of 3/12/24, the quarterly assessment dated [DATE] is still listed as In Progress. […]

• No harm, potential for more than minimal, patternF867Aug 26, 2021

  Based on observation, staff interviews, quality assurance performance improvement (QAPI) plan review, and policy review the facility failed to develop and implement adequate and appropriate action plans to correct identified concerns related to nursing staff preparing medications in advance for multiple residents. (Resident numbers 1-17) The findings include: An observation of medication cart 45 was conducted in the presence of employee B (agency contracted licensed practical nurse) and the Director of Nursing (DON) on 10/14/21 at approximately 8:56 AM. The top drawer of medication cart was observed to contain paper medication cups containing medications for resident numbers 1-17. The cups were labeled with the residents first or last name. […]