Troy Hills Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF835Feb 27, 2023

  Based on observations, interview, review of medical records and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure: a.) that policies and procedures were developed and implemented to mitigate the spread of infections, and b.) documented on-going staff education and in-services were completed to combat breaks in infection control practices. The multiple observed breaches in infection control practices by multiple facility disciplines, were identified on 02/08/23, 02/09/23, and 02/10/23 on 4 of 4 resident care Wings. […]

• Immediate jeopardy, widespreadF880Feb 27, 2023

  Part A Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility, who has been in an active COVID-19 outbreak status since 10/23/22, failed to ensure: a.) a system was in place and followed to prevent the spread of multidrug resistant infections (organisms resistant to multiple antibiotic treatments including Methicillin Resistant Staph Aureus [MRSA], extended spectrum beta-lactamase [ESBL], vancomycin resistant enterococcus [VRE]) and COVID-19 (a deadly virus), and b.) facility policies and current infection control guidance was followed to limit the spread of infection. […]

• Immediate jeopardy, patternF886Feb 27, 2023

  Based on interview and document review, it was determined that the facility, who was experiencing an outbreak of COVID-19 (a potentially deadly virus) failed to take immediate action to prevent the spread of COVID-19 by failing to: a.) follow facility policy and pertinent guidance to conduct immediate COVID-19 testing for residents by either, a broad-based or contact tracing approach when two Certified Nurse Aide's (CNA #1) who was symptomatic with a cough and fatigue worked on Wing 2, tested COVID-19 positive on 02/05/23 and worked on 02/03/23 and 02/04/23, and CNA #2, who was symptomatic with a cough and congestion tested COVID-19 positive on 02/03/23 and worked on Wing 1 on 02/01/23, b.) conduct immediate resident broad-based testing per facility policy on 02/08/23, 02/11/23 and… […]

• Actual harm, isolatedF689Feb 27, 2023

  Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to: a.) ensure the facility policy for Falls Management and Accidents/Incidents policy was followed to determine the causal factor and interventions were updated to prevent recurrent falls, for a cognitively impaired resident (Resident #45), who was identified as high fall risk, had a history of falls with injury which included a fall on 10/08/21 that resulted in a femur fracture that required hospitalization , a subsequent unwitnessed fall on 05/29/22, and a fall requiring hospitalization on [DATE] after sustaining a hematoma to the head, b.) supervision was provided to prevent recurrent falls c.) implement care plan interventions for a resident (Resident #1)… […]

• Actual harm, isolatedF760Jul 2, 2021

  Complaint Intake: NJ 3 Based on interview and record review, it was determined that the facility failed to ensure a resident was free from significant medication errors for 1 (Resident #1) of 3 residents reviewed for medication administration. Resident #1 received four medications in error, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], that were not prescribed to be administered to the resident. This resulted in Resident #1 experiencing a drop in vital signs and the resident had to be transferred to the hospital and admitted to the critical care unit (CCU). Findings included: 1. Resident #1 was initially admitted to the facility on [DATE], discharged to hospital on [DATE], and readmitted to the facility on hospice on [DATE]. […]