Hillside Manor Rehab & Extended Care Center

Based on observations, interviews and record reviews, the facility did not ensure that the residents' environment was maintained in good repair as evidenced by: 1) multiple broken dresser and armoire doors, 2) missing handles from dressers, armoires and nightstands and 3) baseboards separated from walls exposing a large hole and wiring. This was evident for 3 of 10 nursing units. (Units 5, 6, and 10)

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. On 1/14/10, during the initial tour of unit 10, at approximately 10:10 A.M., in room 1006 near B bed, the baseboard molding was observed separated from the wall exposing a hole approximately 4 inches long by 6 inches wide with electrical wiring visible. On 1/20/10, at approximately 10:20 A.M., the baseboard molding was observed in the same condition.

The Maintenance Work Order Log Books dated 11/1/09 through 1/20/10 documented on 1/14/10 a request to fix the hole in the wall in room 1006 B.

On 1/14/10, at approximately 10:12 A.M., the Registered Nurse Supervisor was interviewed and stated she was unaware of the wall needing repair and that the maintenance department was doing renovations throughout the building. She further stated that she would notify maintenance immediately to repair the wall.

On 1/20/10, at approximately 10:25 A.M., the Registered Nurse was interviewed and stated that she had not seen the wall that morning when she did her rounds. She further stated that when any repair is needed, that maintenance is notified through a communication log book and that she would check the log book to see if maintenance had been notified.

On 1/20/10, at approximately 1:55 P.M., the Chief Engineer was interviewed and stated that nursing documented on the log book and maintenance did fix the other items that needed to be fixed on that page of the log book, but must have overlooked the request to repair the wall in room 1006.

2) During an initial tour of the facility's 6th floor on 1/14/2010 at 9:45 AM the following was observed:

In room 609 B, the top drawer for the resident's wardrobe was missing the handle and leaning to one side.

During an initial tour of the facility's 5th floor on 1/14/2010 at approximately 11 AM, the following observations were made:

In room 506 A the top drawer of the resident's wardrobe was extended and leaning to one side.
In room 507 A and 507 B the bedside tables were missing drawer handles. The drawers were also leaning to one side and were not closed.
In room 508 B the bedside table was missing the drawer.
In room 509 B the wardrobe drawer had no handle.
In room 509 A the bedside table door was hanging by one hinge.

The Registered Nurse Supervisor (RNS) who was present on the tour was asked if the facility was aware of the residents' furniture being in disrepair. She stated that there were work orders communicated via the maintenance log by the nursing staff for anything broken to be fixed by maintenance.

The floor maintenance log from 10/09-1/10/10 was reviewed and documented a request dated 11/14/2009 for "509 B top drawer on closets are missing their handles". There was no other evidence of work requests for the other rooms that were observed.

On 1/19/2010 at 10 AM, an interview was conducted with the RN in charge on the 5th floor and he stated that the Engineering department usually checks with the floor two times per day and they fix what they can within their shift.

An interview was conducted with the facility's Chief Engineer on 1/19/2010 at 3:30 PM. He stated that the work request tickets were usually picked up between 9 AM and 9:30 AM each day. He further stated that regarding the residents' furniture "I know we have problems"and that this was due to unavailability of replacement parts to fix the broken items.

415.5(h)(2)

Based on observations, interviews and record review, the facility did not ensure that each resident's mechanical equipment was maintained in good repair as evidenced by: 1)There were greater than 15 requests for repair of a resident room heater over a 2 month period with no documented evidence of the repairs. This was evident for 1 sampled resident (#19) in one (1) of ten (10) nursing units. (5th Floor)

Findings are:

Resident #19 has resided in the facility since 10/30/05 with diagnoses including Hypertension, Seizure Disorder and Arthritis.

The 5th floor "Maintenance Log Book" documented 15 requests between 11/24/09 and 1/11/10 to "please fix heater in 509...both residents are complaining that the heater blows out cold air..."

Resident #19's heater was observed in the "heat" position at 11:28 A.M. on 1/19/10. There was warm air blowing from the heater. At 11:33 A.M., the heater was observed to be blowing cold air while the control was in the heat position.

An interview was conducted with the resident on 1/19/10 at 10:20 A.M. The resident stated that he has lived in the facility for several years and there was always a problem with getting heat in his room. The resident was asked if the facility had been made aware of the problem. He replied, "several times, they come and do something and then it doesn't work right after." The resident also demonstrated that he removes the heater cover and kicks the left lower corner to "get it to come on", because "that's the only way to get heat in the room."

An interview was conducted with an Engineering Technician on 1/20/10 at approximately 12 P.M. He was asked how the facility documented the completion of requested repairs. He stated that "we are supposed to write it down in the maintenance log but we keep the copies and write on those." Copies of the requests to fix the heater in room 509 were reviewed. There were 8 work orders with no documented evidence that the work requests had been completed.

The facility's Chief Engineer was interviewed on 1/20/10 at 1:55 P.M. He stated that multiple requests for repair of the same issue was possibly due to lack of communication among nursing staff. He was also asked if he was aware that the resident in room 509 has been kicking his heater for it to work. He stated that the resident has lived in the facility for a long time and is able to time the compressor and kick it when it would have come on anyway.

415.5(e)(1)(2)

Based on observation and staff interviews, the facility did not ensure that resident care equipment was maintained in a manner to prevent the spread of infection as evidenced by: 1) opened and outdated tube feeding supplies, 2) uncovered and unlabeled personal care items in 2 rooms, and 3) unlabeled urinals in a bathroom shared by 4 residents. This was evident for one (1) of ten (10) nursing units. (Unit 6)

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During an initial tour of the facility's 6th floor on 1/14/2010 at 9:45 A.M., the following were observed:

1) Opened gastric tube irrigation sets dated 1/12/10 were observed in the bedside tables of rooms 607A, and 619 B.

2) Uncovered and unlabeled toothbrushes were observed on the shelf above the sink in rooms 619, and 623. There was also an uncovered and unlabeled toothbrush on a shelf in the bathroom between rooms 618 and 619.

3) Two (2) unlabeled urinals were observed in the bathroom between rooms 607 and 608.

The Registered/Charge Nurse, who accompanied surveyor on the tour, was interviewed at that time about the facility's policy for changing irrigation sets for tube fed residents. She stated that the irrigation sets are to be replaced daily by the 11-7 nursing staff.

The 6th floor Registered Nurse Supervisor(RNS) and the facility's Clinical Educator were interviewed on 1/19/10 at approximately 11 A.M. The Clinical Educator stated that the facility policy requires irrigation sets to be changed at least every 24 hours. The RNS stated that the nurse may have written the wrong date by mistake.

An interview was conducted with a Certified Nursing Assistant (CNA) on 1/20/10 at 9:30 A.M. She was asked about the care of resident personal care items. She stated that the items such as toothbrushes are to be placed in a ziploc bag and put away in the resident's drawer after each use. She also stated that the urinals should have the resident's name and are placed on the bottom shelf of the bedside table when not in use.

415.19(a)(1-3)