HILLCREEK REHABILITATION AND CARE

Nursing Home Inspector

3116 BRECKINRIDGE LANE
LOUISVILLE, KY 40220
Jefferson County
Phone: 502-459-9120
Provider Number: 185095
Last Inspection: 10/06/2016

About the Nursing Home

Number of Beds: 172
Number of Residents: 156
Beds Available: 16
Percent Occupancy: 91%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

0

Facility
13

County
12

KY
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

0

2016
42

2015
34

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

8/29/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 9/30/2015
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 9/30/2015
 
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Isolated : Minimal 3 9/30/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 9/30/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Immediate 5 9/30/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 9/30/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 9/30/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Immediate 5 9/30/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 9/30/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 9/30/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 9/30/2015
 

6/5/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 7/18/2014
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 7/18/2014
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 7/18/2014
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 7/18/2014
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 7/18/2014
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Pattern : Minimal 4 7/18/2014
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 7/18/2014
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 7/18/2014
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Pattern : Minimal 4 7/18/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

8/4/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide written records when a resident is transferred or discharged. Isolated : Minimal 3 8/31/2017
 

3/4/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Immediate 5 4/13/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Immediate 5 4/9/2016
 

4/16/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 5/28/2015
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 5/28/2015
 

1/16/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide timely notification to the resident before transfer or discharge. Isolated : Minimal 3 1/26/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg KY State Avg
Number of Residents 156 93.77 79.68
Registered Nurses 0.45 0.84 0.86
Licensed Practical / Vocational Nurses 1.19 1.10 0.87
Certified Nursing Assistants 1.68 2.33 2.40
Total Staff Hours 3.31 4.27 4.13

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% KY State Avg%
of high risk long-stay residents with pressure ulcers 3 6 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 90 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 92 91 95
of long-stay residents experiencing one or more falls with major injury 2 3 3
of long-stay residents who have depressive symptoms 0 1 2
of long-stay residents who lose too much weight 3 7 7
of long-stay residents who received an antianxiety or hypnotic medication 15 26 31
of long-stay residents who received an antipsychotic medication 10 13 19
of long-stay residents who self-report moderate to severe pain 7 6 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 28 23 21
of long-stay residents whose need for help with daily activities has increased 19 18 16
of long-stay residents with a catheter inserted and left in their bladder 5 2 2
of long-stay residents with a urinary tract infection 4 5 4
of low risk long-stay residents who lose control of their bowels or bladder 43 61 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 94 79 84
of short-stay residents who had an outpatient emergency department visit 20 10 14
of short-stay residents who made improvements in function 66 61 59
of short-stay residents who newly received an antipsychotic medication 2 2 2
of short-stay residents who self-report moderate to severe pain 29 16 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 70 79 83
of short-stay residents who were rehospitalized after a nursing home admission 23 22 22
of short-stay residents who were successfully discharged to the community 56 57 46
of short-stay residents with pressure ulcers that are new or worsened 1 1 1