Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview and policy review the facility failed to ensure residents were treated with dignity
with respect related to names boldly printed on the back of a wheelchair as well as devices hanging off the
back of a wheelchair. This affected one (Resident #18) of one sampled resident reviewed for dignity.
Findings include:
Review of Resident #18's medical record revealed she was admitted on [DATE] with diagnoses that
included; essential hypertension, iron deficiency anemia, gastro-esophageal reflux, dementia without
behaviors, hearing loss, Alzheimer's disease, urinary tract infection, and altered mental status.
Review of Resident #18's quarterly Minimum Data Set (MDS) dated [DATE] revealed the following.
Resident #18's speech was clear, she usually understood, understands, and her cognition was severely
impaired. Resident #18 was dependent on two staff for bed mobility, required extensive assistance of two
staff for transfers, did not walk, used a wheelchair, and did not use a restraint.
Observation of Resident #18 on 12/10/19 at 9:57 A.M. revealed she was seated in a wheelchair in a
common area. The back of Resident #18's wheelchair had another person's name on it and the seat belt
was fastened and dangling from the back of the wheelchair.
Observation of Resident #18 on 12/11/19 at 8:28 A.M. revealed she was in the same wheelchair, in a
common area, at 9:54 A.M. she was in the same wheelchair in the activity room, and at 11:29 A.M. she was
again in the dining room in the same wheelchair.
Interview of Assistant Director of Nursing (ADON) #159 on 12/11/19 at 11:29 A.M. confirmed another
person's name was on the back of the wheel chair Resident #18 was using. ADON #159 stated families
donated wheelchairs and they were used for other residents. ADON #159 confirmed a seatbelt was
dangling off the back of the wheel chair and Resident #18 did not use a seat belt.
Interview of the Director of Nursing (DON) on 12/11/19 at 1:49 P.M. confirmed it was not dignified to have a
name printed on the on the back of a wheelchair, nor was it dignified having the seatbelt dangling off the
back of the wheelchair.
Review of the facility policy regarding dignity (dated 11/28/16) revealed each resident is accepted as a
valued individual, who deserves to be treated with dignity and respect.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
365444
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365444
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hill View Retirement Center
1610 28th Street
Portsmouth, OH 45662
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of
Resident #18's medical record revealed she was admitted on [DATE] with diagnoses that included;
hypertension, anemia, gastro-esophageal reflux, dementia without behaviors, hearing loss, Alzheimer's
disease, urinary tract infection, and altered mental status.
Review of Resident #18's quarterly MDS dated [DATE] revealed the following. Resident #18's speech was
clear, she usually understood, understands, and her cognition was severely impaired.
Review of Resident #18's plan of care dated 03/06/17 revealed no advanced directives were identified on
the plan of care.
Review of Resident #18's December 2019 physician's orders revealed the resident had advanced
directives, but no specific advance directive was identified.
Review of Resident #18's medical record revealed on 11/23/03 she formulated a living will and on 06/06/11
the resident's durable power of attorney elected Do Not Resuscitate Comfort Care-Arrest (DRNCC-A) as
their advanced directive.
Interview of Assistant Director of Nursing (ADON) #159 on 12/11/19 at 11:29 A.M. confirmed there was no
order for DRNCC-A for Resident #18.
Interview of the DON on 12/11/19 at 1:49 P.M. confirmed there was no physician order for DNRCC-A for
Resident #18.
Interview of ADON #16 on 12/11/19 at 2:29 P.M. confirmed there was no care plan for advanced directives
for Resident #18.
4. Review of Resident #163's medical record revealed an admission date of 11/21/19 with the admitting
diagnoses of epilepsy, major depressive disorder, diabetes mellitus and neuropathy.
Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear
speech, understands others, makes herself understood and had no cognitive deficit as indicated by a Brief
Interview for Mental Status (BIMS) score of 13.
Review of the resident's Do Not Resuscitate (DNR) Identification Form, not dated revealed the resident was
determined to be a DNR comfort care (DNRCC) status.
Review of the resident's physician's orders failed to identify an order to reflect the resident's wishes for the
DNRCC status.
Review of the resident's plan of care failed to identify a care plan addressing the resident's DNRCC status.
Review of the resident's Care Conference Note dated 12/04/19 revealed the resident had a DNRCC
advance directive.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365444
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365444
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hill View Retirement Center
1610 28th Street
Portsmouth, OH 45662
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
On 12/11/19 at 9:15 A.M. interview with the DON verified the resident had no physician's order for the
DNRCC status in place.
On 12/11/19 at 9:55 A.M. interview with Registered Nurse (RN) #200 verified the resident did not have an
advance plan of care addressing her desired code status.
Residents Affected - Some
Review of the facility's advanced medical directives (dated 09/08/04) revealed the facility would ensure a
resident's choice concerning the implementation of advance directives would be followed.
Based on Record Review and Interview the facility failed to obtain a physician order for Advance Directives,
including Do Not Resuscitate-Comfort Care provisions. This affected four residents(Resident #31, #50, #18,
and #163) out of four reviewed for Advance Directives. The facility census was 68.
Findings include:
1. Record Review of Resident #31 revealed the resident was admitted to the facility on [DATE] with the
following medical diagnoses: severe sepsis, mesenteric artery abscess with ischemic bowel, malaise,
hyperlipidemia, depression, hypertension, chronic embolism and thrombosis, constipation, chronic pain,
muscle weakness, diabetes mellitus type II, and difficult ambulation.
The most recent Minimum Data Set (MDS) assessment completed on 10/23/19, indicated the resident had
minimal cognitive impairment.
Review of current physician orders revealed the resident did not have a valid Do Not Resuscitate-Comfort
Care (DNR-CCA) order in place either in paper chart or electronic record, but did have an DNR-CCA form
dated 11/21/19 in the chart. The resident did not have a care plan to address code status.
On 12/12/19 at 09:29 A.M. interview with Registered Nurse (RN) #162 verified the resident did not have a
written physician order in place in regards to her DNR-CCA status. She also verified the resident had no
care plan to address her code status.
2. Record Review of Resident #50 revealed the resident was admitted to the facility on [DATE] with the
following medical diagnoses: pulmonary embolism, depression, constipation, bipolar disorder, unspecified
psychosis, schizophrenia, Guillian-Barre syndrome, acute embolism and thrombosis, dementia,
hypertension, and hyperlipidemia.
The most recent MDS assessment completed on 11/09/19, indicated the resident was rarely/never
understood.
Review of current physician orders revealed the resident did not have a valid DNR order in place either in
paper chart or electronic record, but did have a DNR-CCA form dated 11/09/19 in the chart. The resident
was accepted into hospice services on 11/07/19. The resident did not have a care plan to address code
status.
On 12/12/19 at 09:29 A.M. interview with RN #162 verified the resident did not have a written physician
order in place in regards to her DNR-CCA status. She also verified the resident did not have a care plan to
address her code status.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365444
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365444
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hill View Retirement Center
1610 28th Street
Portsmouth, OH 45662
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review. observation, and staff interview the facility failed to ensure a resident maintained
good nutrition with respect to maintaining food and liquid consistency. This affected one of three residents
reviewed for decline in activities of daily living (Resident #11).
Residents Affected - Few
Findings include:
Review of Resident #11's medical record revealed she was admitted on [DATE] with a diagnoses that
included; cerebral infarction, hypertension, generalized anxiety, constipation, psychosis, protein calorie
malnutrition, restlessness, agitation, major depression, dementia without behavioral disturbance, and
insomnia.
Review of Resident #11's admission physician orders dated 06/21/19 revealed the resident was ordered a
mechanical soft diet with regular consistency liquid.
Review of Resident #11's admission Minimum Data Set (MDS) dated [DATE] revealed her cognition was
severely impaired. Resident #11 had no behaviors and did not reject care. Resident #11 required extensive
assistance of two staff for bed mobility, to transfer, and required supervision with set up help to eat.
Resident #11 had no swallowing problems, no significant weight changes, a mechanically altered diet, and
no dental problems. Resident #11 had no special treatments, and she received therapy after admission.
Review of Resident #11's nursing progress notes dated 09/11/19 revealed the resident was pocketing food
and her diet was changed to pureed foods with regular consistency liquids. On 09/25/19 Resident #11's diet
was changed again to pureed foods with nectar consistency liquids, built up utensils and a no spill cup.
Review of Resident #11's quarterly MDS dated [DATE] revealed the following changes; she had unclear
speech, sometimes she understood, sometimes she understands, was dependent on one staff to eat.
Resident #11 received therapy that ended on 08/26/19 and she received no restorative nursing programs.
Review of Resident #11's weights revealed the following. On 09/13/2019 she weighed 147.7 pounds, on
09/20/2019 her weight was 147.0 pounds, and on 09/27/2019 her weight was 129.4 pounds.
There was no evidence the Resident #11 received services to prevent a down grade in her diet, a change
in the consistency of her liquids, or the need for adaptive equipment. Resident #11 was not evaluated by
therapy for services until 10/11/19 when occupational therapy (OT) evaluated her. Resident #11 was not
evaluated by speech therapy (ST).
Observation of Resident #11 on 12/11/19 at 11:49 A.M. in the dining room revealed the resident received
pureed food, nectar thick liquids, built up utensils, and staff was feeding her.
Interview of Assistant Director of Nursing (ADON) #159 on 12/12/19 at 5:16 P.M. confirmed there was no
evidence Resident #11 received services to maintain her diet consistency and no evaluation of her diet
after her diet was downgraded. No plan was developed and implemented to maintain the resident's ability to
eat.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365444
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365444
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hill View Retirement Center
1610 28th Street
Portsmouth, OH 45662
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, and staff interview the facility failed to ensure a resident received
services to maintain their range of motion following a stroke. This affected one of three residents reviewed
for decline in activities of daily living (Resident #11).
Findings include:
Review of Resident #11's medical record revealed she was admitted on [DATE] with a diagnoses that
included; cerebral infraction, essential hypertension, generalized anxiety, constipation, psychosis, protein
calorie malnutrition, restlessness, agitation, dysarthria following cerebral infarction, major depression,
dementia without behavioral disturbance, and insomnia.
Review of Resident #11's admission Minimum Data Set (MDS) dated [DATE] revealed her speech was
clear she understood, was understood, and her cognition was severely impaired. Resident #11 had no
behaviors and did not reject care. Resident #11 required extensive assistance of two staff for bed mobility,
to transfer, for locomotion on unit, and had no limitations in functional range of motion. Resident #11 had no
falls. Resident #11 had no special treatments, and she received therapy after admission.
Review of Resident #11 quarterly MDS dated [DATE] revealed the following changes; she had functional
limitation of range of motion on one side of both upper and lower extremities, and had two or more falls with
no injury. Resident #11 received therapy that ended on 08/26/19 and she received no restorative nursing
programs.
There was no evidence the Resident #11 received services to maintain her range of motion. Resident #11
was not evaluated for range of motion by therapy until 10/11/19 when occupational therapy evaluated her
for services.
Interview of Assistant Director of Nursing (ADON) #159 on 12/12/19 at 5:16 P.M. confirmed there was no
evidence Resident #11 received services to maintain her range of motion. No plan was developed and
implemented to maintain the resident's range of motion.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365444
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365444
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hill View Retirement Center
1610 28th Street
Portsmouth, OH 45662
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and medical record review the facility failed to ensure a resident had an order for a catheter
and received services to prevent urinary tract infections. This affected one of one sampled resident
reviewed for urinary catheters (Resident #38).
Findings include:
Review of Resident #38's medical record revealed she was admitted on [DATE] readmitted on [DATE] with
diagnoses that included; acute cystitis with hematuria, neuromuscular dysfunction of the bladder,
hemiplegia and hemiparesis, and dysphagia.
Review of Resident #38's annual Minimum Data Set (MDS) dated [DATE] revealed her cognition was
severely impaired, she had delusions, had other behaviors one to three days, that did not impact her or
other residents, she did not reject care and she did not wander. Resident #38 did not have a urinary
catheter and was always incontinent of urine.
Review of Resident #38's 5-day Medicare MDS dated [DATE] revealed she was frequently incontinent of
urine.
Review of Resident #38's nurses progress notes dated 11/13/19 revealed the resident had not voided in the
past two shifts. The physician was notified, and a urinary catheter was inserted.
Review of telephone orders for Resident #38 revealed on 11/14/19 orders were received to schedule a
urology appointment due to urinary retention and placement of a catheter.
Review of December 2019 physician orders revealed no orders for a urinary catheter.
Observation of Resident #38 on 12/10/19 at 9:53 A.M. revealed she was seated in a wheelchair in the
activity room and the urinary catheter tubing was resting on the floor. Observation of Resident #38 on
12/12/19 at 8:11 A.M. revealed she was seated in a wheelchair in common area with the catheter tubing
resting on the floor.
Interview of Licensed Practical Nurse (LPN) #167 on 12/12/19 at 8:20 A.M. confirmed Resident #38's
catheter tubing was on the floor on 12/12/19 at 8:11 A.M. and it should be off the floor. LPN #167 adjusted
the tubing.
Interview of Assistant Director of Nursing (ADON) on 12/12/19 at 3:41 P.M. confirmed there was no order
for the indwelling catheter.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365444
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365444
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hill View Retirement Center
1610 28th Street
Portsmouth, OH 45662
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation and interview the facility failed to provide appropriate respiratory care by not
labeling oxygen tubing with the appropriate date and time that it was provided to the resident. This affected
one (Resident #4) out of three reviewed for oxygen use. The facility census was 68.
Residents Affected - Few
Findings include:
Record review of Resident #4 revealed the resident was admitted to the facility on [DATE] with the following
medical diagnoses: myocardial infarction, insomnia, anxiety, muscle weakness, hypertension,
hypothyroidism, dementia, hyperlipidemia, dementia, syncope, pulmonary embolism, transient ischemic
attack, and osteoarthritis.
The most recent MDS assessment completed on 11/28/19 indicated moderate/severe cognitive
impairment.
Review of physician orders revealed the was to receive continuous oxygen at 2-3 liters per minute per nasal
cannula for a diagnoses of pulmonary embolism and shortness of breath. The resident was care planned
for oxygen delivery with measurable goals and appropriate interventions.
On 12/09/19 at 05:39 P.M., observation of Resident #4 revealed the oxygen tubing provided to the resident
was not labeled with the date and time it was provided to the resident for continuous oxygen administration
On 12/10/19 at 08:15 A.M., the oxygen tubing remained unlabeled and undated on observation.
On 12/11/19 at 11:55 A.M., observation of Resident #4 revealed the oxygen tubing on the portable oxygen
tank remained unlabeled with the appropriate date and time provided to the resident for use.
On 12/12/19 at 09:00 A.M., observation of Resident #4 revealed oxygen tubing remained unlabeled and
undated.
On 12/12/19 at 09:00 A.M., interview with Licensed Practical Nurse (LPN) #167 verified that the oxygen
tubing for Resident #4 remained unlabeled with the appropriate date and time it was provided to the
resident.
Review of the facility policy on the use of oxygen and nebulizers revealed that this policy is undated during
this review. The policy states the disposable tubing, masks, cannulas, handheld nebulizers and humidifiers
are to be replaced weekly and dated to ensure compliance.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365444
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365444
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hill View Retirement Center
1610 28th Street
Portsmouth, OH 45662
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review and staff interview, the facility failed to follow proper infection control
procedures to prevent the potential spread of infection. This affected one (Resident #167) of one resident
reviewed for isolation precautions.
Residents Affected - Few
Findings Include:
Review of Resident #167's medical record revealed an admission date of 12/06/19 with the admitting
diagnoses of clostridium difficile (c-diff), diabetes mellitus, congestive heart failure and restless leg
syndrome.
Review of the resident's admission Health Care Nursing admission assessment dated [DATE] revealed the
resident was alert and oriented. She understood others, made herself understood and had memory
problems. The assessment indicated the resident required one assist from staff for activities of daily living.
Review of the plan of care dated 12/09/19 revealed the resident had c-diff. Interventions included to
disinfect all equipment used before it leaves the room, the resident requires supervision, reminders with
hand washing after being toileted and before and after meals, educate resident/family/staff regarding
preventative measures to contain the infection, encourage good nutrition and hydration, give all medications
and IV therapy as ordered, monitor for symptoms of weakness, dehydration, fever, nausea, and vomiting
and blood in stool, use as much disposable equipment as possible or use dedicated equipment such as
thermometer and blood pressure cuff.
Review of the resident's admission physician's orders dated 12/05/19 indicated orders for Vancomycin 250
milligrams (mg)/5 milliliters (ml) with the special instructions to take 12.5 mg by mouth every six hours for
14 days for c-diff, Flagyl 500 mg by mouth every six hours until 12/14/19 for c-diff and maintain c-diff
precautions.
On 12/10/19 at 10:41 A.M. observation of the resident revealed a cart in the resident's room containing
personal protective equipment (PPE) with no sign on the door alerting staff or visitors the resident had
isolation precautions.
On 12/10/19 at 11:30 A.M. observation of State Tested Nursing Assistant (STNA) #129 delivering the
resident's lunch meal revealed the STNA entered the resident's room, adjusted the resident's chair, bedside
table and delivered the meal without donning PPE.
On 12/11/19 at 1:40 P.M. observation of Registered Nurses (RN) #159 and #161 provide the physician
ordered dressing change to the resident's left leg wound revealed the staff had not utilize any PPE while
providing the dressing change.
On 12/11/19 03:01 PM interview with RN #160 verified the resident was on Vancomycin (an antibiotic) for
C-diff, staff should utilize PPE, and there was not a sign on the door alerting the staff and/or visitors of the
being on contact isolation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365444
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365444
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hill View Retirement Center
1610 28th Street
Portsmouth, OH 45662
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation and staff interview the facility failed to ensure a sanitary and comfortable resident
environment. This affected seven of 68 residents currently residing in the facility
Residents Affected - Some
Findings include:
1. Observation of Resident #11 on 12/10/19 at 9:41 A.M. revealed the resident was in her room seated in a
wheelchair with a pommel cushion in place. The covering was missing from the center of the cushion
exposing discolored foam. Resident #11 stated she was embarrassed by it and attempted to cover it with
her pants.
Observation with the Director of Nursing (DON) on 12/12/19 between 4:00 P.M. and 4:09 P.M. confirmed
Resident #11's pommel cushion still had missing covering.
2. Observation of Resident #38 on 12/10/19 at 9:53 A.M. revealed the wheelchair covering on the right
wheel was soiled, there was dried food on the brake, dried food was on the leg rest, and the covering on
the left leg rest was torn with exposed foam.
Observation with the DON on 12/12/19 between 4:00 P.M. and 4:09 P.M. confirmed Resident #38's wheel
chair brakes, wheel covering, and leg rests were dirty, and the left leg rest cover was torn with exposed
foam.
3. Observation of Resident #31 on 12/10/19 on 10:11 A.M. revealed the seat of the resident's wheelchair
seat was soiled and the left seat corner was torn exposing a metal edge.
Observation with the DON on 12/12/19 between 4:00 P.M. and 4:09 P.M. confirmed Resident #31's
wheelchair seat was soiled, and the left seat corner was torn exposing a metal edge.
4. Observation of the activity room on 12/11/19 at 9:40 A.M. revealed seven chairs in the room had worn
covering with exposed foam padding.
Observation with the DON on 12/12/19 between 4:00 P.M. and 4:09 P.M. confirmed the seven chairs were
in disrepair.
The facility identified Residents #28, #8, #17 and #10 used these chairs on a regular basis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365444
If continuation sheet
Page 9 of 9
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Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the December 12, 2019 survey of Hill View Skilled Nursing and Rehabilitation Cente?
This was a inspection survey of Hill View Skilled Nursing and Rehabilitation Cente on December 12, 2019. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Hill View Skilled Nursing and Rehabilitation Cente on December 12, 2019?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.