Hammonds Lane Center

Inspectors wroteBased on observations and staff interviews, the facility failed to 1) maintain a sanitary and comfortable environment, as evidenced by persistent odors of urine and unsanitary conditions throughout multiple resident care units and common areas. This deficient practice was observed on six separate dates during the survey; and 2) maintain residents' bathing/shower rooms that were operational and in good repair to meet the basic hygiene needs and preferences of the facility's residents. This was evident for 9 out of 12 resident bathing/shower stalls observed during the survey.

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment for the residents. This was evident for 4 resident rooms out of 21 resident rooms observed on the A wing nursing unit and 3 resident rooms out of 11 resident rooms reviewed on the B wing nursing unit during the survey.

Inspectors wroteBased on observations and staff interviews it was determined the facility failed to store food in accordance with professional standards for food safety during the annual survey.

Inspectors wroteBased on record review and interviews with resident and staff, it was determined that the facility failed to maintain accurate medical records in accordance with accepted professional standard and practices. This was evident for 11 (Resident #11, #23, #33, #34, #41, #13, #27, #72, #84, #5, and #97) residents out of 68 residents reviewed during the annual survey.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure that residents were provided care in a manner that protected and promoted dignity for 2 of 3 residents reviewed for dignity (Residents #40 and #93).

Inspectors wroteBased on review of facility reported incidents (FRIs) and interview with staff, it was determined that the facility failed to report allegations of abuse within 2 hours to the Office of Health Care Quality (OHCQ). This was evident for 3 (#356914, #356923, and #356927) FRI's out of 15 FRI's reviewed during the annual and complaint survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to 1.) provide written notification of transfer to the resident representative and provide written notification of the facilities bed hold policy upon transfer to the hospital (Resident #41); 2.) ensure the local ombudsman was notified of a facility-initiated transfer to the hospital (Resident #37and #41); and 3.) ensure a resident received accurate written information regarding the bed-hold policy (Resident #109). This was evident for 3 out of 6 residents reviewed for hospitalization during the survey.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan for residents. This was evident 3 out of 13 residents (Resident #13, #41, #97) investigated for smoking during the survey.

Inspectors wroteBased on staff interviews, resident interviews, observations, and facility record reviews, it was determined that the facility failed to provide residents with adequate supervision as evidenced by residents having cigarettes and a lighter stored in their room. This was evident for 2 (Resident #24 and #97) out of 13 residents reviewed for smoking during an annual recertification survey.

Inspectors wroteBased on surveyor observations, facility record reviews, and staff interviews, it was determined that the facility failed to: 1) maintain proper temperature controls for stored drugs and biologicals; 2) ensure the removal of expired emergency medication from the medication storage room; 3) ensure that residents' medication is stored in the medication carts; and 4) ensure the removal of expired medication from the medication cart. This was evident for 2 of 2 medication storage rooms and 1 of 4 medication carts reviewed during an annual recertification survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure a resident who requires dental services on a routine or emergent basis receives necessary or recommended dental services in a timely manner. This was evident for 1(Resident #41) reviewed for dental services.

Inspectors wroteBased on observation and interview with staff, it was determined that the facility failed to ensure face masks were included Personal Protective Equipment (PPE) inside the PPE carts outside residents' rooms. This was evident for 3 PPE carts on the C wing and 4 PPE carts on the A wing.

Inspectors wroteBased on observations and interviews with staff and residents, the facility failed to ensure residents have an enclosed closet space protected from casual access from others by having a closet door. This was found to be evident for 2 out of 21 resident rooms observed during the annual survey.

Inspectors wroteBased on observations and interviews of facility staff it was determined the facility failed to ensure effective pest control as flying gnats and flies were observed throughout the building. This was found to be evident during the survey.

Inspectors wroteBased on the review of facility-reported incidents, review of pertinent records, and interviews with facility staff and other involved medical staff, it was determined that the facility failed to 1.) protect a resident (#14) from injury while providing care causing the resident to fall out of bed and fracturing a rib, resulting in harm to the resident, 2.) provide appropriate staff support required for toileting and transferring resulting in Resident #214 sustaining a fall with a right femoral neck fracture, resulting in harm to the resident; and 3.) to keep Resident #309 from exiting the building alone and without supervision resulting in harm. This was found to be evident for 3 of 19 residents reviewed for accidents during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to: 1.) administer medications as ordered by the physician, for 4 of 4 residents (#97, #58, #213, #365) observed during a medication administration and record review; 2.) document a resident (#68) was receiving oxygen therapy and; 3.) document interventions taken when a resident's (#88) tracheostomy tube became dislodged. This was evident for 6 of 6 medical records reviewed for professional nursing documentation during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on review of pertinent facility documents and interview with facility staff, it was determined that the facility failed to have a facility assessment that was accurate and complete including information relevant to the needs of the residents the facility serves.

Inspectors wroteBased on observations, record revies and interviews of facility staff it was determined the facility failed to: 1.) document that daily activities were provided to residents (Resident # 9 and # 60) and 2.) document medical information in a resident's medical record (Resident #25, #211, #365). This was evident for 5 out of 90 residents reviewed during a facility's annual survey.

Inspectors wroteBased on observation and interview it was determined that the facility failed to make sure the residents on Unit C had their call bells within reach to call for assistance. This deficient practice was evident in 2 of 4 (#47 & #48) residents observed on Unit C during the annual survey.

Inspectors wroteBased on family interview, ADL record review, and staff interviews it was determined that the facility staff failed to ensure a resident's desire to have scheduled showers of two per week honored by the facility. This was true for 1 out of 2 (#261) residents reviewed for choices.

Inspectors wroteBased on medical records and interview it was determined that the facility failed to maintain a resident's privacy as evidenced by a Nurse Practitioner discussing a resident's medical diagnoses in a hallway. This deficient practice occurred in 1 of 1 (#98) resident's reviewed for privacy practices during the annual survey.

Inspectors wroteBased on observation and staff interview, the facility failed to provide residents with housekeeping services that promote a comfortable and homelike environment. This was evident for Unit C and room [ROOM NUMBER]A-1 observed during the facility's annual survey.

Inspectors wroteBased on administrative and medical record review and interviews with facility staff it was determined the facility failed to prevent verbal abuse by an agency staff member towards a resident. This was found to be evident for 1 of 26 (Resident # 37) residents reviewed for abuse during the resident's annual Medicare/Medicaid survey.

Inspectors wroteBased on administrative review and interviews with facility staff, it was determined the facility failed to: 1.) report to the proper authority to include the police department, that staff used another staff license to work at the facility and 2.) notify the state agency when a resident (R#309) eloped from the facility. This was found to be evident during a review of the facility's investigation of facility reported incidents and 1 of 19 residents reviewed for accidents during the facility's annual Medicaid/Medicare survey.

Inspectors wroteBased to medical record review and interviews it was determined that the facility failed to complete thorough investigations when investigating facility reported incidents. This deficient practice was evident in 2 of 8 facility reported incidents involving Residents #92 and #310) reviewed during the annual survey.

Inspectors wroteBased on medical record review and interview with staff it was determined the facility staff failed to notify the resident and/or the resident's representative(s) of a hospital transfer and the reason for the transfer in writing. This was found to be evident for 1 (Resident # 62) of 3 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on medical record review and interview, the facility failed to provide a completed bed hold policy notice to the resident or resident representative (Resident # 25). This was evident in 1 of 1 resident reviewed during the facility's annual survey for care planning.

Inspectors wroteBased on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to: 1.) accurately code for falls this was evident for 2 (Resident #52, #263) out of 2 for falls and 2.) accurately code: Hearing, Speech and Vision. This was evident for 1 (R#90) out of 1 reviewed for Hearing, Speech and Vision and 3.) accurately code hospitalization. This was evident for 1 (R #107) our of 5 reviewed for hospitalization during the survey process.

Inspectors wroteBased on observation, medical record review, and interviews it was determined that the facility staff failed to implement patient centered care plans for: 1.) residents who received oxygen therapy (#47, #68, #88), 2.) use of a Wander Guard (#309) and 3.) ensure that a resident's pain care plan was followed for pain management. This deficient practice was evidenced in 5 (#47, #68, #88, #309 & 219) resident records reviewed for oxygen therapy, use of a Wander Guard, and Activities of Daily Living (ADL's) during the investigation stage of the facility's annual Medicare/Medicaid survey during the annual survey.

Inspectors wroteBased on medical record review and interviews it was determined that the facility failed to ensure that the nursing staff was competently trained to care for residents who had a tracheostomy. The deficient practice was evident in 1 of 1 (Resident #88) residents who resides in the facility with a tracheostomy.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to: 1.) have a system in place to identify potential drug diversion as evidenced by failure to ensure Controlled Drug Administration Records were kept in a manner that an accurate reconciliation could be completed and failed to have an effective system in place to ensure nursing staff signed that the controlled drug count was correct at the time the count occurred. This was found to be evident for 1 of 8 (Resident #60) residents reviewed for narcotics and 1 out of 6 medication carts reviewed and 2.) the facility contracted pharmacy delivery company failed to deliver a resident's medication without informing the facility of the cancellation of the medication delivery (Resident #213). This was evident for 1 of 10 residents reviewed for activities of daily living during a facility recertification survey.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure a resident's drug regimen was free from unnecessary drugs. This was evident for 1 of 66 residents (Resident #365) reviewed during a facility's recertification survey.

Inspectors wroteBased on observations and interview with facility staff it was determined that the facility failed to: 1.) properly store resident's medications and facility supplies in accordance with currently accepted professional standards. This was evident in 1 out of the 4 medication storage rooms within the facility and; 2.) ensure that expired medications were disposed of properly. This was found to be evident for 1 resident (#2) when 3 medication carts were reviewed for narcotic reconciliation during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to meet the needs of the residents regarding the timeliness of providing laboratory services. This was evident for 1 resident out of 66 (Resident #7) residents reviewed for during the annual survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to maintain infection control practices: 1.) in room [ROOM NUMBER] and of Resident #103's room as well as in 3 (#47, #48, & #77) of 4 resident's observed for infection control practices; and 2.) contain soiled linen on Unit B at the point of collection. This was evident for 1 of 3 units observed during observation rounds of the annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to ensure that residents were offered a pneumococcal and influenza vaccine. This was found to be evident for 3 (Resident #111, #25 and #108) of 5 residents reviewed for immunizations during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to maintain an effective pest control program as evidenced by numerous alive ants and multiple spiders seen in resident's rooms. This deficient practice has the potential to affect resident who reside on C-Wing.

Inspectors wroteBased on observation and interviews of facility staff it was determined that food service employees failed to ensure that equipment was maintained and food was stored properly to reduce the risk of foodborne illness.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to provide Resident #92 with the most dignified existence. This was evident for 1 of 56 residents investigated for dignity during the survey process.

Inspectors wroteBased on clinical record review, staff interview, and resident interview it was determined that the facility staff failed to ensure residents' choices regarding showers and getting weighed were honored (#92 and #93). This was true for 2 out of the 28 residents reviewed during the investigative stage of the survey.

Inspectors wroteBased on record review, it was determined that the facility staff failed to follow a resident's wishes as to when the resident's health care agent authority to change life-sustaining treatments became effective. This was evident for 1 (Residents #102) of 8 residents reviewed for advance directives during an annual recertification survey.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior(#92).

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident and/or the resident representative. This was found to be evident for 2 (Resident # 37 and 62) out of 56 residents reviewed for a facility-initiated transfer during the investigative portion of the survey.

Inspectors wroteBased on review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, at the time of the resident transfer for hospitalization. This was evident for 1(# 37) of 4 residents reviewed for Hospitalization during the annual recertification survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected a resident's status (#44, 92). This was evident for 2 of 2 residents reviewed for accurate MDS assessments during the annual survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to turn and reposition Resident #92 every 2 hours as ordered and failed to apply Prevalon boots as ordered to Resident #92. This was evident for 1 of 10 residents investigated for limited range of motion during the survey process

Inspectors wroteBased on a observation, review of resident clinical records and staff interview it was determined that the facility staff failed to plan and develop a care plan to address a resident's elopement status. This was evident for 1 (Resident 102) out 5 residents reviewed for accidents during an annual recertification survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to 1) revise Resident #102's impaired swallowing care plan to reflect current interventions identified by the interdisciplinary team, and 2) revise Resident #102's behavior care plan to reflect current recommendations from the facility psychologist and failed to revise Resident #7's care plan. This was evident for 2 (Resident #102, #7) of 2 residents reviewed for care planning.

Inspectors wroteBased on medical record review and staff interviews and observation, it was determined that the facility failed to administer a medication in accordance with generally accepted standards of nursing practice. Nursing staff signed/initialed on the Medication Administration Record (MAR) that a medication was held but failed to notify the physician and receive further instructions. This was evident for 1 (Resident #63) of 5 residents reviewed for medication regimen review during the survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to obtain a pulmonary consultation for Resident #7, failed to apply ted stocking to Resident #30 and failed to turn and reposition Resident #92 every 2 hours as ordered, failed to apply Prevalon boots to Resident #92 as ordered and frequently used a painful stimuli to arouse a resident(#102). This was evident for 4 of 56 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to apply palm guards as ordered to Resident #7. This was evident for 1 of 56 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the dietician failed to thoroughly assess and document assessments for Resident #92 when weight loss was noted. This was evident for 1 of 56 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner(#1, #31, #102). This was evident for 3 of 56 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure Resident #2 was free from psychiatric medications. This was evident for 1 of 56 residents selected for review during the annual survey process.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure medications were kept in a locked and secured location. This was true for 1 out of the 3 nursing units.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood work as ordered by the physician for Resident #57. This was evident for 1 of 56 residents selected for review during the survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain the medical records for Residents (#92 and #56) in the most complete and accurate form. This was evident for 2 of 56 residents selected for review during the survey process.

Inspectors wroteBased on observations and interviews with staff it was determined that the facility failed to ensure residents had a means of directly contacting staff. This was evident in 1 Public bathroom and 1 Staff bathroom that was accessible to residents.

Inspectors wroteBased on observation and interview of facility staff, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Inspectors wroteBased on observation and staff interview, it was determined the facility staff failed to dispose of garbage and refuse properly.