Hampton Woods Nursing Center, Inc

Inspectors wroteBased on record reviews, self-reported incident (SRI) review, facility policy review and interview, the facility failed to prevent the tampering with and possible diversion of resident liquid morphine. This failure had the potential to affect three residents (#18, #32, and #36) who were receiving morphine at the time of the incident of three residents reviewed for abuse, neglect and misappropriation. The facility census was 60.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure Resident #63 had an accurate advanced directive on file. This affected one resident (#63) of two residents reviewed for advanced directives. The facility census was 52.

Inspectors wroteBased on resident and family interview, staff interview, review of facility medication incident report, record review, and facility policy review, the facility failed to ensure residents were free of significant medication errors. This affected one resident (Resident #9) out of four residents reviewed for medication administration. The facility census was 53.

Inspectors wroteBased on record review and interview, the facility failed to timely notify the hospice provider of Resident #62's change in condition, resulting in an unwanted transfer to the Emergency Department (ED). This affected one resident (Resident #62) of three residents reviewed for falls. The facility census was 61.

Inspectors wroteBased on observation, staff and resident interviews, and review of facility mealtimes, the facility failed to ensure residents were offered a snack as required when there was greater than 14 hours between dinner and breakfast. This had the potential to affect all residents except for one resident (#44) identified by the facility as receiving nothing by mouth. The facility census was 60.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Tuberculosis (TB) Risk Assessment was completed in an accurate manner. This had the potential to affect all residents who resided in the facility. The facility census was 60.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #7 was fed in a dignified manner. This affected one resident (#7) out of five residents in the facility identified as needing physical assistance with meals. The facility census was 60.

Inspectors wroteBased on record review and interviews, the facility failed to ensure resident Do Not Resuscitate forms were appropriately filled out for Residents #262 and #15. This finding affected two residents (#262 and #15) out of two residents reviewed for advanced directives. The facility census was 60.

Inspectors wroteBased on record review, interview, and review of the facility policy the facility failed to ensure the physician was notified of daily weight gains of two or more pounds in a day or of blood sugar over 300 per physician order. This affected one resident (#23) of one resident reviewed for daily weights and had the potential to affect nine residents (#1, #4, #6, #13, #16, #20, #35, #43, and #47) who had orders for daily weights. This also affected one resident (#27) out of one resident reviewed for blood sugars and had the potential to affect 12 residents (#1, #2, #10, #16, #17, #21, #24, #27, #45, #47, #52, #164) who received blood glucose monitoring. The facility census was 60.

Inspectors wroteBased on record review, review of the Internet Quality Improvement and Evaluation System (iQIES) Minimum Data Set (MDS) 3.0 Validation Report, staff interview, and facility policy review the facility failed to ensure Resident #19's MDS assessments were submitted in a timely manner. This affected one resident (#19) out of 23 residents reviewed for MDS submission. The facility census was 60.

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to ensure comprehensive care plans reflected advanced directives and indwelling urinary catheter use for Resident #262 and advanced directives and fluid restriction for Resident #15. This affected two residents (#15 and #262) out of 22 residents reviewed for care plans. The facility census was 60.

Inspectors wroteBased on observation, record review, staff interview, and review of the facility policy, the facility failed to ensure Resident #16's medication was not left at bedside unsecured. This affected one resident (#16) out of five residents reviewed for medication administration. The facility census was 60.

Inspectors wroteBased on observation, staff and resident interviews, medical record review, and facility policy review, the facility failed to track fluids consumed for Resident #15 as ordered by the physician. This affected one resident (#15) out of one resident reviewed for fluid restriction. The facility identified three residents (#15, #17, and #214) with physician's orders for fluid restrictions. The facility census was 60.

Inspectors wroteBased on observation, record review, and review of the facility policy, the facility failed to ensure masks or pipes for the nebulizer (a machine that turns liquid medication into a fine mist) were covered when not in use for Resident #16 and #35. This affected two residents (#16 and #35) out of three residents reviewed for respiratory care. The facility identified 16 residents (#3, # 9, #10, #16, #20, #35, #39, #42, #44, #45, #50, #163, #164, #214, #215, #263) who used nebulizers. The facility census was 60.

Inspectors wroteBased on interviews, observation, record review, review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes and review of facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during high contact resident care. This affected three residents (#54, #164, and #262) out of five residents observed for EBP. This had the potential to affect 22 residents (#1, #2, #3, #4, #7, #16, #21, #22, #27, #33, #37, #42, #44, #46, #54, #162, #164, #212, #214, #213, #262, and #264) who had orders for enhanced barriers. The facility census was 60.

Inspectors wroteBased on observation, record review, interview, facility policy and procedure review, self-reported incident (SRI) review, and facility investigation review the facility failed to prevent an incident of neglect when Resident #42 was not properly assisted with activities of daily living (ADL) including bed mobility, bathing, and incontinence care according to the resident care card to prevent an injury. Actual Harm occurred on 10/27/23 during the 7:00 P.M. to 7:00 A.M. shift when Resident #42, who was dependent on staff for ADLs, including two-person assistance for bed mobility, bathing, and toileting, was found with significant bruising including deep purple bruises on her forehead, under her left and right eyes, and on the outside of her left eye. [...]

Inspectors wroteBased on observation, record review, review of the facility policy and interview the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of a pressure ulcer for Resident #14. Actual Harm occurred on 10/03/23 when Resident #14, who was totally dependent on staff for activities of daily living (ADL) including bed mobility, toileting, and transfers was found to have an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his left gluteal (buttock) area. There was no documented evidence of adequate intervention(s) or monitoring to prevent the development of this wound or to ensure the pressure ulcer was identified prior to being unstageable. This affected one resident (#14) of two residents reviewed for pressure ulcers. [...]

Inspectors wroteBased on observation, record review, interview, facility policy and procedure review, self-reported incident (SRI) review, and facility investigation review the facility failed to ensure an injury of unknown origin resulting in serious bodily injury for Resident #42 was timely reported to the State agency, within two hours and failed to ensure law enforcement was notified. This affected one resident (#42) of one resident reviewed for abuse. The facility census was 62.

Inspectors wroteBased on interview, record review, and review of the facility policy the facility failed to obtain daily weights as ordered. This affected two residents (#39 and #58) out of three residents reviewed for daily weights. This had the potential to affect eight residents (#7, #13, #16, #19, #25, #39, #48, and #58) who had orders for daily weights.

Inspectors wroteBased on interview, observation, record review, and facility policy review the facility failed to ensure Resident #39 was free from significant medication errors. This affected one resident (#39) out of two residents reviewed for insulin administration. This had the potential to affect 15 residents (#12, #13, #14, #16, #17, #23, #27, #29, #31, #35, #39, #43, #46, #48, and #52) with orders for insulin. In addition, the facility did not ensure Resident #39 was not administered two glucagon kits (a subcutaneous injection that worked by triggering the liver to release stored sugar to raise the blood sugar) without a physician order affecting one resident (#39) out of three residents reviewed for medication administration. The facility census was 62.

Inspectors wroteBased on interview, observation, record review, and pharmacy guidelines review the facility failed to ensure Resident #39's insulin was not expired upon administration. This affected one resident (#39) out of two residents reviewed for insulin administration. This had the potential to affect 15 residents (#12, #13, #14, #16, #17, #23, #27, #29, #31, #35, #39, #43, #46, #48, and #52) with orders for insulin.

Inspectors wroteBased on record review and interview, the facility failed to notify residents with a Medicaid payor source and/or their representatives when their resident fund balances reached two hundred dollars ($200.00) less than the resource limit to prevent the potential loss of eligibility for Medicaid services. This finding affected three (Residents #10, #15 and #19) of four residents reviewed for resident fund accounts. The facility census was 48.

Inspectors wroteBased on observation, record review and interview, the facility failed to properly store and dispose of loose or expired medications and expired glucometer control solutions as well as expired disinfectant wipes used to clean the medication carts and glucometers. This finding affected five residents (Residents #1, #4, #22, #32, and #147) who received blood glucose testing (BGTs) on the 300 and 400 halls and one resident (Resident #4) of one resident reviewed for expired glucagon (medication for low blood sugar) who resides on the 400 hall. The facility census was 48.