Hathaway Manor Extended Care

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1) who was severely cognitively impaired, unable to make their needs known and was dependent on staff for bed mobility, the Facility failed to ensure Resident #1 was free from the use of physical restraints when, on 5/27/26 during the overnight shift, Certified Nurse Aide #1 observed and reported to Nurse #1, that Resident #1, who was in bed, had each corner of the bed sheet that was on top of him/her, tied to the straps emanating (originating) from the beds air mattress, that was beneath him/her. Resident #1 was unable to untie and remove the bed sheet, which was therefore restraining him/her from getting up, if desired.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1) who had been observed by two staff members restrained in bed when the bed sheet that was on top of him/her was tied (secured) to his/her mattress at each corner, the Facility failed to ensure staff consistently implemented and followed the Facility Abuse Policy, when the staff members did not immediately report the allegations to their shift supervisor or the Administrator/Designee, as required.

Inspectors wroteBased on record review and interview, the facility failed to ensure for one Resident (#11), out of a total sample of 26 residents, that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed to ensure a physician's order for an as needed Trazodone (antidepressant) medication contained a duration of use and failed to ensure the prescriber reassessed the Resident's condition and documented a clinical rationale for the continued use of as needed Trazodone medication as required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered individualized comprehensive care plan was developed and implemented for two Residents (#90 and #80), out of a total sample of 26 residents. Specifically, the facility failed:1. For Resident #90, to develop a care plan for a cervical (upper neck) fracture; and2. For Resident #80, to develop a care plan for smoking.

Inspectors wroteBased on record review and interview, the facility's Consultant Pharmacist failed to identify irregularities during the monthly Medication Regimen Review (MRR) related to the administration of an antidepressant medication for one Resident (#11), out of a total sample of 26 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for two Residents (#90 and #8), out of a total sample of 26 residents. Specifically, the facility failed to ensure:1. For Resident #90, a cervical fracture diagnosis was accurately documented; and2. For Resident #8, accurate COVID-19 test results were scanned into the medical record.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to ensure they maintained complete and accurate medical record when nursing documentation in Resident #1's Electronic Medication Administration Record (MAR) and the Controlled Substance Register was found to be incomplete and did not accurately reflect what medications were or were not administered.

Inspectors wroteBased on interviews and record reviewed, for one Resident (#50) of 26 sampled residents, the facility failed to provide timely dental services. Specifically, for Resident #50, the facility failed to initiate replacement of lost/missing dentures timely.

Inspectors wroteBased on records reviewed and interviews for one Resident (#122) out of 26 sampled residents, who had a court appointed legal guardian due to incapacitation (the inability to make his/her own health care decisions), the facility failed to ensure that his/her Legal Guardian was fully informed in advance and given information including the risk and benefits of psychotropic medications (medications that can affect mood and behavior) prior to their use.

Inspectors wroteBased on record review and staff interview, for one Resident (#138), of two closed records reviewed, the facility failed to document the recapitulation of the Resident's stay that included his/her course of illness/treatment.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure staff provided appropriate care and services for one Resident (#38) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 26 sampled residents. Specifically, Resident #38 did not receive the physician ordered amount of tube feeding, staff administering tube feedings were not signing off administration, and there were no physician's orders on how much water to administer with and between medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the total program of care was reviewed by a physician for one Resident (#42), out of a total sample of 26 residents. Specifically, the facility failed to ensure the Resident's former primary physician and new primary physician evaluated the significant weight loss of Resident #42.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#42), in a sample of 26 residents, had been seen by a physician every 60 days.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure food items were properly dated and stored in three of three kitchenettes.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1), who was confused and unable to make his/her needs known, the Facility failed to ensure Resident #1 was free from physical and verbal abuse when, on 1/21/24 around 7:00 P.M., Nurse #1 was witnessed by other staff members treating Resident #1 in a verbally and physically abusive manner.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was a Diabetic, had experienced an acute episode of hypoglycemia (low blood sugar) and required administration of glucose gel for treatment, the Facility failed to ensure Resident #1 was provided nursing care and treatment in accordance with professional standards of practice, when on 11/29/23, after Nurse #1 administered the glucose gel, she failed to recheck Resident #1's blood glucose level, left him/her unattended in his/her bed and later found Resident #1 (who was unable to transfer or ambulate without the physical assistance from staff) lying on the bathroom floor. Resident #1 was later diagnosed with hypoglycemia, acute right pubic bone fractures and was admitted to the Hospital.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, required physical assistance from staff for transfers and mobility, and who had been administered medication by nursing to treat an acute episode of hypoglycemia (low blood sugar), the Facility failed to ensure he/she was provided adequate supervision by nursing in an effort to maintain his/her safety to prevent an incident/accident resulting in an injury. On 11/29/23, Nurse #1 administered glucose gel to Resident #1 to treat his/her low blood sugar, however Nurse #1 failed to recheck his/her blood glucose level, left him/her unattended in his/her bed and later found Resident #1 lying on the bathroom floor crying out in pain when range of motion was attempted to his/her right leg. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who had undergone a right total hip arthroplasty, had a history of arthritis of the hip and required pain management, the Facility failed to ensure nursing adequately assessed and effectively helped manage his/her complaints of increased pain. On 12/10/23, at approximately 8:30 A.M., Resident #2 complained of increased right hip pain after being repositioned in bed, and had requested pain medication, however Nurse #2 did not administer pain medication to Resident #2 until two and half hours after his/her initial complaints of increased right hip pain. An x-ray was obtained of Resident #2's right hip and he/she was found to have mild soft tissue swelling and an acute periprosthetic fracture of his/her right hip.

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2), the Facility failed to ensure they maintained a complete and accurate medical record related to nursing documentation in his/her Medication Administration Record (MAR) and Nurse Progress Notes.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure he/she was free from verbal and mental abuse from a staff member when on 10/28/23, Certified Nurse Aide (CNA) #1 responded to Resident #1's call light and request for assistance with care, and per Resident #1, CNA #1 was rude, angry, abrupt, and intimidated him/her. Resident #1 became distressed, was tearful when recounting the incident with other staff members, and reported that he/she was afraid of CNA #1. Although CNA #2 said she witnessed CNA #1 verbally abuse Resident #1, she also said she did not intervene or attempt to stop the abuse, but instead stood in the doorway and watched to protect the resident.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact and required supervision to minimal assistance to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 10/28/23, after an alleged incident of verbal abuse and mental abuse of Resident #1 by Certified Nurse Aide (CNA ) #1 that occurred during the provision of care, was witnessed by one staff member (CNA #2), and Resident #1 who was emotionally distressed by how he/she had been treated by CNA #1 also reported the incident of alleged abuse to three other staff members (CNA #3, CNA #4 and Unit Secretary #1), however none of them immediately reported the abuse to their supervisor as required, and as a result CNA #1 continued to work in the Facility for several days placing Resident #1 and other residents at risk [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure that after Resident #1 experienced a witnessed fall on 10/28/23, where he/she landed on the floor on both of his/her knees, that nursing notified his/her Physician of the fall.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact and required supervision to minimal assistance to meet his/her care needs, the Facility failed to ensure he/she was provided nursing care and treatment in accordance with professional standards of practice, when on 10/28/23, Resident #1 fell while CNA #1 was providing care to him/her, Resident #1 got him/herself off the floor, and Certified Nurse Aide (CNA) #1 proceeded to walk with him/her to the bathroom before informing and having nursing assess him/her for physical injury, and after being made aware of Resident #1's fall, Nurse #1 did not complete an incident report or document an assessment of Resident #1.

Inspectors wroteBased on record review and interview, the facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD), when the facility did not employ a full-time dietitian.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles and included appropriate cautionary instructions, and the expiration date when applicable.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to practice acceptable standards of infection control and prevention. Specifically, 1. For three Residents (#20, #112, #81) of five residents reviewed, the facility failed to conduct COVID-19 testing during an outbreak per facility policy, and 2. The facility failed to ensure staff adhered to infection control protocols for testing during a COVID-19 outbreak.

Inspectors wroteBased on observations, interviews, and records reviewed, for one Resident (#60), of 26 sampled residents, the facility failed to ensure the Resident received care and treatment to prevent the development of and promote the healing of pressure injuries. Specifically, for Resident #60, the facility failed to initiate the wound consultant's recommendations timely.

Inspectors wroteBased on observations, interviews, and records reviewed, for one Resident (#112) of 26 sampled residents, the facility failed to ensure enteral nutrition and fluids provided via a gastrostomy tube (G-tube- a feeding tube in abdomen used to provide nutrition) were provided in accordance with professional standards and manufacturer's recommendations. Specifically, for Resident #112, the facility failed to change the feeding set every 24 hours as indicated resulting in increased risk of infection.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure for one Resident (#99), of a total sample of 26 residents, dialysis services were provided in accordance with the facility's policy. Specifically, for Resident #99, the facility and the dialysis center failed to effectively communicate pre- and post-dialysis.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#32) with a history of trauma, out of a total sample of 26 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure pharmacy recommendations were reviewed and addressed for two Residents (#73 and #75), out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #73, to ensure the consultant pharmacist's recommendations were addressed for Gradual Dose Reduction (GDR) of the antipsychotic medication, Zyprexa and the antidepressant medication, Sertraline; and 2. For Resident #75, to ensure the consultant pharmacist's recommendations were addressed for the GDR of the anxiolytic medication (used for the treatment of anxiety disorders), Buspirone.