Hathorne Hill Rehabilitation and Healthcare Center

Inspectors wroteBased on interviews, observations, and policy review, the facility failed to ensure staff treated one Resident (#140) in a dignified manner during the dining experience out of a total sample of 26 residents. Specifically, for Resident #140 who was dependent on staff for assistance with meals, the facility failed to provide assistance when his/her meal was delivered.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for one Resident (#46) out of a total sample of 26 residents. Specifically, for Resident #46 the facility failed to provide assistance and/or supervision with meals as per the plan of care.

Inspectors wroteBased on record review and interview the facility failed to ensure that for two out of five staff records reviewed (Nurse #2 and Additional Staff #2), who did not receive the covid vaccination, signed a statement certifying that they are exempt from vaccination and they received information about the risks and benefits of COVID-19 vaccine.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement interventions related to pressure ulcer care and prevention for one Resident (#46) out of a total of 23 sampled Residents. Specifically, the facility failed to implement an air mattress as recommended by the Wound Physician for Resident #46 after he/she developed a stage III pressure ulcer at the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain a sanitary oxygen filter for one Resident (#93) out of a total sample of 23 residents.

Inspectors wroteBased on record review and interview, the facility failed to follow the dietary plan for one Resident (#44) of 23 sampled residents. Specifically, the facility served Resident #44 fish, which was a documented allergen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to accurately document the completion of shaving for one Resident (Resident #22) of 23 sampled residents.

Inspectors wrote5. Resident #65 was admitted to the facility in March 2023, and had diagnoses which included dementia, cellulitis, cerebral ischemia, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #65 scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of Resident #65's nursing skin check note dated 3/10/23, indicated he/she was admitted with a left lower extremity abrasion, pressure area to coccyx, and Prevalon heel protectors (a device used to reduce the risk of pressure injuries by keeping the heel floated, relieving pressure), applied to bilateral lower extremities. His/her skin was warm and dry. Review of Resident #65's nurse practitioner note dated 3/20/23, indicated the presence of pressure area to the Right buttock but failed to indicate the wound was evaluated or measured. [...]

Inspectors wroteBased on interviews, record review, staff education and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skillsets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to: 1) Ensure the licensed nursing staff were trained and demonstrated competency to identify, assess, evaluate, intervene, and respond to a significant change in condition of a wound, for one Resident (#182), out of a total sample of 44 Residents. Resident #182 was admitted with a Stage 2 pressure ulcer that progressed and deteriorated to a Stage 4 pressure ulcer. Resident #182 developed a pressure ulcer to the midthoracic spine while in the facility. and; [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure its administration used its resources effectively to provide appropriate wound care. Specifically, the facility administration failed to: 1) provide nursing staff education and training to provide competent, safe, and effective wound care management; 2) provide continuation of the wound care program following the resignation of its Wound Nurse and implement an effective wound care program for pressure ulcer (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care per the Facility Assessment Tool. These failures resulted in the development of a Stage 4 pressure ulcer with purulent drainage and odor for one Resident (#182) out of a total sample of 44 residents. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure it completed a baseline care plan for one Resident (#182) out of 44 sampled residents. Specifically, the facility failed to complete a baseline care plan to address a Stage 2 pressure ulcer present on admission. The baseline care plan failed to include goals and interventions. The Stage 2 coccyx pressure ulcer then developed into a Stage 4 pressure ulcer on 11/8/23.

Inspectors wroteBased on record review and interviews, the facility failed to provide supervision for one Resident (#94) out of a total sample of 44 residents. Specifically, the facility failed to implement the fall intervention, which resulted in the Resident falling and fracturing his/her left hip.

Inspectors wroteBased on observation, interviews, and records reviewed for one Resident (#381) of 44 sampled residents, the facility failed to provide mental health services to a Resident with a known history of trauma and a diagnosis of post-traumatic stress disorder (PTSD). Specifically, for Resident #381 the facility failed to implement a physician's order for a psychiatric evaluation or develop a comprehensive plan of care, resulting in increased depression, thoughts of being better off dead, and an emergent hospital evaluation.

Inspectors wroteBased on observations, interviews, and records reviewed for one Resident (#78) of 44 sampled residents, the facility failed to provide pain management that met professional standards of practice. Specifically, the facility failed to obtain a physician's order for pain medication prior to administration.

Inspectors wroteBased on observation, interview, and policy review for four Residents (#25, #93, #118, #381) of 39 sampled residents, the facility failed to ensure medications were dated and unexpired, and securely stored. Specifically: - For Resident #25, the facility failed to ensure outdated medications were not available for administration and ensure medications with shortened expiration dates after being opened were labeled with open dates. - For Resident #93, #118 and #381, the facility failed to secure medications found in their bedrooms.

Inspectors wroteBased on observation, record review, policy review and interviews, the facility failed to maintain and implement an infection control program designed to help prevent and identify the development and transmission of disease and infection. Specifically: - The facility failed to monitor, track, and analyze infectious diseases during the month of November 2023. - For Resident #381, the facility failed to implement transmission-based precautions for the management of active Clostridioides difficile disease.

Inspectors wroteBased on observations, interviews, policy review, and record review the facility failed to provide care in a dignified manner for one Resident (#96) out of 44 sampled residents. Specifically, the facility failed to cover a urinary catheter bag for privacy.

Inspectors wroteBased on observations, interviews and records reviewed the facility failed to evaluate for the self-administration of albuterol (an emergency inhaler) for one Resident (#118) out of 44 sampled residents. Specifically for Resident #118, the facility failed to ensure it assessed for self-administration, obtain physician orders for self-administration, or care plan for medication self-administration, resulting in a risk for pulmonary complications.

Inspectors wroteBased on interviews and record review the facility failed to notify the physician or other provider of a significant decline in health status for two Residents (#182, #101) of 44 sampled residents. Specifically: 1. For Resident #182, the facility failed to notify the physician his/her skin deteriorated from a Stage 2 to a Stage 4 and had signs of possible infection. In addition, the facility failed to notify the physician that Resident #182 developed a midspine thoracic wound. 2. For Resident #101, the facility failed to notify the physician he/she was admitted to the facility with a Stage 2 pressure ulcer on the coccyx and to request treatment orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents, specifically, the facility failed to provide assistance with showers for one Resident (#78) out of a total sample of 44 Residents. Resident #78 was admitted to the facility in March 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified lack of coordination, muscle weakness, and abnormal posture. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #78 has a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicating he/she has intact cognition. The MDS also Indicated Resident #78 requires extensive assistance for bed mobility and is dependent for bathing. [...]

Inspectors wroteBased on observation, interview, policy review, and records reviewed for two Residents (#1 and #A1) of 44 sampled residents, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. Specifically, the facility failed to obtain a physician order to treat surgical wounds for Resident #1 and Resident #A1.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow the plan of care for an indwelling urinary catheter/Foley (a flexible tube that passes through the urethra and into the bladder to drain urine) for one Resident (#12) out of a total sample of 44 residents. Specifically, the facility staff failed to ensure the correct size indwelling urinary catheter was in place for Resident #12 as ordered by the physician.

Inspectors wroteBased on record review and interviews, the facility failed to implement a Trauma Informed care plan for one Resident (#43) out of a sample of 44 residents. Specifically, the facility failed to implement a history of Post Traumatic Stress Disorder (PTSD) care plan.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and obtain a physician's order for the use of bed rails, for one Resident (#103) out of 44 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed ensure that PRN (as needed) psychotropic medication was limited to 14 days, and that the physician evaluated the appropriateness to extend the use and document the rationale and the duration for the PRN medication for two Residents (#68 and #103) out of a total sample of 44 residents.

Inspectors wroteBased on observation, interview, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. One nurse out of two nurses observed made 3 errors in 33 opportunities resulting in a medication error rate of 9.09%. These errors impacted two Residents (#25 and #78) of the four residents observed.

Inspectors wroteBased on observations, interviews, and records reviewed for one Resident (#25) out of 44 sampled residents, the facility failed to ensure that the Resident was free from a significant medication error. Specifically, the facility failed to ensure blood pressure lowering medication was held when a physician's order indicated for it not to be administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate one Resident's (#104) allergy to milk out of a total sample of 44 residents.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate documentation for two residents (#94, #A1) out of a sample of 44 residents. Specifically: 1. For Resident #94, the facility documented nonskid strips were placed on his/her floor when none were present. 2. For Resident #A1, the facility failed to accurately document an as needed order for an abdominal wound dressing.