Hereford Nursing & Rehabilitation

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 15 (Resident #19) reviewed for Resident Rights. The facility failed to ensure Resident #19 had a DNR in place which was signed by a physician and dated by the notary public. This failure could cause the loss of valuable time when dealing with a Resident's medical emergency and possible unwarranted death.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 (Resident #8 and Resident #30) of 15 residents reviewed for abuse, neglect, exploitation, and misappropriation of resident property.1. The facility failed to implement their policy titled Abuse/Neglect and report Resident #8's black eye to state authorities.2. The facility failed to implement their policy titled Abuse/Neglect and report Resident #30's missing diamond ring to state authorities. This failure placed residents at increased risk of abuse, neglect, exploitation and misappropriation of their property. Findings Included:1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #8 and Resident #30) of 15 residents reviewed for reporting abuse, [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated for 2 (Resident #8 and Resident #30) of 15 residents reviewed for investigating abuse, neglect, exploitation, and misappropriation of resident property.1. The facility failed to complete a thorough investigation of Resident #8's injury of unknown source (black eye).2. The facility failed to complete a thorough investigation of misappropriation of Resident #30's property (missing diamond ring). These failures could place residents at risk of continued abuse/misappropriation of property in the facility. Findings Included:1. [...]

Inspectors wroteBased on interview and record review the facility failed to complete a significant change assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for 2 (Resident #4 and Resident #39) of 15 residents reviewed for timing of assessments.1. The facility failed to complete Resident #4's significant change MDS within 14 days of her admission to hospice care on 07/16/25.2. The facility failed to complete Resident #39's significant change MDS within 14 days of her admission to hospice care on 12/26/24. These failures could place residents at risk of not receiving necessary care/coordination of care. Findings Included:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 15 residents (Residents #37, #35, and #40) reviewed for infection control. CNA C failed to utilize clean gloves while performing incontinence care for Resident #37. LVN D failed to disinfect the blood pressure cuff between uses for Resident #35 and Resident #40. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure pantry foods were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (LVN D, LVN E, CNA G, and CNA H) of 4 staff members and 2 of 2 residents (Resident #2 and Resident #45) in that: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 14 residents (Resident #4) reviewed for accommodation of needs. Resident #4's call light was not within her reach. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for1 of 14 (Resident #13) residents reviewed for bed rails. Resident #13 had (1) one-third bed rail, on the right side of her bed with no documentation of resident consent, or safety assessment prior to installation. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (Hall 200) and 1 of 1 medication room reviewed for drug labeling and storage and expired drugs. 4.5 pills were loose in the bottom of medication cart drawers of Hall 200 Medication cart. Medication room revealed a medication for Resident #36 that expired in June of 2023. These failures could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to keep resident rooms free from accident hazards for 3 of 3 residents (Residents #13, #19, #20) who were observed. The facility failed to follow smoking policy by Resident #13, Resident #19 and Resident #20 having smoking materials of lighters and cigarettes in rooms. This failure could place residents at risk of accident hazards.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored food was properly stored per food label. 2. The facility failed to practice proper hand sanitation while preparing food. Findings Included: Observation of shelved foods on 6/7/2023 at 10:00am revealed the following: 1. Plastic bottle labeled tartar sauce no expiration date noted ??? sitting on shelf with spice containers with a label on back indicated refrigerate after opening. Observation on 6/7/23 During an observation on 6/7/23 at 10:30 AM, observed [NAME] A preparing puree food. [NAME] A stopped prepping puree food, walked to trash can to discard a can, and returned to preparing puree food. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 14 residents (Resident #1) reviewed for immunization records. The facility failed to ensure records regarding patient care, including bed rails, was accurate and complete. This deficient practice placed residents at risk for inaccurate records to ensure continuity of and appropriate care.