Hertford Rehabilitation and Healthcare Center

Inspectors wroteBased on record review, resident, and staff interviews, the facility failed to document and provide written information to residents/representatives regarding their right to refuse medical/surgical treatment or to formulate an advance directive for 7 of 13 residents reviewed for advance directives (Residents #5, #8, #15, #40, #58, #72, and #80).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours per day seven days a week for 1 of 34 days reviewed for sufficient staffing.

Inspectors wroteBased on staff interview and review of the Facility Assessment, the facility failed to ensure the staffing plan considered specific staffing needs for each unit and shift as required and failed to evaluate contracted services utilized by the facility to provide necessary care for its residents during normal operations and emergencies which had the potential to affect 64 of 64 residents.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to maintain an effective pest control program as evidenced by the presence of flies that affected resident rooms 5 of 12 rooms observed on the 300 Hall (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]).

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of use of anticonvulsant medication (Resident #55) and use of anticoagulant medication (Resident #55 and Resident #26) for 2 of 22 residents whose MDS assessments were reviewed.

Inspectors wroteBased on observations, record review, staff interviews, and Responsible Party (RP) interview, the facility failed to provide an ongoing resident centered activities program that included one on one (1:1) activities to meet the interests of a resident who did not participate in group activities for 1 of 1 resident reviewed for activities (Resident #55).

Inspectors wroteBased on record review, and staff and Consultant Pharmacist interviews, the facility failed to have effective systems in place for the return of discontinued controlled medications to the pharmacy which resulted in the controlled medication being diverted from the medication storage cart for 1 of 2 residents reviewed for misappropriation of residents' property (Resident #44).

Inspectors wroteBased on record reviews, and staff interviews, the facility failed to notify the resident and Resident Representative in writing of the reason for transfer/discharge to the hospital. The deficient practice affected 5 of 5 residents reviewed for hospitalization (Resident #28, Resident #24, Resident #2, Resident #47, and Resident #8). The following included: a. Resident #28 was admitted to the facility on [DATE]. A review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. A review of Resident #28's nursing progress note dated 5/26/25 revealed she was discharged to the hospital on 5/26/25 due to a critical low hemoglobin and altered mental status. Review of the medical record revealed no written notification of transfer for the Responsible Party or the resident for 5/26/25. b. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to document accurate information on the daily nurse staffing sheets for 34 of 34 days (5/01/25 through 6/03/25) reviewed.

Inspectors wroteBased on record review and staff interviews, the facility failed to have a Registered Nurse (RN) on duty at least 8 hours a day with a facility census of greater than 60 residents for 6 of 91 days reviewed (6/11/2023, 6/18/2023, 6/22/2023, 6/25/2023, 6/28/2023, and 6/29/2023).

Inspectors wroteBased on observations and staff interviews the facility failed to remove expired medication, date open medications, and failed to refrigerate medication according to the manufacturer's recommendations for 1 of 2 medications cart reviewed (Hall 300).

Inspectors wroteBased on observation, record review, and staff interviews, resident interviews, Responsible Party (RP) interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the 2/24/22 focused infection control and complaint survey, and the 10/26/21 and 1/31/23 recertification and complaint survey. This was for 7 recited deficiencies on the current complaint and recertification survey of 5/16/24 in the areas of Care Plan Timing and Revision (F657), Activities of Daily Living Care Provided for Dependent Residents (F677), Respiratory/Tracheostomy Care and Suctioning (F695), Registered Nurse (RN) 8 hours/7 Days a Week, Full Time DON (F727), Posted Nurse Staffing Information (F732), Label and Store Drugs and Biologicals (F761), and Infection Prevention and Control (F880). [...]

Inspectors wroteBased on observation, record review, staff interviews, Resident interview, and Responsible Party (RP) interview, the facility failed to protect a resident's right to be free from neglect for 2 of 2 resident reviewed for neglect (Resident #10 and Resident #217).

Inspectors wroteBased on observation, record review, staff interviews, Resident interview, and Responsible Party (RP) interview, the facility failed to provide incontinence care to residents that were incontinent and dependent on staff for activities of daily living (ADLs) for 2 of 5 residents reviewed (Resident #10 and Resident #217).

Inspectors wroteBased on observation, record review, Resident interview, and staff interviews, the facility failed to ensure that a resident with reported hearing difficulties was evaluated for 1 of 1 resident reviewed for vision and hearing (Resident #24).

Inspectors wroteBased on observation, record review, Resident interview, and staff interviews, the facility failed to obtain a physician order for a continuous positive airway pressure (CPAP) machine for 1 of 1 resident reviewed for respiratory care (Resident #7).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement infection prevention program policies and procedures when Nurse Aide (NA) #3 failed to perform hand hygiene after performing incontinence care for 1 of 1 resident observed for incontinence care (Resident #10), and NA #1 failed to perform hand hygiene between resident rooms when passing meal trays (room [ROOM NUMBER] and room [ROOM NUMBER]) for 1 of 1 NA observed during meal tray delivery.

Inspectors wroteBased on observations and staff interviews the facility failed to post nurse staffing information in a location that was readily accessible to residents and visitors on 4 of 4 days during the survey (5/13/2024, 5/14/2024, 5/15/2024, and 5/16/2024).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide written notice of discharge or transfer to the Responsible Party (RP) for 1 of 3 residents reviewed for hospitalization (Resident #1).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to update the care plan in the area of contracture management for 1 of 1 resident reviewed for limited range of motion (Resident #39).