Hopkins Center for Rehabilitation and Healthcare

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 04/07/2024 to 04/12/2024, the facility did not ensure infection control practices were followed. This was evident during the Dining Task for 1 of 4 dining rooms. Specifically, Certified Nursing Assistant #8 did not perform hand hygiene in between residents while assisting multiple residents with hand hygiene prior to lunch being served.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey conducted from 04/07/2024 through 04/12/2024, the facility did not ensure that the direct care staffing information based on payroll data was submitted based on the schedule specified by the Centers for Medicare and Medicaid Services. Specifically, the facility failed to submit the direct care staffing data for 10/01/2023 - 12/31/2023 timely.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey the facility did not ensure each resident received adequate supervision to prevent accidents. Specifically, multiple residents were observed with smoking materials (packs of cigarettes and lighters) in their possessions. The facility allowed residents to keep packs of cigarettes and lighters in their clothing and closets, and the facility security personnel allowed residents to leave the smoking room with smoking materials. This was evident for 5 of 5 residents reviewed for accident hazards, out of 38 sampled residents. (Residents # 62, #65, #80,#119, #203)

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure safe food handling and storage was practiced to prevent food-borne illness. Specifically, (1) expired food was found stored in the kitchen refrigerator and (2) 5-gallon bottles of emergency water were expired. This was evident during the Kitchen Observation task.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification and abbreviated survey, the facility did not ensure that a resident who is unable to carry out Activity of Daily Living (ADL) receives the necessary services to maitain personal hygiene. Specifically, Resident #44 was not provided assistance with toileting as recommended in the resident's Activity of the Daily Living. This was evident for 1 resident reviewed for Activity of Daily Living out of a sample of 38 Residents The facility's policy, procedure, and information titled Activity of the Daily Living was reviewed on 12/2021. The policy documented Purpose: is to support the resident who is certain to decline in order to lessen the likelihood of complications e.g. pressure ulcers and contractures. Procedure: [...]

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey, the facility did not ensure a resident with limited Range of Motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM. Specifically, a resident with a left-hand contracture was not provided with a splint device/Rolled Gauze as per physician order. This was evident in 1 of 1 resident reviewed for physical restraint, out of 38 sample residents. (Resident # 144) The finding is. Resident # 144 had diagnoses which include Dementia, Contracture of Joints, and Osteoarthritis. The most Minimum Data Sets Assessment (MDS) dated [DATE] documented the resident had severely impaired cognition. [...]

Inspectors wroteBased on interviews and record review conducted during the recertification survey the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that were complete and accurately documented for each resident. Specifically, Certified Nursing Assistants (C.N.A'S) documented completion of application of gauze roll to left hand in the medical record when they were not being provided. This was evident in 1 of 1 resident reviewed for physical restraint, out of 38 sample residents. (Resident # 144) The finding is. Resident # 144 had diagnoses which include Dementia, Contracture of Joints, and Osteoarthritis. As per the most Minimum Data Sets assessment dated [DATE] documented that the resident had severely impaired cognition. [...]

Inspectors wroteBased on observation, record review, and staff interview conducted during the recertification survey, the facility did not ensure that residents were informed orally and in writing about their right to file a complaint with the state survey agency and provided with contact information on how to do so (New York State Nursing Home Complaint Hotline).

Inspectors wroteBased on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure that the survey results were posted in a place readily accessible to residents, resident representatives or legal representatives without having to ask for them. Specifically, the survey results were located in a folder placed inside a wall-mounted plastic bin above a counter-height security desk. The finding is: The facility policy and procedure titled Federal Rights of Residents reviewed on 01/01/2018 documented: the resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents and must post notice of their availability. [...]

Inspectors wroteBased on observations, and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, (1) oxygen tubing was observed touching the floor on several occasions; (2) Certified Nursing Assistant (CNA) was observed going into a resident's room on contact precautions without wearing a gown and gloves; and (3) A RN was observed touching a resident's head and and bedding with gloves on prior to connecting tube feeding without performing hand hygiene and donning clean gloves. This was evident for 2 out of 38 residents reviewed in the investigation sample (Resident # 268, Resident #34) and one random observation (Unit 2W) .

Inspectors wroteBased on observations and interview conducted during the Recertification survey, the facility did not ensure that a resident was cared for in a manner that that maintained or enhanced his or her dignity. Specifically, a resident's Foley catheter bag and tubing were left uncovered and exposed to public view. This was evident for 1 of 2 residents reviewed for Dignity (Residents # 269).

Inspectors wroteBased upon observation, record review and staff interview during the recertification survey, the facility did not ensure that necessary housekeeping services to maintain a clean, sanitary, and comfortable interior were provided. Specifically, a resident's room and the common area in front of the elevators had a strong odor of urine. This was evident for 1 of 8 resident units observed for Environmental Observations (Unit 3W). The finding is: The facility policy titled Routine Cleaning and Disinfection dated 3/24/11 documented it is the facility's policy to ensure the provision of routine cleaning and disinfection of odor to provide a safe, sanitary environment and to prevent the development and transmission of infection to the extent possible. Consistent surface clearing and disinfection will be conducted with detail focus on high touch areas to include, but not limited: [...]

Inspectors wroteBased on record review and staff interviews during the recertification survey, the facility did not ensure that a person-centered care plans with measurable goals, time frames and interventions were developed to address a resident's concerns. Specifically, there was no documented evidence that the comprehensive care plan included individualized, person-centered interventions to address a resident's Dementia. This was evident for 1 resident out of a total of 38 sampled residents (Resident #110).

Inspectors wroteBased on observation, record review and staff interview conducted during the recertification surrey, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. Specifically, a resident room was noted with numerous flies on several occasions. This was evident for 1 out of 8 units observed for Environmental Observations (Unit 3W). The finding is: The facility policy titled Pest Control Program, revised 11/28/2018, documents Hopkins Center will maintain an effective pest control program that eradicates and contains the common household pests. Hopkins Center has a written agreement with a qualified outside pest service to provide comprehensive pest control services on a weekly basis to Hopkins Center. [...]