Hazel Hawkins Memorial Hospital D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice related to pain management for one of four sampled residents (Resident 1) when Resident 1 did not receive the right dosage of oxycodone (a controlled drug used to treat moderate to severe pain) to manage severe pain to right hip. This failure had the potential to affect Resident 1's well-being. Findings: Review of Resident 1's clinical record titled, admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including displaced subtrochanteric fracture of right femur (a severe injury to the thigh bone where the fractured ends is out of alignment), aftercare following joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with new, artificial part), polyneuropathy (multiple nerve damage), presence of right artificial hip, and need assistance with personal care. Review of Resident 1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an observation on 3/11/24 at 11:27 AM, Resident 69 was observed in bed, with the two upper siderails in the raised position. Review of Resident 69's face sheet indicated Resident 69 admitted to the facility on [DATE]. Review of Resident 69's physician order, dated 4/19/23, indicated Resident 69 had an order for bilateral (both sides) upper side rails to be up when in bed for bed mobility. A review of Resident 69's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 10:20 AM, Resident 16 was seen lying in bed, with the two upper siderails and two lower siderails in the raised position. Review of Resident 16's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 16's physician order, dated 7/4/23, indicated Resident 16 had an order for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement, comprehensive, resident-centered, care plans for five out of twenty sampled residents, (Residents 51, 42, 47, 43 and 82), when the activity care plans of Residents 51, 42, 47, 43 and 82, were not comprehensive and resident-centered. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. Review of Resident 51's face sheet (a document that gives resident's information at a quick glance) indicated, Resident 51 was admitted to the facility on [DATE] with diagnoses including unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), unspecified chronic kidney disease (longstanding disease of the kidneys leading to renal failure) and essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition). During an observation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure sanitary practices of both kitchens and their foods were stored under sanitary conditions when: 1. A wilted head of lettuce, green onion, and cut salad were stored in a refrigerator; 2. No air gap (space between the top of the drain overflow and the discharge pipe or hose to prevent back flow of contaminated water) for a dishwasher, ice machine, 3-way sink (commercial and manual dishwashing sink), and food preparation sink in kitchen; 3. The egg salad stored in a refrigerator was measured at 44.5 degrees Fahrenheit (a unit of measurement of temperature) These failures had the potential to result in food borne illnesses among residents in the facility. Findings: 1.During an initial kitchen 1 observation and interview with facility's certified dietary manager L (CDM L) on 3/11/24 at 10:00 a.m., a wilted, brown colored head of lettuce, yellow and black colored wilted bunch of green onion leaves, and wilted cut salad in a plastic bag were in a refrigerator in kitchen 1. CDM L acknowledged these…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to refer 2 of 18 sampled residents (Resident 6 and 35) to the appropriate agency for a level two PASRR (pre-admission screening and resident review, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) evaluation when 1.Resident 6's PASRR Level one was positive, and 2.Resident 35 was diagnosed with schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) not due to a substance or known physiological condition after admission. This failure had the potential to put the residents at risk of not receiving appropriate care and services. Findings: 1. A review of Resident 6's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including psychotic disorder (a collection of symptoms that affect the mind,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document care consistent with professional standards of practice, to prevent pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) from possibly getting worse for one out of six residents (Resident 238) investigated with pressure ulcer, when staff did not document whether they turned and repositioned Resident 238 every two hours, from 6/23/23 to 6/27/23. This failure resulted in the lack of documentation for whether Resident 238 was turned and repositioned. Findings: Review of Resident 238's face sheet (a document that gives resident's information at a quick glance) indicated, Resident 238 was admitted to the facility on [DATE] with diagnoses including fracture (a complete or partial break in a bone) of unspecified part of neck of right femur (thigh bone), subsequent encounter for closed fracture (bone is broken but the skin is intact) with routine healing, unspecified heart failure (a chronic condition in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to follow physician's orders for oxygen (a component of air essential to living organisms) rate administration for 1 of 3 sampled resident (Resident 48). This failure had the potential to compromise Resident 48's health and well-being. Findings: Review of Resident 48's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 48 readmitted to facility on 3/6/2023. Review of Resident's admission diagnoses including systemic inflammatory response syndrome (a condition in which there is inflammation [a normal part of the body's response to injury or infection] throughout the whole body), anemia (a condition in which the body does not have enough healthy red blood cells to provide oxygen to body tissues), and chronic kidney disease (a gradual loss of kidney function over the time). Review of Resident 148's physician orders ,dated 3/7/2024, indicated, Oxygen at 2 LPM (LPM: liters per minute, oxygen measured in liters per minute) via nasal cannula (NC, a medical device to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility had a medication error rate of 5.88% when two medication errors occurred out of 34 opportunities during the medication administration for two of 12 residents (Residents 30 and 31). Both residents did not receive their medications as ordered. The failures resulted in medications not given according to the physician's orders and had the potential for them not receiving the full therapeutic effects of the medications. Findings: 1. During a medication administration observation with Registered Nurse (RN) A on 3/11/24 at 11:49 a.m., she was observed giving two medications to Resident 30 including a bottle of Systane Lubricant Eye drops. At the bedside, RN A instilled one drop of Systane eye solution into each of the resident's eyes. A review of Resident 30's physician's order, dated 10/9/22, indicated for Refresh Tears Solution (Carboxymethylcelulose Sodium) [active ingredient, a type of lubricant], to instill 1 drop in both eyes three times daily for dry eyes. During a concurrent interview and record review with RN A on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when insulin (medication to lower blood sugar) pens were not labeled with an expiration date when stored at room temperature; expired medications were identified in two of two medication carts, and in two of two medication rooms; and the temperature was not being monitored and maintained twice daily for two out of two medication refrigerators as per facility policy and procedures (P&P). This failure had the potential for the insulin to be administered past the 28-day expiration date; expired medications given to the residents; and loss of drug potency due to unmonitored temperatures. Findings: 1. During a visit to the Northside Medication Room with Licensed Vocational Nurse (LVN) D on 3/11/24 at 9:21 a.m., the medication refrigerator was identified. A quick review of the contents inside reflected it contained several refrigerated medications including two boxes of flu vaccine and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure to accommodate food dislikes for one out of three sampled residents (Resident 58). This failure had the potential for decreased meal intake and negative effects on health and well-being for Resident 58. Findings: During lunch observation in the facility's south building's dining room on 3/11/2024 at 12:23 p.m., cut pieces of carrots along with other food items were on Resident 58'slunch plate. Review of Resident 58's lunch tray card, dated 3/11/2024, indicated under dislikes No: Carrots, Cauliflower. Review of facility's lunch menu for 3/11/2024 indicated carrots lyonnaise along with other food items. During a concurrent interview, and record review of Resident 58's lunch tray card with certified nursing assistant K (CNA K), on 3/11/2024 at 12:30 p.m., CNA K acknowledged carrots under dislikes for Resident 58. CNA K stated dietary staff should not have provided carrots to Resident 58 as indicated under food dislikes for Resident 58. During an interview with facility's certified dietary manger L (CDM L)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control practice to prevent the spread of infection when: 1. A nasal cannula (NC: a medical device to provide supplemental oxygen to residents) tubing was on the floor, and dated 3/3; 2. A Foley catheter (F/C: a semi-flexible plastic tube, one end inserted into the bladder [body organ that stores urine] and the other end is attached to a bag that collects urine) drain bag's cover touched the floor; 3. Nursing staff failed to disinfect the shared blood pressure (BP) cuff (the device used to measure BP) before and after use for Resident 82. These failures had the potential for the spread of infections and communicable diseases among residents. Findings: 1.During an observation on 3/11/2024 at 10:38 a.m., NC tubing, that was dated 3/3, and was attached to a room air concentrator (RAC: a medical device that take in air from the room and filter out nitrogen to provides higher amounts of oxygen) lay on the floor next to nightstand when it was not in use in Resident 54's room.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the minimum requirement to provide 3.5 Direct Care Service Hours Per Patient Day (DHPPD, it is the total number of actual direct care service hours performed by direct caregivers per patient day divided by the average patient census) for eight days for the month of August to meet the resident's needs for one of two residents (Residents 1). This failure had the potential to affect Resident 1 and other residents ' care and wellbeing. Findings: 1. A review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including type 2 diabetes (DM, high blood sugar), hemiplegia and hemiparesis (one-sided weakness and paralysis), and depression (a mood disorder that interferes with daily life). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/02/23, the MDS indicated he had a brief interview of mental status (BIMS, a structured cognitive test) score of 15 (cognitively intact).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a comfortable and safe temperature level for two of three sampled residents (Resident 59, and Resident 384 ) and in hallway temperature was not maintained in the range of 71 to 81 degrees Fahrenheit. This failure had the potential for the residents to have an uncomfortable environment. Findings: 1. During an interview on 6/20/22 at 9:45 a.m., Resident 59 stated, I feel cold all the time, I use extra blankets, and hat. Vent is blowing cold air all the times, I informed a staff about the cold room last week. During an observation on 6/20/22 at 3:03 p.m., thermostat indicated 69 degrees Fahrenheit in hallway near Nurse's Station. During a follow up observation on 6/21/22 at 8:51a.m., thermostat indicated 70 degrees Fahrenheit in hallway near nurse's station. During a review of Resident 59's clinical record indicated she was admitted with diagnoses that include anemia (condition in which blood lacks adequate healthy red blood cells) unspecified osteoarthritis (Condition which can affect any joint in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility document review, the facility failed to follow proper sanitation and food handling practices when: 1. Pans were stacked and stored wet; 2. There were undated, unlabeled, and outdated food items in the reach-in refrigerator and dry storage area; and 3. Colanders were stacked and stored wet. These failures had the potential to cause food contamination and food-borne illness to 83 of 85 residents who received their food from the kitchen. Findings: 1. During the initial kitchen tour on 6/20/22 at 9:10 a.m., with [NAME] 1 (Cook 1) six metal pans of various sizes were observed stacked on the counter next to the stove. The pans were upright and stacked inside of one another. All of six pans were wet on the inside and outside surfaces of the metal containers. [NAME] 1 stated he had washed the metal pans after breakfast in the three-compartment sink. [NAME] 1 confirmed the pans were wet and he stated the pans should not be stacked and stored wet and should be air-dried. Review of the facility's Food Service and Nutrition Department procedure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 20 sampled residents (Residents 31 and 8). Failure to accurately assess the residents had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions. Findings: 1. Review of Resident 31's Change of Condition Evaluation, dated 3/7/2022, indicated Resident 31 had an unwitnessed fall and was found sitting on the floor. Resident 31's MDS dated [DATE] was reviewed. Section J1800 asked the question, Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent? The person who completed the MDS coded 0, which indicated Resident 31 did not have any falls during the specified time frame. During an interview and concurrent record review with the Minimum Data Set Nurse (MDSN) on 6/22/2022 at 11:15 a.m., the MDSN reviewed Resident 31's medical record and confirmed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of 20 sampled residents (Resident 14) when nursing staff did not apply Resident 14's left hand brace as ordered. This failure had the potential to affect the resident's care, health and well-being. Findings: Review of Resident 14's clinical record indicated she was admitted on [DATE] and had the diagnoses of Alzheimer's disease (a condition characterized by memory loss), osteoarthritis (degenerative joint disease) of hand, and pain in left hand. Review of Resident 14's physician order, dated 8/25/20, indicated apply brace to left hand, ON in Am [morning] and OFF in PM [evening]. May remove during hygiene and activities of daily living (ADL) care. Check for skin redness or irritation every shift. Review of Resident 14's care plan for 'chronic pain' indicated, Interventions: apply brace to left hand, ON in Am and OFF in PM. During an observation on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three out of 12 sampled residents (Residents 5, 31, and 46) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 5 received lorazepam (brand name: Ativan; an anti-anxiety medication) without adequate indication for use, and without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) since April 2020 (more than 2 years ago); and trazodone (medication for depression) without a GDR since August 2018 (almost for 4 years ago); 2. Resident 31 received sertraline (brand name: Zoloft; medication for depression) since April 2021 without an attempted GDR; and 3. Resident 46 received sertraline since March 2019 (more than 3 years ago) without evidence of an attempted GDR. The failure resulted in unnecessary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and facility document review, the facility failed to ensure food served was palatable and attractive. These deficient practices had the potential to impact the residents' nutritional status and not meet the residents' desire to be served food they felt was palatable and attractive. Findings: During an interview with Resident 60 on 6/20/2022 at 10:42 a.m., Resident 60 stated the food in the facility had no seasoning. Review of the facility menu for 6/21/2022 lunch indicated chicken parmesan breast, parslied fettuccini, seasoned cauliflower, garlic breadstick, and fruit cocktail with whipped topping. A test tray of regular and dysphagia 1 (pureed) diet was conducted on 6/21/2022 at 12:45 p.m. During the test tray, in the presence of certified dietary manager B (CDM B), the regular chicken and the regular/dysphagia 1 broccoli (replaced cauliflower) tasted bland. The regular broccoli appeared pale, overcooked and the texture was mushy. CDM B agreed the regular chicken and the regular/dysphagia 1 broccoli tasted bland. CDM B agreed the regular broccoli was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.