Hopkins Center for Rehabilitation and Healthcare

Based 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. The findings are: The facility policy titled Hand Washing/Hand Hygiene that was revised on 02/2023 documented that facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy stated to use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap (antimicrobial or nonantimicrobial) and water before and after direct contact with residents, after contact with a resident's intact skin, before and after assisting a resident with meals. During…

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, 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) The findings are: 1) The facility policy and procedures titled Smoking Policy first dated 04/25/11, revised 06/03/21 documented the following: Facility is a smoke free facility, and the residents and families are advised of this practice during the pre-admission screenings and in the facility admission agreement. The policy also documented that the residents are…

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 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. The findings are: 1. The facility policy and procedure titled Food Safety Requirements dated 7/2021 documented food will be stored, prepared, and served in accordance with professional standards for food service safety. Food service safety refers to handling, preparing and storing food in ways that prevent foodborne illness. Refrigerated storage labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by date, or frozen (where applicable)/discarded. On 03/10/2022 at 10:06AM during the initial tour of the kitchen in the walk-in refrigerator #1 the following was observed: sliced bologna labeled on 3/6/2022, a seprate container contained 3 bologna…

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 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: The nursing assistant will follow the plan of care as per instruction and document in plan of care. The nurses notes will indicate the resident's performance, the resident' participation and the resident's refusal. 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 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. The MDS further documented the resident required a total assistance when performing Activity of Livings (ADLS), and the resident had impairment on both upper extremities and lower extremities. On 03/11/22 between 11:29 AM and 12:45 PM, the resident was observed on the recliner…

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 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. The MDS also documented the resident required a total assistance when performing Activity of Livings (ADLS). The MDS further documented that the resident had impairment on both upper extremities and lower extremities. On 03/11/22…

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, 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). The findings are: The facility policy and procedure for Federal Rights of Residents, revised 01/01/18, documented the following: The facility must furnish a written description of legal rights which includes a posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State Survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit. On 07/29/19 at 10:25 AM, the State Agent (SA) held a Resident Council Meeting interview with 11 residents. Four of the residents regularly attend the Resident Council meeting. 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 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. On 07/29/19 at 11:31 AM, the facility lobby was observed. The survey results were inside a folder labled Do Not Remove that was placed inside a wall-mounted plastic box above the security desk. 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 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) . The findings are: 1) Resident # 268 was admitted on [DATE] with diagnoses which include acute respiratory distress, Chronic Obstructive Pulmonary Disease, shortness of breath, asthma, and hypoxemia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident is alert and oriented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). The findings are: Review of facility's policy Appropriate use of Indwelling catheters revised in March 2019 documented the nursing staff will ensure and maintain privacy of all residents with the use of dignity bags when the residents are out of bed to the wheelchair. Resident # 269 was admitted on [DATE] with diagnoses which include hemiplegia, hypertension, BPH, Renal insufficiency, septicemia, UTI, hyperlipidemia, aphasia, CVA and depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident's cognitive level is severely impaired. The resident requires extensive assistance and two person assist…

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 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: Toilet flush handles, Bed rails, Tray tables, Call buttons, TV remote, Telephone, Toilet seats, Monitor controls panels, touch screen 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). The finding are: Resident # 110 was originally admitted to the facility on [DATE] with diagnoses which include Dementia, Depression, and Hypertension. The Quarterly MDS dated [DATE] documented that the resident cognitively level is moderately impaired and the resident requires extensive assistance and two person assist for most activities of daily living. The CCP (Comprehensive Care Plan) for Dementia dated 5/12/19 documented the following generic interventions: addressing the resident in a quiet manner, anticipates…

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, 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. The facility will receive weekly pest control service and the kitchen will receive [NAME] services in the evening, a communication book is maintained on all units as a way of communicating any problems that staff may have. Hopkins Center will ensure that…

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.