Harbert Hills Academy N H

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored for 1 of 3 (Resident # 47) residents. The findings include: Review of the facility policy titled, Medication Storage Policy and Procedure, dated 7/15/2025, revealed .It is the policy and procedure of [NAME] Hills Academy Nursing Home to keep medications stored on medication carts which are locked and kept behind the nurse's desk when not in use. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Secondary Parkinsonism, Paranoid Schizophrenia, Vascular Dementia, Major Depressive Disorder, Alzheimer's Disease, and Delusional Disorders. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #47 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Review of the Physician Orders dated 3/2/2026, revealed…

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 facility policy, medical record review, observation and interview the facility failed to complete assessments before or during use of a specialized harness (a chest harness connected to his wheelchair that pulled over his shoulders on both sides and snaped on both sides above his waste) for 1 of 1 (Resident #24) sampled residents reviewed for physical restraints. The findings include: 1. Review of the undated facility policy titled SIDERAILS POLICY, revealed, .PHYSICAL RESTRAINT .[Named Facility #1] is a restraint-free facility .ACKNOWLEDGEMENT OF RESTRAINT POLICIES .restraint use in our facility will only be considered to treat a medical symptom/condition that endangers the physical safety of the resident or other residents and under the following conditions .a last resort measure after a trial period where less restrictive measures have been undertaken and proven unsuccessful .with a physician order .with the consent of the resident or legal representative .If restraint use is deemed necessary, 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 policy review, medical record review, observation, and interview the facility failed to develop a person-centered comprehensive care plans for 4 of 15 residents (#9, #34, #38, #42) sampled residents. The findings include: 1. Review of the facility's policy titled, MDS & CARE PLAN POLICY AND PROCEDURE dated 7/26/2021, revealed .The facility must develop and implement a comprehensive person-centered care plan for each resident .with measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .care plans will be completed within 13 days of admission, and quarterly thereafter . 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Schizophrenia, Viral Hepatitis, Delusional Disorders, Bipolar, Psychosis, Dementia, Auditory Hallucinations. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status…

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 policy review, Pharmacy Services Agreement review, medical record review, and interview the facility failed to provide pharmaceutical services that assure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate account of medication destruction for 5 of 5 (Resident #3, #6, #15, #29, and #36) sampled residents reviewed for drug destruction. The findings include: 1. Review of the undated facility policy titled, Drug Destruction Policy and Procedure, revealed .It is the policy of [Named Facility #1] to ensure the destruction of unused or expired medications .The purpose of this policy is to ensure compliance with federal regulations .Label/Store Drugs and Biologicals .It is the responsibility of nursing staff, administrative staff, and the contracted pharmacist .Outdated or unused medications will be returned to [Named Pharmacy] where [Named Pharmacist] will destroy the medication . 2. Review of the Pharmacy Services Agreement revealed, .[Named…

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 review of federal regulations, Quarterly Payroll Based Journal (PBJ), and interview, the facility failed to report PBJ for Quarter 2 in 2024 (January 1-March 31). The findings include: 1. Review of the federal regulation 483.70(p) revealed, .The facility must electronically submit to CMS (Centers for Medicaid and Medicare Services) complete and accurate direct care staffing information . 2. Review of Quarterly Payroll Based Journal (PBJ) dated January 1, 2024-March 31, 2025, revealed, .No RN (Registered Nurse) Hours .Four or More Days within the Quarter with no RN Hours . During an interview on 4/9/2025 at 4:10 PM, the Administrator confirmed the facility failed to submit the required PBJ data for the second quarter of 2024.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review and interview, the facility failed to implement appropriate infection prevention and control practices for 1 of 1 sampled resident (Resident #22) who required enhanced barrier precautions (EBP an infection control strategy that uses gloves and gowns to reduce the spread of multidrug resistant organisms (MDRO microorganisms that are resistant to at least one class of antimicrobial (substance that kills bacteria) agents) in nursing homes during medication administration. The findings include: 1. Review of undated Policy titled Enhanced Barrier Policy .to safe guard residents from multidrug-resistant organisms (MDROs) during high-contact resident care activities while preserving their quality of life through focused infection control practices .This policy applies to all staff members .The policy applies to residents .with .PEG (Percutaneous Endoscopic tube is a feeding tube inserted through the skin and into the stomach, used for long-term nutritional support…

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 the policy review, medical record review, and interview, the facility failed to resubmit a PASRR [Preadmission Screening and Resident Review] after the resident had the addition of a new antipsychotic medication and a new mental health diagnosis for 4 of 5 sampled residents (Resident #5, #13, #18, and #34) reviewed for PASRR. The findings include: 1. Review of the facility's policy titled, CARE PLAN POLICY AND PROCEDURE, dated 7/26/2021, revealed .Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR [Preadmission Screening and Resident Review], it must indicate its rationale in the resident's medical record . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Diabetes, Psychosis, Anxiety, and Depression. Resident #5 had a PASRR completed on admission in 2004 with diagnosis of mild mental retardation. 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 policy review, observation, and interview the facility failed to ensure infection control practices to prevent the spread of infection when 3 of 3 nurses (Licensed Practical Nurses (LPN) #1, LPN #3, and LPN #4) failed to perform hand hygiene and to clean equipment during medication administration. The findings include: 1. Review of the facility undated policy titled, Handwashing Policy, revealed .all employees are required to wash hands before and after any direct resident care as follows .Washes all surfaces of hands and wrist with liquid soap for at least 20 seconds .Dries hands on clean paper towel .Turn off faucet with a second .clean dry paper towel . Review of the PROTOCOL FOR ADMINISTRATION OF MEDICINES & [and] WATER FLUSHES PER PEG TUBE [percutaneous endoscopic gastrostomy], revealed .Check for placement .flush with 30 cc [cubic centimeters] of water .Mix approximately 20-30 cc of water .crush or liquid medicines .give per peg, flush with 30 cc of water .reconnect tube feeding .Rinse syringe with warm water and return to bag .wash hands . 2. Observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to implement Comprehensive Care Plans for 2 of 13 (Resident #13 and #34) sampled residents reviewed for care planning. The findings include: 1. Review of the facility's policy titled, Care Plan Policy and Procedure, dated 7/23/2021 revealed, .implement a comprehensive person-centered care plan .meet a resident's medical .mental and psychosocial needs . 2. Review of the medical record revealed Resident #34 was admitted on [DATE], with diagnoses of Anxiety Disorder and Cognitive Deficit. Review of the annual MDS dated [DATE], revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, and had diagnoses of Anxiety, Depression, and Psychotic Disorder. Review of the Care Plan dated 9/13/2023, revealed Resident #34 was not care planned for psychotic features, hallucinations, or harm to self. During an interview on 10/11/2023 at 5:43 PM, the Director of Nursing (DON)…

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 policy review, medical record review, observation, and interview, the facility failed to perform complete neurological (neuro) checks, revise the Care Plan, implement appropriate fall interventions, and notify the provider for 3 of 3 (Resident #15, #22, and #28) sampled residents reviewed for accidents. The findings include: 1. Review of the facility's undated policy titled, .FALLS AND RESIDENT INCIDENTS, revealed .A fall is defined when a resident accidently touches the floor .Identified residents with the potential for a fall or have fallen will have 1 falling star, visual aide placed beside their door to alert the nursing staff .The nursing home staff using the fall-risk assessment sheet will identify these residents. New admissions will be evaluated upon admission and pre-existing residents that have fallen will be evaluated using this form . Review of the facility's undated policy titled, FALL PROTOCOL: RESIDENTS AT RISK FOR FALLS, revealed .THREE FALLS .(within 90 days) .Request attending…

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 interview, and observations, the facility failed to ensure narcotics were not expired on the medication cart, the drug destruction sheets were accurately documented and signed by the pharmacist and Director of Nursing (DON) and failed double lock and secure accurate inventories of controlled substances on 2 of 2 medication carts (Medication Cart #1 and Medication cart #2). The findings include: 1. Review of the facility undated policy's titled, Policy on Disposal of Medicines, revealed .Medication that are expired are to be placed in the basket located behind the door in the med [medication] room .These medications will be properly disposed of monthly by the pharmacist . Review of the policy's titled, Drug Destruction Policy and Procedure, dated 10/5/2021, revealed .It is the policy of [Named Nursing Home] to ensure the destruction of unused or expired medications .It is the responsibility of nursing staff, administrative staff, and the contracted pharmacist .Outdated or unused medications will be returned to the Name Pharmacist where pharmacist [Named Pharmacist] will…

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 policy review, medical record review, observation, and interview, the facility failed to ensure a medication administration rate of less than 5 percent (%) when 1 of 3 nurses (Licensed Practical Nurse (LPN) #1) failed to properly administer medications for 1 of 7 (Resident #23) sampled residents observed during medication administration. This resulted in a medication administration error rate of 7.41%. The findings include: 1. Review of the facility's undated policy titled, Medication Pass Policy, revealed .Medications will be administered as ordered .refer to the MAR [Medication Administration Record] . 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of Dysphagia, Anxiety Disorder, Gastrostomy Status, Major Depression, and Dementia. Review of the Physician's Orders dated 9/13/2023, revealed .Decrease Abilify to 1 mg via PEG . Review of the Medication Administration Record, dated October 2023 revealed, .Abilify [antipsychotic] 1 mg [milligram]…

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 policy review, observation, and interview, the facility failed to ensure medications were properly stored in 2 of 4 medication storage areas (Medication Storage Room, Medication Cart #1, and Medication Cart #2) when the facility had opened, undated, and expired medications, and controlled substances that were not secured behind two locks on the medication cart. The findings include: 1. Review of the facility's undated policy titled, Policy on Disposal of Medication, revealed .Medications that are expired are to be placed in the basket located behind the door in the med [medication] room. These medications will be properly disposed of monthly by the pharmacist . 2. Observation and interview on 10/10/2023 at 10:35 AM, revealed Medication Cart #1 had one open and undated bottle of Diazepam (sedative and controlled substance) with an expiration date of 2/2023. Licensed Practical Nurse (LPN) #2 was asked should the medication carts have open, undated, and expired medication. LPN #2 stated, .No . Observations in the Medication Storage Room on 10/9/2023 at 10:46 AM, revealed 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.