Hereford Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 15 (Resident #19) reviewed for Resident Rights.The facility failed to ensure Resident #19 had a DNR in place which was signed by a physician and dated by the notary public.This failure could cause the loss of valuable time when dealing with a Resident's medical emergency and possible unwarranted death.Findings included:Review of Resident #19's admission record reflected Resident #19 was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, unspecified, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Type 2 Diabetes Mellitus with Hypoglycemia without coma, Adult Failure to Thrive, Anxiety Disorder, unspecified, Covid-19, Insomnia, and Major Depressive Disorder, Single Episode, unspecified. Review…

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 written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 (Resident #8 and Resident #30) of 15 residents reviewed for abuse, neglect, exploitation, and misappropriation of resident property.1. The facility failed to implement their policy titled Abuse/Neglect and report Resident #8's black eye to state authorities.2. The facility failed to implement their policy titled Abuse/Neglect and report Resident #30's missing diamond ring to state authorities.This failure placed residents at increased risk of abuse, neglect, exploitation and misappropriation of their property.Findings Included:1. Record review of Resident #8's admission record dated 08/06/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or…

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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #8 and Resident #30) of 15 residents reviewed for reporting abuse, neglect, exploitation, and misappropriation of resident property.1. The facility failed to report Resident #8's black eye to state…

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, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated for 2 (Resident #8 and Resident #30) of 15 residents reviewed for investigating abuse, neglect, exploitation, and misappropriation of resident property.1. The facility failed to complete a thorough investigation of Resident #8's injury of unknown source (black eye).2. The facility failed to complete a thorough investigation of misappropriation of Resident #30's property (missing diamond ring).These failures could place residents at risk of continued abuse/misappropriation of property in the facility.Findings Included:1. Record review of Resident #8's admission record dated 08/06/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or more of the following: attention,…

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 complete a significant change assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for 2 (Resident #4 and Resident #39) of 15 residents reviewed for timing of assessments.1. The facility failed to complete Resident #4's significant change MDS within 14 days of her admission to hospice care on 07/16/25.2. The facility failed to complete Resident #39's significant change MDS within 14 days of her admission to hospice care on 12/26/24.These failures could place residents at risk of not receiving necessary care/coordination of care.Findings Included:1. Record review of Resident #4's admission record dated 08/06/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease. Her admission record did not mention hospice.Record review of Resident #4'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 Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 15 residents (Residents #37, #35, and #40) reviewed for infection control. CNA C failed to utilize clean gloves while performing incontinence care for Resident #37. LVN D failed to disinfect the blood pressure cuff between uses for Resident #35 and Resident #40. These failures could place residents at risk for cross contamination and infection.The findings included:1.Resident #37Record review of Resident #37 undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident #37 had a medical history of type two diabetes, muscle weakness, and chronic kidney disease. Record review of Resident #37's annual MDS dated [DATE] revealed the following:*Section C- Cognitive Patterns, 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure pantry foods were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: In an observation of the walk-in pantry on 07/16/2024 at 8:50 AM the following was observed: 1. (4) graham cracker pie crusts in a package, not sealed and open to air with no date or label. 2. (1) open gallon of Big Chief Imitation Vanilla Flavor expiration date April 16, 2024, with no open date. In an observation of the freezer on 07/16/2024 at 8:55 AM the following was observed: 1. (1) box of hamburger patties with approximately 20 patties in the box, open to air with no open date. A small amount of freezer burn on the top patties was observed. In an…

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 program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (LVN D, LVN E, CNA G, and CNA H) of 4 staff members and 2 of 2 residents (Resident #2 and Resident #45) in that: LVN E did not don PPE gown before administering ordered medications via Peg-tube to Resident #2 LVN E did not don PPE gown before administrating Foley Catheter Care, Incontinent Care, and Wound Care-Stage 3 pressure ulcer to coccyx on Resident #45 CNA G did not don PPE gown before assisting LVN E with Foley Catheter Care, Incontinent Care and Wound Care Stage 3 pressure ulcer to coccyx on Resident #45 CNA H did not don PPE gown before, assisting LVN E with Foley Catheter Care, Incontinent Care, and Wound Care-Stage 3 pressure ulcer to coccyx on Resident #45 LVN D did not don PPE gown before administering liquid feeding via Peg-tube to Resident #2 These deficient practices have 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 ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 14 residents (Resident #4) reviewed for accommodation of needs. Resident #4's call light was not within her reach. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life. Findings included: Record review of Resident #4's face sheet, dated 07/17/2024, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, parkinsonism (slowed movements, tremors), urinary tract infection, dementia (memory loss), anxiety disorder, neuromuscular dysfunction of bladder (incomplete bladder emptying), and a history of falling. Record review of Resident #4's quarterly MDS, dated [DATE], revealed a BIMS score of 00 out of 15 which indicated Resident #4 had severe cognitive impairment. Resident #4…

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 attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for1 of 14 (Resident #13) residents reviewed for bed rails. Resident #13 had (1) one-third bed rail, on the right side of her bed with no documentation of resident consent, or safety assessment prior to installation. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living. Findings included: Record Review of Resident #13's Face Sheet dated July 16, 2024revealed that a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include but not limited to weakness, cognitive communication deficit,…

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 drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (Hall 200) and 1 of 1 medication room reviewed for drug labeling and storage and expired drugs. 4.5 pills were loose in the bottom of medication cart drawers of Hall 200 Medication cart. Medication room revealed a medication for Resident #36 that expired in June of 2023. These failures could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. Findings included: Observation and interview on 07/16/2024 at 10:26 AM of medication room revealed a medication for Resident #36 that had an expiration date of 06/2023. LVN D stated that the medication was discontinued and was not sure why the medication was still in the medication room. LVN D was unable to give a negative outcome for having expired medication in the medication room. Observation on 07/16/2024 at 10:46 AM revealed 4.5 pills were found…

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, the facility failed to keep resident rooms free from accident hazards for 3 of 3 residents (Residents #13, #19, #20) who were observed. The facility failed to follow smoking policy by Resident #13, Resident #19 and Resident #20 having smoking materials of lighters and cigarettes in rooms. This failure could place residents at risk of accident hazards. Findings included: Resident #13 Record review of Resident #13's face sheet dated 6/8/23 revealed a [AGE] year-old male admitted into the facility on 5/29/2018. Resident #13's diagnoses included: aphasia (communication deficiencies), muscle wasting and atrophy, cognitive communication deficit, mood disorder, chronic embolism and thrombosis (deep veins in the lower extremities), vascular dementia, nicotine dependence, and major depressive disorder. Record review of Resident #13's MDS assessment dated [DATE] revealed a BIMS score of 02 and required extensive assistance or two-person assist in all areas of daily…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored food was properly stored per food label. 2. The facility failed to practice proper hand sanitation while preparing food. Findings Included: Observation of shelved foods on 6/7/2023 at 10:00am revealed the following: 1. Plastic bottle labeled tartar sauce no expiration date noted ??? sitting on shelf with spice containers with a label on back indicated refrigerate after opening. Observation on 6/7/23 During an observation on 6/7/23 at 10:30 AM, observed [NAME] A preparing puree food. [NAME] A stopped prepping puree food, walked to trash can to discard a can, and returned to preparing puree food. Gloves were not worn, and no hand hygiene was practiced between these actions. During an interview on 6/8/2023 at 2:30pm with [NAME] A, DM, translated due to language barrier, stated that all kitchen staff are responsible…

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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 14 residents (Resident #1) reviewed for immunization records. The facility failed to ensure records regarding patient care, including bed rails, was accurate and complete. This deficient practice placed residents at risk for inaccurate records to ensure continuity of and appropriate care. Findings included: Record review of Resident #1's face sheet dated on 6/8/23 revealed a [AGE] year-old woman who was admitted into the facility on 3/26/23. Diagnoses included encephalopathy (disease that affects the brain causing altered mental status), hyperlipidemia (elevated lipids), unspecified psychosis, disorientation, cardiac arrhythmia, hypo-osmolality and hyponatremia (low plasma). Record review of Resident #1's MDS assessment dated [DATE] indicated a brief interview for mental status of 05 indicating severe cognitive…

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.