Hall of Fame Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Hall of Fame Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF757Mar 5, 2021

  Based on medical record review, review of hospital records, interviews with staff and Physician #5, observations, review of the facility policy titled Anticoagulation Protocol, and review of the Medscape Guidelines 2020, the facility failed to ensure adequate monitoring was completed for one resident (Resident #11) who received the oral anticoagulant (blood thinning) medication, [MEDICATION NAME]. The failure to monitor the anticoagulant therapy resulted in Immediate Jeopardy and potential serious-life threatening harm for Resident #11 who did not receive ordered [MEDICATION NAME] time (PT) and International Normalized Ratio (INR) testing after having a critical level of 13.28 on [DATE] and receiving an antidote of Vitamin K the previous day. […]

• Actual harm, isolatedF686May 1, 2023

  Based on observation, record review and interview, the facility failed to ensure care planned interventions were in place to prevent Resident #30 from developing a pressure ulcer, and failed to ensure the pressure ulcer was comprehensively assessed, properly treated, and interventions were initiated to promote healing. Actual harm occurred on 09/15/22 when Resident #30 who was cognitively impaired, at risk for pressure ulcer development, and required extensive assistance of staff for bed mobility, was found to have a pressure ulcer to the left heel that was first assessed to be a Stage III (full thickness skin break into subcutaneous tissue but does not go into the muscle and bone) ulcer which deteriorated to an unstageable (full-thickness skin and tissue loss in which the extent of… […]

• Actual harm, isolatedF760Mar 5, 2021

  Based on medical record review, hospital emergency department records, and interviews, the facility failed to ensure Resident #14 received his antibiotic as ordered for [MEDICAL CONDITION]. Actual harm occurred when Resident #14 did not receive an ordered antibiotic for four days, and was admitted to the hospital on [DATE] for bilateral lower extremity [MEDICAL CONDITION]. This affected one (Resident #14) of three residents reviewed for antibiotic use. The facility's census was 51 residents. Findings include: Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. […]

• No harm, potential for more than minimal, widespreadF727Mar 26, 2026

  Based on record review and interview, the facility failed to ensure the Director of Nursing (DON) duties were completed by the registered nurse (RN). This had the potential to affect all 48 residents residing in the facility.Findings include:Review of the key personnel list indicated the Director of Nursing (DON) as Registered Nurse (RN) #419. The list indicated Licensed Practical Nurse (LPN) #423 as the Assistant Director of Nursing (ADON). Review of the personnel file for ADON LPN #423 revealed an employee action form dated 10/21/22 indicating a salary increase effective 10/09/22. Under the comments sections was a handwritten note effective 10/09/22 currently acting DON and all clinical lead, approved by the Administrator. Interview on 03/25/26 at 5:03 P.M. […]

• No harm, potential for more than minimal, widespreadF809Mar 26, 2026

  Based on review of the Resident Council minutes, observation, staff interview, resident interview and review of the mealtime policy, the facility failed to ensure meals were served in a timely manner. This affected five residents (#13, #31, #47, #48, and #56) of five residents reviewed for frequency of meals and had the potential to affect all 47 residents who received meals from the kitchen. The facility identified one resident (Resident #4) as receiving nothing by mouth (NPO). […]