Havencare at Hancock Hall

In the surveyor’s words

From the most serious findings on record at Havencare at Hancock Hall, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761May 1, 2025

  Based on observation for 1 of 2 medication storage rooms (One North) and staff interview, the facility failed to remove expired medications from the medication refrigerator and failed to ensure the refrigerator temperatures were monitored. The findings included: A tour of the One North medication storage room on 4/25/25 at 12:09 PM with LPN #1 identified the following medications in the refrigerator inclusive of two medications that were expired: 1a. 2 Boxes of Bisacodyl suppositories package of 12 unopened. b. 2 packages of fleet glycerin suppositories (1 unopened the other ¾ full). c. 6 injectors of Toujeo solo star insulin unopened. d. 1 package of Brimonide eye drops 0.15% ophthalmic solution unopened. e. 1 Lyumjev Kwik pen 100 units/milliliters. f. […]

• No harm, potential for more than minimal, patternF684Jan 29, 2024

  Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of eleven (11) residents, (Resident #12) reviewed for medication administration the facility failed to ensure the correct medication was administered to the correct resident, and for eleven (11) of twenty six (26) residents (Resident #1,#2, #3, #4, #5, #6, #7, #8, #9, #10, and #11), the facility failed to ensure all medications were administered in accordance with physician's orders. The findings include: 1. […]

• No harm, potential for more than minimal, isolatedF550May 1, 2025

  Based on clinical record review, review of facility documentation, and interviews for 1 of 3 sampled residents (Resident #57) reviewed for abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner. The findings include: Resident #57 had diagnoses that included dementia and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #57 was moderately cognitively impaired and required one person assist with bed mobility, and two persons with transfers. The care plan dated 2/4/25 identified Resident #57 had the potential for mood changes related to dementia and was at risk for functional deficits. […]

• No harm, potential for more than minimal, isolatedF600May 1, 2025

  Based on interviews and record and policy review for 1 of 3 residents (Resident #58) sampled for abuse, the facility failed to protect a resident from physical abuse. The findings included: Resident #58's diagnoses included Alzheimer's disease, unspecified psychosis and pseudobulbar affect. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was severely cognitively impaired, required set up help with eating and was dependent on staff for transfers and dressing. The Resident Care Plan dated 2/4/25 identified Resident #58 had a potential risk for behaviors due to delusions. […]

• No harm, potential for more than minimal, isolatedF686May 1, 2025

  Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #61) reviewed for pressure ulcer, the facility failed to ensure an initial comprehensive skin assessment was completed for a newly identified skin condition and failed to regularly assess a resident's weight to ensure a pressure-relieving mattress adjusted according to manufacturer guidelines and for for 1 of 3 residents (Resident #72) reviewed for pressure ulcer/injury, the facility failed to maintain air mattress settings according to manufacture guidelines. […]