Hertford Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Hertford Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Jan 31, 2023

  Based on observations, record review, staff, Wound Care Physician, and Medical Director interviews, the facility failed to provide ongoing skin assessments, monitor consistently, and ensure treatments and interventions were implemented to prevent pressure ulcer development and worsening for a resident at risk for pressure ulcers who was admitted to the facility without pressure ulcers. On 10/02/22 Resident #67 was identified with a stage 2 pressure ulcer on his sacrum that worsened to a stage 4 pressure ulcer on 11/9/22. On 12/25/22 Resident #67 was diagnosed with osteomyelitis on admission to the hospital. […]

• Immediate jeopardy, patternF835Oct 26, 2021

  Based on observation, staff interview and record review the facility failed to implement effective systems for administration to ensure that all staff were educated and competent to clean and disinfect a shared glucometer for 2 of 2 medication aides observed to perform fingerstick blood glucose tests with the use of a shared glucometer (Med Aide #1 and Med Aide #2). Immediate Jeopardy began on 10/19/21 when administration did not ensure effective protocols or systems were in place to ensure medication aides were educated and competent to clean and disinfect a shared glucometer. This was evident for 2 of 2 medication aides observed to perform fingerstick blood glucose tests (Med Aide #1 and Med Aide #2). […]

• Immediate jeopardy, patternF880Oct 26, 2021

  Based on observations, staff interviews and record review the facility failed to use an approved procedure to clean and disinfect a shared glucometer used for 5 of 5 residents (Resident #15, #2, #50, #38 and #1) reviewed for fingerstick blood glucose tests. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA) approved disinfectant in accordance with the manufacturer of the glucometer increased the likelihood of the spread of blood borne infections between residents. Failure to disinfect a shared glucometer was observed when 2 of 2 medication aides were observed to perform a fingerstick blood glucose test on residents (Med Aide #1 and Med Aide #2). […]

• Immediate jeopardy, isolatedF689Mar 30, 2021

  Based on observations, record reviews, staff interviews, resident interview, and Medical Doctor (MD) interview, the facility failed to identify a hazardous construction area adjacent to the sidewalk leading to the 200 Hall entrance of the building used by one of one sampled resident (Resident #1). The area did not restrict access or have any visual caution signage. Resident #1 navigated his motorized wheelchair down the sidewalk. When he attempted to turn the motorized wheelchair around on the sidewalk, one wheel fell off the pavement. Resident #1 fell into a construction trench filled with rocks and the wheelchair fell on top of him. Resident #1 was unable to telephone for help and laid in the trench until a passerby found him. […]

• Actual harm, patternF697Jan 31, 2023

  Based on record review and staff, and physician interviews the facility failed to obtain and administer Oxycodone/acetaminophen (a controlled substance medication ordered to treat pain) as ordered for a resident who was newly admitted to the facility with a recent fracture of the upper and lower left humerus (a long bone located in the upper arm between the shoulder joint and elbow joint). The resident was transferred to the Emergency Department (ED) for unmanaged pain on two occasions (12/24/22 and 12/30/22) where he was provided with Oxycodone/acetaminophen as ordered which was effective in relieving the resident's pain. […]