Hessmer Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 7, 2023

  Based on record review, observation, and interview the facility failed to ensure residents received adequate supervision to prevent elopement, and failed to supervise an unsafe smoker, for 1 (#1) of 5 (#1#2, #3, #4, #5) residents reviewed for elopement. This deficient practice resulted in an immediate jeopardy situation on 03/13/2023 at 3:26 p.m., when Resident #1 who had a history of exit seeking behaviors, had been identified as a high elopement risk, and was placed on a secured unit, was left unsupervised while outside smoking. Resident #1 wandered off the facility grounds through an unlocked courtyard gate unnoticed by staff. Resident #1 was found by S1 Admin in a field, behind the facility 1/4 of a mile away, and returned, uninjured, to the facility at approximately 3:43 p.m. […]

• No harm, potential for more than minimal, widespreadF802Feb 5, 2025

  Based on observations, interviews and record review, the facility failed to ensure support personnel were competent to safely and effectively carry out the functions of the food and nutrition service. This deficient practice had the potential to affect the 75 residents who were prepared and served meals from the kitchen. Findings: Review of the facility's undated policy entitled Dietary Daily Functions revealed, in part . dietary staff preparing meal trays to be served to residents are to check all menu items to determine the correct serving utensil. Dietary staff are to monitor and record the parts per million (ppm) of sanitizer solution in the 3-part sink. 200ppm is desired. Observation on 02/03/2025 at 10:59 a.m. […]

• No harm, potential for more than minimal, patternF800Feb 5, 2025

  Based on observations, interviews, and record review, the facility failed to provide each resident with a nourishing diet that met his or her daily nutritional needs. This deficient practice had the potential to affect the 75 residents who were prepared and served meals from the kitchen. Findings: Review of the facility's undated policy entitled Diet Orders revealed, in part .The facility will serve diets as ordered by the physician. A regular diet contains all food groups and is planned to provide all then nutrients necessary to provide and maintain proper nutrition. For a pureed diet, foods are processed in a food processor. Procedures have been developed to puree food to provide correct and adequate portions equivalent to portions used on regular diets. […]

• No harm, potential for more than minimal, patternF812Feb 5, 2025

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect 75 residents who were prepared and served meals from the kitchen. Findings: Review of the facility's undated policy entitled Storage: Freezer revealed, in part .label and date all items. Review of the facility's undated policy entitled Storage: Dry Food revealed, in part .keep all containers tightly closed. Observation on 02/03/2025 at 8:48 a.m. revealed a Ziploc bag of thawed sausage links dated 12/26/2024 in the refrigerator. Three grey pans, each containing 4 undated bags of thawed chicken pieces, were in the refrigerator. […]

• No harm, potential for more than minimal, patternF584Jan 31, 2024

  Based on observation and interview, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, comfortable and home-like environment by failing to ensure: 1.Residents' room (Room A) maintained in good condition 2.Residents' assistive devices were maintained in good condition for 4 (Resident #25, Resident #52, Resident #64 and Resident #74) of 29 residents sampled for environment. Findings: Resident #52 Review of Resident #52's medical record revealed an admitted [DATE] with diagnoses that included Cerebral Infarction, Type 2 DM, Generalized Muscle Weakness, Abnormalities of Gait and Mobility, Altered Mental Status, Encephalopathy, Cognitive Communication Deficit and Malignant Neoplasm of Left Kidney. […]