Hopkins Rehabilitation and Care Center

In the surveyor’s words

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

• Actual harm, isolatedF684Dec 4, 2024

  Based on observation, medical record review, hospital record review, review of the facility's fall investigation, resident interview, staff interview, and policy review, the facility failed to ensure Resident #34, who fell during staff care, was provided timely, adequate and necessary assessment/monitoring and care to treat a fracture and prevent discomfort and potentially additional injury. In addition, the facility failed to adequately and timely assess and report to the physician a change in Resident #41's eye condition to ensure timely and proper care was provided. Actual harm occurred on 10/17/24, when Resident #34 sustained a fall with injury during a physical therapy treatment that was not reported or immediately treated. […]

• Actual harm, isolatedF689Dec 4, 2024

  Based on observation, medical record review, hospital record review, review of the facility's fall investigation, review of witness statements, resident interview, staff interview, and policy review, the facility failed to ensure a Resident #34, who was at risk for falls, was provided necessary assistance to prevent an avoidable fall from occurring that resulted in major injury to the resident. Actual harm occurred on 10/17/24, during a physical therapy treatment, when Resident #34, sustained a fall with injury while ambulating with Physical Therapy Assistant (PTA) #420. […]

• Actual harm, isolatedF686Feb 1, 2024

  Based on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive pressure ulcer program to prevent the development of pressure ulcers and to ensure pressure ulcers were comprehensively assessed, properly treated, and interventions were initiated to promote healing. Actual Harm occurred on 12/19/23 when Resident #6, who had moderate cognitive impairment, was at risk for skin breakdown and required extensive assistive from two staff for bed mobility developed a new in-house acquired unstageable (dry, leathery, brown or black necrotic (dead avascular) tissue - Eschar, full-thickness pressure injuries in which the base is obscured by slough and/or eschar due to damage of underlying soft tissue from pressure and/or shear)… […]

• Actual harm, isolatedF689Oct 31, 2023

  Based on observation, medical record review, review of an incident report, review of witness statements, review of the mechanical lift user manual, facility policy review, review of the nursing staff schedule, review of a disciplinary form and interview, the facility failed to properly operate a mechanical lift during a transfer of Resident #48. Actual harm occurred on 09/22/23 at approximately 4:00 P.M. when a mechanical lift was used by one-staff member instead of two-staff members, as care planned and per the facility policy, resulting in Resident #48 sustaining a left tibia and left fibula fracture and visit to the emergency room . Subsequently, Resident #48 suffered from severe pain to the left leg resulting in an interference of physical activity. […]

• No harm, potential for more than minimal, widespreadF725Dec 4, 2024

  Based on observations, resident interviews, staff interviews, and review of the facility assessment and staff schedules, the facility failed to ensure adequate and sufficient staff levels to meet the needs of the residents. This had the potential to affect all residents residing in the facility. The facility census was 64. Findings include: Observation on 11/24/24 from 8:00 A.M. to 9:00 A.M. during tour of the facility, revealed a daily staffing sheet dated 11/23/24 for the 11:00 P.M. to 7:00 A.M. shift that indicated there were three nurses and five Certified Nursing Assistant (CNAs) to cover the night shift. Observation during the tour of the facility revealed there were only two CNAs in the facility for a census of 64. Interview on 11/24/24 at 8:25 A.M. […]