HRH Transitional Care Unit(A D/B/A Entity of Hrhs)

In the surveyor’s words

From the most serious findings on record at HRH Transitional Care Unit(A D/B/A Entity of Hrhs), in the surveyor’s own words.

• No harm, potential for more than minimal, patternF700Feb 19, 2026

  Based on clinical record review, observation, and staff interview, it was determined that the facility failed to assess residents for side rail use, review the risks and benefits of side rail use, and obtain informed consent from the resident or responsible party for use of side rails for four of nine sampled residents. (Resident 4, 36, 37, 38) Findings include: Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses that included arthritis and abnormalities of gait and mobility. A Minimum Data Set assessment completed January 21, 2026, revealed that the resident had no memory impairment and required moderate assistance of staff for bed mobility. […]

• No harm, potential for more than minimal, patternF694May 28, 2021

  Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for the care and maintenance of intravenous catheters were obtained for one of 18 residents reviewed (Resident 114). Findings included, The facility's policy regarding intravenous therapy (IV - a tube placed in a vein that can be used to deliver fluids and/or medications), dated June 22, 2020, included that catheters that were capped were to be maintained using three milliliters (ml) of saline (sterile salt and water solution) by flushing with 3 ml of saline, then administering the antibiotic, then flushing with 3 ml of saline after each use, or at least every eight hours to maintain patency (open/unobstructed). […]

• No harm, potential for more than minimal, isolatedF684May 28, 2021

  Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow physician's orders and care plans for two of 18 residents reviewed (Residents 104, 119) who were to be on intake and output monitoring. Findings include: Physician's orders for Resident 104, dated May 24, 2021, included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan, dated May 25, 2021, included an order to monitor the resident's intake and output (I&O - the measurement of a resident's fluid intake by mouth, feeding tubes, or intravenous catheters, and output from kidneys, gastrointestinal tract, drainage tubes, and wounds) every shift until discharged . […]

• No harm, potential for more than minimal, isolatedF689May 28, 2021

  Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide an environment that was as free of accident hazards as possible for one of 18 residents reviewed (Resident 112) who was at risk for falls. Findings include: The facility's policy regarding fall prevention and management, dated February 11, 2021, revealed that all residents at risk were to be considered for fall prevention interventions. Possible interventions for all residents included keeping the call bell within reach and instructing the resident to call for assistance with ambulation (walking). […]

• No harm, potential for more than minimal, isolatedF697May 28, 2021

  Based on clinical record reviews and staff interviews, it was determined that the facility failed to administer pain medications as ordered by the physician for one of 18 residents reviewed (Resident 108). Findings include: physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 108's Medication Administration Records (MAR's) for May 2021 revealed that on May 25, 2021, at 9:50 a.m. the resident's pain rating was an 8 and staff administered 2 mg of [MEDICATION(S)]. There was no documented evidence that the physician was notified that the resident's pain rating exceeded the ordered pain scale of 4-6, and no documented evidence that an order was received to administer the 2 mg of [MEDICATION(S)] for the resident's current pain rating of 8. […]