Mitchell-Hollingsworth Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mitchell-Hollingsworth Nursing & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF600Sep 18, 2025

  Based on record review, interviews, document review, and policy review, the facility failed to ensure that one of six residents (Resident (R) 137) reviewed for abuse, was free from abuse of 38 sample residents. This failure had the potential to affect resident safety. Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated [DATE], recorded It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.1.Review of R137's undated admission Record located in the electronic medical record (EMR) under the Profile tab, indicated R137 was initially… […]

• No harm, potential for more than minimal, isolatedF605Sep 18, 2025

  Based on record review, interview, and policy review, the facility failed to ensure one of five residents (Resident (R) 7) reviewed for unnecessary medications had an appropriate diagnosis for the use of an atypical antipsychotic medication with dementia of 38 sample residents. Findings include:Review of the facility's policy titled, Use of Psychotropic Medications, reviewed 04/22/25, revealed: Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. […]

• No harm, potential for more than minimal, isolatedF628Sep 18, 2025

  Based on record review, interview, and facility policy review, the facility failed to ensure two of three residents (Resident (R) 3 and R12) Resident Representative (RR) or Family Member (FM) reviewed for facility initiated emergent transfer to the hospital received a written notice of transfer and/or a written bed hold notice from a sample of 38 residents. This failure had the potential to affect the resident and their Resident Representative by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired, and contribute to the possibility of denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. […]

• No harm, potential for more than minimal, isolatedF689Sep 18, 2025

  Based on record review, interviews, and facility policy review, facility failed to conduct a thorough falls root cause analysis for two of eight residents (Residents(R) 137 and R3) reviewed for falls of 38 sample residents. This failure could result in the facility's inability to discover the reason behind the resident's fall and put the appropriate interventions in place based on the reason for the fall.Findings include:Review of the facility's policy titled, Fall Prevention Program, dated 11/20/24, recorded When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the residents' care plan and update as indicated. f. Document all assessments and actions. g. […]

• No harm, potential for more than minimal, isolatedF700Sep 18, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure alternatives were attempted prior to the use of side rails for two of two residents (Resident (R) 7 and R12) reviewed for side rails out of 38 sample residents. This failure had the potential to increase accidental entrapment or injury from bed rail usage when an alternate assistive device may have been effective.Findings include:Review of the facility's policy titled, Proper Use of Bed Rails, reviewed 07/07/25, revealed: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails.Resident Assessment: .2. […]