Northampton Manor Nursing and Rehabilitation Cente

In the surveyor’s words

From the most serious findings on record at Northampton Manor Nursing and Rehabilitation Cente, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 29, 2024

  Based on record review and interview, it was determined that the facility failed to ensure that residents with an elopement risk had the appropriate interventions in place to prevent an elopement. This was evident for 1 (#109) of 10 residents reviewed for elopement. Evidence was provided by the facility that an action plan was developed, and corrective measures were implemented on 4/30/24, immediately after the incident, to remove the immediacy of the noncompliance and correct the deficient practice. On 8/20/24, a determination of immediate jeopardy was made regarding the deficient practice with the potential for past non-compliance. The Director of Nursing and Corporate Clinical Director Nurse #2 were informed at 5:45 PM. […]

• No harm, potential for more than minimal, widespreadF607Aug 29, 2024

  Based on records review and interviews, it was determined that the facility failed to implement their abuse policies and procedures by 1) failing to report all allegations of abuse to the state agency and the facility's abuse coordinator and 2) failing to conduct a thorough investigation of all allegations of abuse. This was evident for 1 of 1 policies and procedures reviewed for abuse, neglect, exploitation, or mistreatment and has the potential to affect all residents of the facility. The findings include: A review of the facility's abuse, neglect, exploitation or mistreatment policies and procedures was conducted on 8/26/24 at 2:19 PM. The policies and procedure indicated in the bottom of the document that it had a complete revision on 11/1/2017. […]

• No harm, potential for more than minimal, widespreadF609Aug 29, 2024

  Based on records review and interviews, it was determined that the facility failed to 1) have an effective system in place to ensure that all allegations of abuse are reported to the state agency, 2) to ensure that reports are sent within the mandated timeframe, and 3) to report the results of the investigation no later than 5 working days after the incident. This was evident in 6 (Resident #19, #9, #6, #25, #67, and #92) of 21 residents reviewed for abuse. The findings include: 1) On 8/26/24 at 2:50 PM, a review of facility reported incident MD00200510 revealed that, on the morning of 12/12/23, Resident #25 reported to a staff member that a GNA (geriatric nursing assistant) had made a movement like s/he was going to hit the resident. […]

• No harm, potential for more than minimal, widespreadF610Aug 29, 2024

  Based on record review and staff interview, it was determined that facility staff failed to conduct a thorough investigation of abuse and maintain evidence of the investigation. This was evident for 7 (#424 #19, #9, #41, #92 #322, #67 ) of 21 residents reviewed for abuse and for 3 facility reported incidents reviewed for abuse (FRIs) (#MD00194834, and #MD00207292, and #MD00191798), of 34 FRIs investigated during the recertification survey. The findings include: 1). On 8/27/24 at 12:03 PM a review of the Office of Health Care Quality (OHCQ) report #MD00194834 revealed an allegation that staff mistreated Resident #322 on 7/27/23 when they ripped the remote control from the resident's hand. On 8/27/24 at 12:10 PM, the facility's investigation file was obtained and reviewed. […]

• No harm, potential for more than minimal, widespreadF730Aug 29, 2024

  Based on record review and interview, it was determined that the facility failed to ensure that all Geriatric Nursing Assistants (GNAs) had annual performance evaluations. This was evident for 3 GNAs (GNA #11, GNA #13, and GNA #14) of 3 GNAs reviewed during the Sufficient and Competent staffing task portion of the recertification survey. This had the potential to impact all residents. The findings include: On 8/20/24 at 10:00 AM, the annual performance evaluations were requested for GNA #11, GNA #13, and GNA #14 for 2019 through 2023. On 8/20/24 at 1:00 PM, the requested files were received and reviewed and revealed that each file lacked evidence of a performance evaluation in 2022, and GNA #13's file also lacked evidence of performance evaluations in 2020, 2021, and 2023. […]