Ruth Wilson Hurley Manor

In the surveyor’s words

From the most serious findings on record at Ruth Wilson Hurley Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF865Jul 21, 2022

  Based on record review and interview, the facility failed to develop a QAPI plan. Findings: A QAPI attendance form, dated 03/31/22, documented the IP, DM and AD were the attendees. On 07/22/22 at 1:48 p.m., the IP reported the facility did not have a current QAPI plan. On 07/22/22 at 2:22 p.m., the administrator reported the QAPI plan was not current, the meetings were not regular and the committee was in the process of being re-vamped.

• No harm, potential for more than minimal, widespreadF868Jul 21, 2022

  Based on record review and interview, the facility failed to establish and maintain a QAA committee. Findings: A QAPI attendance form, dated 03/31/22, documented the IP, DM and AD were the attendees. On 07/22/22 at 1:48 p.m., the IP reported the facility did not have a current QAPI plan. On 07/22/22 at 2:22 PM the administrator reported the QAPI plan was not current, the meetings were not regular and the committee was in the process of being re-vamped.

• No harm, potential for more than minimal, patternF812Dec 6, 2024

  Based on observation and interview, the facility failed to maintain a clean ice machine. The administrator identified 29 residents who received ice from the kitchen. Findings: On 12/03/24 at 10:38 a.m., the DM stated the kitchen staff cleaned the storage chest of the ice machine weekly and removed all the ice and cleaned/sanitized the storage chest of the ice machine monthly. The DM stated the kitchen staff did not clean the mechanical workings of the ice machine. The DM stated there was a company which came and ran sanitizer through the ice machine, but did not know how often the company did so. On 12/06/24 at 2:21 p.m., the internal mechanics of the ice machine was observed to have a moist green and black substance along the edges of the water reservoir, covers, inlets, and tubing. […]

• No harm, potential for more than minimal, patternF641Aug 23, 2023

  Based on observation, record review, and interview, the facility failed to ensure residents' assessments were accurate for four (#3, 5, 12 and #18) of 16 sampled residents whose assessments were reviewed for accuracy. The Resident Census and Conditions of Residents, dated 08/21/23, documented a census of 36 residents. Findings: 1. Res #3 was admitted with diagnoses which included weakness and fracture of the right femur. On 08/20/23 at 4:00 p.m., Res #3 was observed sitting on the edge of the bed. A 1/8 side rail was up on the left side of bed. On 08/20/23 at 4:00 p.m., Res #3 reported they used the side rail to assist them in getting out of bed at times. The resident reported they had requested the rail a long time ago and the doctor had approved it. […]

• No harm, potential for more than minimal, patternF656Aug 23, 2023

  Based on observation, record review, and interview, the facility failed to ensure care plans were developed for three (#3, 5, and #18) of three sampled residents who used bed rails and one (#11) of one sampled resident reviewed for falls. The DON identified seven residents who used side rails and 19 residents who had fallen in the last six months. Findings: 1. Res #3 was admitted with diagnoses which included weakness and fracture of the right femur. On 08/20/23 at 4:00 p.m., Res #3 was observed sitting on the edge of the bed. A 1/8 side rail was up on the left side of bed. On 08/20/23 at 4:00 p.m., Res #3 reported they used the side rail to assist them in getting out of bed at times. The resident reported they had requested the rail a long time ago and the doctor had approved it. […]