Inspection Reports for
Hancock Hall

The complaint investigation included allegations of verbal abuse by staff member NA #1 towards Resident #57, physical abuse involving Resident #58 hitting Resident #5, failure to provide appropriate pressure ulcer care for Residents #61 and #72, delayed response to pharmacy medication review recommendations for Resident #36, expired medications found in storage, and failure to follow infection control protocols including PPE use and hand hygiene.

The facility was found to have failed in ensuring respectful treatment of residents, protecting residents from abuse, providing appropriate pressure ulcer care, timely addressing pharmacy medication reviews, removing expired medications and monitoring refrigerator temperatures, and enforcing infection prevention and control practices including PPE use and hand hygiene.

The audit found that Violation #1 was in compliance as of 9/3/24, and the Regional Director of Nursing was notified on 10/17/24 that the violation was back into compliance.

The complaint investigation was substantiated. Resident #1 fell out of the wheelchair during transport by Nurse Aide #1 who did not place footrests on the wheelchair. Resident sustained a forehead laceration requiring emergency department evaluation and staples.

The facility failed to ensure Resident #1 was properly positioned in the wheelchair with footrests in place prior to transport, leading to a fall and a forehead laceration requiring hospital evaluation and staples. Interviews and policy review confirmed noncompliance with proper wheelchair safety procedures.

The complaint investigation found substantiated medication errors including administration of incorrect medication to Resident #12 and multiple medication omissions for eleven other residents. The facility reported the errors, notified responsible parties, and monitored residents with no ill effects noted.

The facility failed to ensure correct medication administration for one resident and failed to administer medications according to physician orders for eleven residents. Medication omissions and errors were identified, with no ill effects noted, and the facility provided education to staff following the event.

The complaint investigation found neglect in incontinent care provision for three residents. The neglect was substantiated by clinical record reviews, staff interviews, and direct observation. Residents were found in wet briefs after five hours without care. Staff acknowledged the delay and failure to notify supervisors.

The facility neglected to provide incontinent care and morning personal care for Residents #1, #2, and #3 for a period of five hours on 11/17/23, despite care plans requiring assistance and timely care. Staff interviews revealed that nurse aides were overwhelmed and did not notify supervisors when behind, resulting in delayed care. The facility provided staff education and initiated weekly audits to address the issue.

The facility failed to electronically submit discharge tracking information within required timeframes, did not document RN assessments after resident falls, failed to complete neurological assessments after multiple unwitnessed falls, administered medication contrary to physician orders, and stored expired intravenous fluid supplies.

The facility was found deficient in several areas including failure to ensure mail delivery on Saturdays, incomplete care planning for a resident removing oxygen, medication administration errors including incorrect dosing and omission of medication doses, and failure to perform proper hand hygiene by staff to prevent infection spread.