Altercare of Nobles Pond, Inc

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure appropriate sanitation and temperature tracking logs were maintained, failed to ensure resident foods were stored at an appropriate temperatures, and failed to ensure the resident refrigerator for outside foods was monitored and food was appropriately labeled and discarded when expired. This had the potential to affect all 61 residents receiving meals from the kitchen. The facility census was 61.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to preserve the dignity of one resident with a Foley (indwelling) catheter. This affected one resident (Resident #98) of two residents reviewed for dignity with Foley catheters. The facility census was 61.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the responsible party was notified of a medication change. This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 61.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure a clean and homelike environment was maintained for Resident #58. This affected one resident (#58) of 61 residents screened for environmental concerns. The facility census was 61.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure Resident #4 was provided appropriate medical treatment in response to a change in condition. Additionally, the facility failed to ensure appropriate wound care and services were provided to Resident #24 and Resident #95. Additionally, the facility failed to ensure daily weights were obtained as ordered for Resident #76. This affected four residents (#4, #24, #76, and #95) of 25 residents reviewed for quality of care and treatment. The facility census was 61.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate care and treatment was provided for Residents #4 and #24's pressure ulcers. This affected two residents (#4 and #24) of two residents reviewed for pressure ulcers. The facility census was 61. Findings Include:1. Resident #4 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, peripheral vascular disease, a urinary tract infection, calculus of the kidney, and osteonecrosis to the left femur from a previous trauma. Review of the admission Assessment and Baseline Care Plan for Resident, dated 02/27/26 and completed by Licensed Practical Nurse (LPN) #588, revealed the resident did have a wound but the location was not documented. The Baseline Care Plan revealed a care plan for wound care was initiated. [...]

Inspectors wroteBased on review of medical record, interview, review of facility investigations, and facility policy review, the facility failed to ensure complete and thorough fall investigations were completed for one resident (#5) of three residents reviewed for falls. The facility census was 61.

Inspectors wroteBased of medical record review, interview and review of facility policy, the facility failed to ensure weights and reweights were obtained as required to ensure accuracy. This affected one (Resident #24) of seven reviewed for weights. The facility census was 61.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure Resident #4 received appropriate care and services to manage the resident's pain. This finding affected one (Resident #4) of four residents reviewed for medication administration. The facility census was 61.

Inspectors wroteBased on review of medical record, interview, and facility policy review, the facility failed to ensure pharmacy recommendations were implemented timely. This affected one (Resident #5) of five residents reviewed for unnecessary medications. The facility census was 61.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents medication regimens had an appropriate indication for use. This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 61.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of 5% or less. A total of 26 medications were administered with six errors for a medication error rate of 23.08%. This affected two residents (Residents #27 and #37) of three residents observed for medication administration. The facility census was 61.

Inspectors wroteBased on observations, interview, and policy and procedure review the facility failed to ensure food was stored in a manner to protect from contamination/spoilage, the oven was maintained in a clean/sanitary manner, and food was prepared/served in accordance with standards for food service safety. This had the potential to affect 68 out of 69 residents receiving food from the kitchen. Resident #127 was identified as not receiving anything by mouth and received no food from the kitchen. The facility census was 69. Findings Include: Observation during tour of the kitchen on 06/09/25 at 8:10 A.M. with the Dietary Manager revealed in the dry goods storage room there was an open bag of cake mix and an open bag of instant mashed potatoes with no label or date as to when opened. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with their preferences during meals. This affected five ( #28, #30, #31, #32, and #40 ) of six residents reviewed for food and drink. The facility census was 69. Findings Include: 1. Review of Resident #28 medical record revealed the resident was admitted on [DATE] with diagnoses including anorexia, adult failure to thrive and anxiety disorder. Review of Resident #28's care plans revealed an intervention dated 11/25/24 to provide the diet per the physician's order and honor preferences. Review of Resident #28's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 exhibited moderate cognitive impairment. Review of Resident #28's physician orders for June 2025 revealed an order for a regular diet, thin liquid consistency. Observation on 06/09/25 at 1:36 P.M. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #21's left palm protector was implemented as ordered to prevent skin breakdown and prevent deformity. This affected one (Resident #21) of one resident reviewed for position and mobility. Findings Include: Review of Resident #21's medical record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness and vascular dementia. Review of Resident #21's physician orders revealed an order dated 01/23/25 for a left palm protector to be placed on in the morning and removed at bedtime and to check skin integrity twice daily. Review of Resident #21's Quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. [...]

Inspectors wroteBased on record review, observation, interview, and review of facility policy, the facility failed to provide enteral feeding as ordered for Resident #127. This affected one (#127) of one resident who received enteral feedings. The facility census was 69. Findings Include: Review of the medical record for Resident #127 revealed an admission date of 05/24/25 with diagnoses including dysphagia oropharyngeal phase, aphasia, and gastrostomy status. Review of the admission Minimum Data Set assessment, dated 05/31/25, revealed Resident #127 was cognitively intact, dependent on staff for activities of daily living, and received 51 percent or more of calories and 501 milliliter (ml) or more of fluids from tube feeding daily. Review of the physician's orders for June 2025 for Resident #127 identified an order dated 05/27/25 for continuous enteral feeding formula Isosource 1.5 at 55 ml per hour. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #34's carbohydrates were monitored during meals, assisted with adding the carbohydrate count to the insulin pump, the resident's care plans were updated to reflect accurate interventions for caring for the resident's insulin pump, the resident's physician orders accurately reflected the amount of as needed insulin to be administered to the resident and the staff were knowledgeable in operating the resident's insulin pump. This resulted in significant insulin medication errors affecting one (Resident #34) of two residents reviewed for insulin administration. The facility census was 69. Findings Include: [...]

Inspectors wroteBased on record review and interview, the facility failed to accurately document the details of a fall and fall investigation. This affected one resident (#10) out of two residents reviewed for falls. The facility census was 69. Findings Include: Review of the medical record for Resident #10 revealed an admission date of 03/17/25 and readmission date of 05/13/25 with diagnoses including bilateral osteoarthritis of the knee, atrial fibrillation, difficulty in walking, type two diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, hypertension, acute and chronic respiratory failure with hypoxia, and weakness. Review of the admission assessment dated [DATE] revealed Resident #10 was at low risk for falls with a score of 4.0 (the assessment indicated high risk was a score of 10.0 or higher). Review of the fall investigation report dated 05/20/25 timed 6:00 A.M. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure call lights were in working order. This affected one resident (#36) of one resident reviewed for call light placement. Findings Include: Review of Resident #36's medical record revealed the resident was admitted on [DATE] with diagnoses including pancytopenia, diabetes mellitus, and atherosclerotic heart disease. Review of Resident #36's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of a plan of care dated 04/21/25 revealed Resident #36 was at risk for falls. Interventions included to encourage Resident #36 to use call light for transfer/ambulation assistance. Observation and interview on 06/10/25 at 12:57 P.M. revealed Resident #36 needed assistance. Resident #36 stated that he had been using the call light, and it was not working. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, self-reported incident (SRI) review, and facility policy review the facility failed to protect Residents #70, #22, #21, #64, #71 from misappropriation of narcotic medication. This affected five residents (#70, #22, #21, #64, #71) of the 29 residents who received narcotic medication. The facility census was 82.

Inspectors wroteBased on review of the medical record, review of the facility stock medications, and interview with the staff the facility failed to ensure medications were obtained timely and initiated as ordered for Residents #26, #65, and #57. This affected three residents (#26, #57, and #65) of nine residents reviewed for medication administration.

Inspectors wroteBased on observations, medical record review, and staff interviews the facility failed to ensure aerosol masks and oxygen tubing were dated as to when they were last changed for Residents #27, #12, #42, #49 and #37, failed to place aerosol mask/mouthpieces in a protective barrier bag for Residents #27, #49 and #37, and failed to ensure the aerosol mask was cleaned for Resident #37. This affected five residents (#27, #12, #42, #49 and #37) of 19 residents with oxygen or aerosol treatments.

Inspectors wroteBased on observation and staff interview the facility failed to ensure urinary drainage bags for Residents #27, #40, and #62 were covered to maintain dignity. This affected three residents (#27, #40, and #62) of nine residents reviewed for dignity and respect.

Inspectors wroteBased on observation and staff interview the facility failed to maintain a clean sanitary environment for Resident #26. This affected one resident (#26) of three residents reviewed for facility sanitation.

Inspectors wroteBased on review of the medical record and interview with the staff the facility failed to ensure showers were given to dependent Resident #26. This affected one resident (#26) of three residents reviewed for showers.

Inspectors wroteBased on observation, review of the medical record and interview with staff the facility failed to timely treat a urinary tract infection for Resident #26 and failed to have a physician's order for indwelling urinary catheters for Residents #27 and #40. This affected one resident (#26) of three residents reviewed for medications and two residents (#27 and #40) of nine residents reviewed for physician's orders.

Inspectors wroteBased on record review and interview, the facility failed to timely notify Resident #56's representative of a fall with injury. This affected one (#56) of seven residents reviewed for accidents. The census was 59.

Inspectors wroteBased on record review and interview the facility failed to ensure baseline care plans were completed for two (Residents #162 and #265) of 25 residents whose records were reviewed during the annual survey. The facility census was 59.

Inspectors wroteBased on interview, record review, review of the facility investigation, review of the coroner's investigation, and review of facility policy, the facility failed to timely assess for injury of Resident #56 after he was found deceased on the floor, failed to timely notify the coroner of a potential head injury for Resident #56 which resulted in a delay of post-mortem evaluation, and failed to ensure a thorough investigation was completed for Resident #56's fall and death. This affected one (#56) of three residents reviewed for falls and one (#56) of three residents reviewed for death. In addition, the facility failed to ensure transfers were performed according to physician orders, which affected one (#28) of seven residents reviewed for accidents. The census was 59.

Inspectors wroteBased on record review and interview, the facility failed to ensure pre and post dialysis assessments were completed per the facility policy. This finding affected two (Residents #5 and #28) of two residents investigated for dialysis services.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff followed appropriate procedures following the fall and subsequent death of Resident #56. This affected one (#56) of three residents reviewed for death. The census was 59.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the multi-use glucometer testing (BGT) machine was disinfected and sanitized after use per the facility policy and manufacturer's directions to prevent the risk of cross-contamination of blood-borne pathogens, failed to ensure respiratory equipment was stored effectively to prevent the potential for cross contamination of airborne pathogens and failed to ensure appropriate infection control was maintained during Resident #261's tracheostomy care This finding affected one resident (Resident #161) of two residents reviewed for blood glucose monitoring, one resident (Residents #13) of four residents investigated for respiratory care and one resident (Resident #261) of one resident investigated for tracheostomy care.