Casa of Hobart

Inspectors wroteBased on record review and interview, the facility failed to initiate and update effective resident-specific interventions to prevent the elopement from the facility of a recently admitted resident with a diagnosis of schizophrenia, a court-appointed guardian and history of running away for 1 of 4 residents reviewed for elopement risk. The resident signed out of the building and exited through the main front door entrance. The nursing staff was unaware of the resident's whereabouts. The resident ambulated approximately 1.5 miles from the facility on a highly traveled road that had no sidewalks. The fire department was dispatched to a private residence after the resident knocked on their door and transported the resident to the hospital. (Resident H)The Immediate Jeopardy began on 5/29/26 when the facility was unaware that the resident had exited the facility without supervision. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement their written policies and procedures for reporting an allegation of abuse, related to an allegation of abuse not reported to the Administrator by staff for 1 of 6 residents reviewed for abuse. (Resident L)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff failing to perform hand hygiene after glove removal and direct resident contact for 4 of 8 residents observed during medication administration. (Residents 93, J, 25, and 85)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were assessed to self-administer medications and had Physician's Orders for the medication for 1 of 1 resident reviewed for accident hazards (Residents C)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's Responsible Party was notified of a change in condition related to increased behaviors and being placed on one-to-one supervision for 1 of 1 resident reviewed for notification of change. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to ensure allegations of abuse were promptly reported by staff for 1 of 2 residents reviewed for abuse. (Resident 28)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to nail care for 2 of 7 residents reviewed for ADLs. (Residents 4 and 5)

Inspectors wroteBased on record review and interview, the facility failed to ensure insulin was given as ordered for 1 of 5 residents reviewed for unnecessary medications. The facility also failed to ensure documentation was completed after a change in condition related to elevated blood pressure for 1 of 1 resident reviewed for hospitalization and lack of follow up documentation regarding an anti-diarrheal medication for 1 of 1 resident reviewed for constipation and diarrhea. (Residents N, B, and M)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure suprapubic catheter (urinary catheter inserted directly into the lower abdomen) care was completed and the catheter was changed as ordered by the physician for 1 of 1 resident reviewed for catheters. (Resident C)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received individualized services and other interventions related to dementia care while residing on a memory care unit for 1 of 5 residents reviewed for dementia care. (Resident 89)

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident received medically related social services related to the timeliness of vision and dental visits for 1 of 2 residents reviewed for vision and 1 of 1 resident reviewed for dental. (Resident B)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure prescription medications were properly labeled for 2 of 8 residents observed during medication administration. (Residents 104 and 12)

Inspectors wroteBased on record review and interview, the facility failed to ensure clinical records were complete and accurately documented related to dietary supplement consumption for 1 of 1 resident reviewed for nutrition and a dental assessment for 1 of 1 resident reviewed for dental. (Resident 20 and B)

Inspectors wroteBased on record review and interview, the facility failed to ensure laboratory tests were completed as ordered, related to a vancomycin trough for 1 of 3 residents reviewed for laboratory testing. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to showers for 2 of 3 residents reviewed for ADLs. (Residents D and B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were in place and implemented related to the opening of a medication capsule without gloves during medication administration for a random observation for infection control.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a safe and sanitary environment to help prevent the potential for transmission of communicable diseases and infections related to a glucometer (blood sugar monitor) not sanitized after it was used for 1 of 2 glucometer tests observed. (LPN 3, Resident S) This had the potential to affect 5 residents with glucometer orders assigned to the nurse. The facility also failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member (CNA 4) when providing care to a resident (Resident F) who was in Enhanced Barrier Precautions (EBP) for 1 random observation for infection control.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's physician was notified of medication being held for 1 of 1 resident reviewed for notification of change. (Resident T)

Inspectors wroteBased on observation, record review and interview, the facility failed to assist a dependent resident with incontinent care in a timely manner related to a delay in answering the call light for 1 of 5 residents reviewed for activities of daily living (ADLs). (Resident J)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received appropriate treatment and care to meet their needs related to blood sugars not monitored, insulin not administered, treatment not given for a low blood sugar, and a blood pressure medication not held as ordered for low blood pressure for 3 of 3 residents reviewed for medications/diabetic care. (Residents D, K, and L)

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were properly labeled and stored for 1 of 3 medication carts observed. (Cherry Lane medication cart).

Inspectors wroteBased on record review and interview, the facility failed to ensure a urinalysis (UA) was collected as ordered for 1 of 1 resident reviewed for infections. (Resident M)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure proper medication storage related to medications prepared in advance, pre-filled saline syringes used to flush PICC (peripherally inserted central catheter) lines and not stored securely, medications and keys left unattended, insulin pens not labeled when opened, and loose pills observed in the medication carts for 1 of 2 units (The Main Station Unit) This had the potential to affect all residents receiving medications from LPN 2.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to a Nurse Practitioner (NP) failing to perform hand hygiene after glove removal, enhanced barrier precautions (EBP) not followed while emptying an indwelling Foley catheter and for a resident with a peripherally inserted central catheter (PICC), disposal of a lancet in the garbage can, and glove use in the hallway during random infection control observations. (Residents 82, C, 12, and F)

Inspectors wroteBased on observation and interview, the facility failed to keep the resident's environment clean and in good repair related to marred walls, marred and dirty floors, marred and dirty heat registers, missing toilet paper holders, feces on bed linen, feces on a shared room divider, cracked ceiling tile, a call light not working, and hot water temperatures above 120 degrees on 5 of 5 units throughout the facility. (Cherry Lane, Cherry Court, Blueberry Lane, Apple Lane and Bakersfield Lane).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was assessed to self-administer medications and had Physician's Orders to self-administer for 1 of 1 resident reviewed for self-administration of medication. (Resident G)

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident's privacy was maintained related to a Nurse Practitioner (NP) completing an assessment of a peg tube (a tube inserted directly into the stomach for nutrition) in a common area for 1 of 1 resident reviewed for tube feeding. (Resident C)

Inspectors wroteBased on record review, and interview, the facility failed to file a grievance form, thoroughly investigate, and resolve grievances for missing personal items that were reported to staff for 1 of 1 resident reviewed for grievances. (Resident 23)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were involved in decisions about their care related to informing them of new medications for 1 of 7 residents reviewed for participation in care planning. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to receiving showers and assistance with eating for 3 of 9 residents reviewed for ADLs. (Residents D, C, and E)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure non-pressure areas were monitored, assessed, and bandages were changed for 1 of 1 resident reviewed for skin conditions non-pressure related, blood pressure parameters were followed for 1 of 1 resident reviewed for dialysis, and a resident was assessed and monitored post cataract surgery for 1 of 1 resident reviewed for vision and hearing. (Residents G and 82)

Inspectors wroteBased on record review and interview, the facility failed to ensure pressure ulcer treatments were completed as ordered and IV (intravenous) antibiotics for a wound infection were administered as ordered for 1 of 1 resident reviewed for pressure ulcers. (Resident F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the resident received the necessary treatment and foot care related to podiatry visits for 1 of 1 resident reviewed for podiatry care. (Resident 69)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure smoking materials were locked in a safe place and not in the residents' rooms for 2 of 2 residents reviewed for smoking and halos were on a resident's bed as ordered for 1 of 1 resident reviewed for falls. (Residents G, F and H)

Inspectors wrote2. During an interview on 1/21/25 at 2:23 p.m., Resident 49 indicated the staff does not drain his catheter bag all night or day, he had to call 911 to get his catheter exchanged, and they do not flush or clean his catheter. On 1/21/25 at 3:39 p.m., the resident had lifted his shirt to show his stomas site and catheter. The catheter was dirty and dried crusted blood around insertion site. On 1/22/25 at 2:58 p.m., the resident indicated no one had cleaned his catheter site today, and they did not flush his catheter yet. The resident lifted his shirt to show his catheter. The catheter was dirty and dried crusted blood remained around the insertion site. The record was reviewed for Resident 49 on 1/22/24 at 2:11 p.m. Diagnoses included, but were not limited to, depression, chronic obstructive pulmonary disease (COPD), quadriplegia, muscle wasting and anxiety. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure food consumption logs and supplements were completed for residents with a history of weight loss for 2 of 3 residents reviewed for nutrition. (Residents F and 82)

Inspectors wroteBased on record review and interview, the facility failed to monitor a fluid restriction for 1 of 1 resident reviewed for dialysis. (Resident 82)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received routine dental services related to decayed and broken teeth for 1 of 3 residents reviewed for dental services. (Resident 73)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a personalized activity program for cognitively impaired and dependent residents related to ongoing stimulation and being invited to activities for 1 of 1 resident reviewed for activities. (Resident 81)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was given the opportunity to participate in their treatment, including understanding the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, related to medication administration for 1 of 4 residents observed during medication administration. (Resident F)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with ongoing sexual behaviors was monitored and behaviors were documented for 1 of 3 residents reviewed for abuse. (Resident C)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were ordered and available timely, including staff being aware of stocked backup medications for 2 of 4 residents observed during medication administration. (Residents G and H)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident-initiated discharge was documented in the resident's medical record and appropriate information was given to the resident for continuation of care, related to a list of medications the resident received at the facility not sent with a resident and no documentation of the resident's status at the time of discharge.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to foley catheter drainage bags not being covered for 1 of 2 residents with urinary catheters. (Resident H)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a Physician's Order for self administration of medications and an assessment to self-administer medications was completed, for 1 of 1 resident reviewed for self-administration of medications. (Resident B)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL's) received assistance with incontinence care in a timely manner for 1 of 3 residents reviewed for ADL's. (Resident G)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure treatments were completed as ordered for non-pressure skin conditions for 1 of 3 residents reviewed for non-pressure skin conditions. (Resident G)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fall interventions were in place for a resident with a history of falls related to the bed being in a low position for 1 of 3 residents reviewed for falls. (Resident H)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure urinary catheter drainage bags were not placed on the floor for a resident with a history of urinary tract infections for 1 of 2 residents reviewed for urinary catheters. (Resident F)

Inspectors wroteBased on record review and interview, the facility failed to ensure clinical records were complete and accurately documented related to insulin administration for 1 of 3 residents reviewed for insulin use. (Resident L)

Inspectors wroteBased on record review and interview, the facility failed to ensure employees (Confidential Interview 2 and Terminated Employee 6) reported allegations of abuse by an employee (Employee 7) toward residents of the Memory Care Unit to the Administrator. This had the potential to affect 18 residents who resided on the Memory Care Unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff members (RN 8), when providing care to a resident (Resident D) who was in Enhanced Barrier Precautions (EBP). This had the potential to affect 21 residents who reside on the Blueberry Lane Unit ( 1 of 5 Units)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care planned interventions to prevent falls were in place, related to anti-roll brakes not initiated in a timely manner for 1 of 4 residents reviewed for falls and accidents. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident who was admitted with a urinary catheter had a correct assessment of the catheter, physician orders for the catheter, and a documented reason for the catheter. The facility failed to ensure urinary catheter care was completed and the urinary catheter was monitored, for 1 of 2 residents reviewed for urinary catheter care. (Resident G)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and Wound Nurse), when providing care to a resident who was in Enhanced Barrier Precautions (EBP), and failed to remove soiled gloves before touching clean surfaces for 1 of 1 random observations for infection control. (Resident D) This had the potential to affect the residents on 4 of 5 Units (Cherry, Blueberry, Apple, and Cherry Lane) and 18 residents who received wound care where staff should use EBP.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was treated with respect and dignity related to not assisting the resident to the bathroom upon request, for 1 of 6 residents reviewed for respect and dignity. (Resident G)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who required maximum to dependent care received incontinent care in a timely manner, for 1 of 3 residents reviewed for incontinent care. (Resident D)

Inspectors wroteBased record review and interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, related to a fracture after a fall not investigated thoroughly for 1 of 6 residents reviewed for quality of care. (Resident E)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care planned interventions to prevent injuries due to a fall were in place, related to floor mats not in place next to the bed and anti-roll brakes not on the wheelchair. The facility also failed to ensure an intervention initiated to prevent further falls was completed related to a urinalysis not obtained, for 2 of 3 residents reviewed for falls. (Residents D and E)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure services to prevent the development of pressure injuries were effectively provided to Resident D, who was admitted to the facility without a pressure ulcer and developed a facility-acquired unstageable pressure ulcer (pressure ulcer known but not stageable due to coverage of wound bed by slough and/or eschar) and also failed to ensure services were provided to Resident E, who developed a facility-acquired stage three (full thickness tissue loss) pressure ulcer, in accordance with the physician orders, for 2 of 3 residents reviewed for pressure ulcers. This deficient practice resulted in Resident D developing a facility-acquired wound initially identified by the facility as an unstageable pressure injury on the sacrum, that required surgical debridement after re-admission into the hospital.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident had Physician's Orders and an assessment to self-administer medication, for 1 of 1 resident reviewed for self-administration of medications. (Resident C)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's Responsible Party was notified of a change in condition, related to pressure sores, for 1 of 3 residents reviewed for notification of family/Responsible Party. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to implement measures to ensure a moderately impaired dependent resident was not lying flat in bed while an enteral (administered into the gastrointestinal tract) tube feeding was infusing, which led to labored breathing, audible crackle lung sounds, projectile vomiting, unresponsiveness, intubation, and ultimately death for 1 of 3 residents reviewed for tube feeding. (Resident B) The immediate jeopardy began on November 11, 2023 when the resident was observed several times by staff during the early and late morning hours with the head of bed flat and the enteral tube feeding infusing. Later that day at 11:15 a.m., the resident was observed with labored breathing, crackles upon auscultation (listening with stethoscope), gurgling and severe projectile vomiting which required suctioning. [...]

Inspectors wroteBased on record review and interview, the facility failed to identify unresolved quality deficiencies, some of which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process, as evidenced by the number of repeated deficiencies cited for pressure ulcers related to not completing treatments as ordered and not completing weekly wound assessments. This deficient practice had the potential to affect 94 of 94 residents residing in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the treatment and services necessary to promote healing related to completing treatments as ordered and obtaining weekly measurements for 5 of 5 residents reviewed for pressure ulcers. (Residents 34, 46, 17, 41, and 85)

Inspectors wroteBased on observation, record review, and interview, the facility failed to store food under sanitary conditions related to outdated food in the reach in cooler and walk in cooler, clean lids stacked on top of each other, and a dirty griddle and convection ovens for 1 of 1 kitchens. (The Main Kitchen) This had the potential to affect the 91 residents who received food from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to maintain a sanitary, safe, and homelike environment related to greasy kitchen pipes, rusty equipment, adhered dirt on floors, marred walls, scuffed doors and floors, cracked tile and missing window blinds for 1 of 1 kitchens and on 4 of 5 halls. (Main Kitchen, and Cherry, Apply, Blueberry and Bakersfield Hallways)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 2 of 2 residents reviewed for self-administration of medication. (Residents 76 and 195)

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's Responsible Party was notified of medication changes for 1 of 1 residents reviewed for notification of change. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were invited to attend and participate in care planning conferences for 3 of 4 residents reviewed for participation in care planning. (Residents 76, 17, and 61)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents were provided assistance with activities of daily living (ADL's) related to assistance with shaving for 1 of 6 residents reviewed for ADL's. (Resident 85)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were able to see the Audiologist and Optometrist on a regular basis and referrals had follow up completed for 2 of 2 residents reviewed for communication and sensory. (Residents 17 and 61)

Inspectors wroteBased on random observations, record review, and interview, the facility failed to ensure oxygen humidification canisters were changed weekly for 1 of 2 residents reviewed for oxygen. (Resident 41)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pain medications were available when requested, side effects were monitored, and the medication was signed out on the Medication Administration Record (MAR) as being administered for 2 of 2 residents reviewed for pain. (Residents 195 and 12)

Inspectors wroteBased on record review and interview, the facility failed to manage medications appropriately related to not administering Ambien (a hypnotic) and not obtaining labs to monitor an anticoagulant medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 195)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were labeled correctly related to inhalers and an antacid bottle for 1 of 4 medication carts observed. (Blueberry Lane Medication Cart)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was seen by the dentist for routine dental services for 2 of 3 residents reviewed for dental services. (Residents 63 and 61)

Inspectors wroteBased on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to monitoring food consumption for 1 of 1 residents reviewed for nutrition. (Resident 76)

Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections related to disinfecting a mattress for 1 of 4 treatments observed and the storage of wash basins on 1 of 5 units. The facility also failed to ensure hand hygiene was completed after direct resident contact for 1 of 6 residents observed for medication administration. (Residents 34, 56, and Apple Lane)