Faith Healthcare Center

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents and/or their responsible party (RP) were provided with a written notice of transfer and/or a written bed hold for one of three residents reviewed for hospitalizations Resident (R)105. This failure had the potential to affect the resident and their Responsible Party (RP) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure respiratory equipment was properly stored for one of one resident reviewed for respiratory care, Resident (R)9, of 23 residents sampled. This failure had the potential to increase the risk of infection and improper respiratory equipment maintenance.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to assess residents for the use of bed rails, obtain physician's orders and informed consent prior to the installation of side rails on residents' beds for two of seven residents reviewed for accidents out of 26 sampled residents (Resident (R) 11 and R14). These failures placed the residents at risk for injury and restraint.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure bed rails were inspected and maintained per the facility policy for two of seven residents (Resident (R) 11 and R14) reviewed for accidents out of 26 sampled residents. There was no evidence that the residents' beds were appropriately inspected and maintained to ensure the installed side rails were safe for residents' use. This failure placed the residents at risk for risk of entrapment.

Inspectors wroteBased on review of facility policy, record review, and staff interview, the facility failed to provide adequate supervision for 1 of 1 resident reviewed. Specifically, on 09/01/25 a demented, confused resident was found across the street, approximately 500 feet, from the nursing home facility by a citizen passing by in a car. This citizen contacted 911 emergency services, detailing that a young lady was on the ground in front of a local grocery store. On 09/04/25 at 7:45PM, the State Agency determined that the facility's noncompliance with one or more federal health, safety, and/or quality regulations had caused or was likely to cause serious harm, psychosocial harm, serious impairment or death. [...]

Inspectors wroteBased on observation, staff interviews and a review of facility dietary policies, revealed the facility failed to ensure proper sanitation of kitchen equipment and overall main-kitchen cleanliness. The facility also failed to properly label leftovers and discard expired foods in 1 of 1 main kitchen. These deficiencies could potentially affect 100 residents who reside in the facility and who consume food from the kitchen.

Inspectors wroteBased on review of the facility policy, observations, and interviews, the facility failed to ensure Resident (R)39 and R74 was without unwanted facial hair. Additionally, the facility failed to ensure dignity while R2's catheter bag was exposed.

Inspectors wroteBased on observations, interviews, and facility policy, the facility failed to ensure residents were free from hazards, specifically leaving unlabeled medicinal substances at the bedside of 1 of 4 residents reviewed for accidents and self-administration of medication. Findings Include: Review of the facility policy titled, Medication Management Program, with a complete revision date of 05/05/23 states, 10. The authorized staff member or licensed nurse must remain with the resident while the medication is swallowed. Never leave medication in a resident room without order to do so. 16. Once removed from the package or container, unused doses should be destroyed following facility policy and documenting the destruction according to facility policy. [...]

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure the call light was within reach for two (Resident (R)50 and R33) of two residents reviewed for call light accessibility. This failure had the potential to impact R50 and R33's physical and emotional well-being by limiting his access to call for help in the event of an emergency.

Inspectors wroteBased on observations, record reviews, interviews and facility policy the facility failed to check the placement of a resident's g (gastrostomy)-tube prior to administrating medications for 1 of 3 residents observed during medication pass administration. Resident (R)395 was admitted to the facility on [DATE] with diagnoses including but not limited to traumatic brain injury.

Inspectors wroteBased on observations, interviews, record review and facility policy, the facility failed administer oxygen according to physician's orders for 3 of 3 residents reviewed for respiratory care, Resident (R)9, R39, and R3.

Inspectors wroteBased on observations, record reviews, interviews and facility policy the facility failed to ensure a medication error rate less than 5 % (percent) for 1 of 3 residents observed during medication pass administration. The medication error rate was 14.29 % (percent) based on 4 medications not being completely administered to Resident (R)395 through his g (gastrostomy)- tube. R395 was admitted to the facility on [DATE] with diagnoses including but not limited to traumatic brain injury.

Inspectors wroteBased on observations, interviews and facility policy, the facility failed to ensure that medications were locked when not being used or being observed by licensed staff in 1 of 8 medication carts.

Inspectors wroteBased on observations, interviews, and facility policy, the facility failed to adhere to foley catheter procedures for 1 of 1 resident reviewed for infection control. Specifically, Resident (R)359's foley catheter bag wasn't properly stored below the bladder to maintain unobstructed urine flow. R359's tubing contained cloudy urine with debris and sedimentation, which could potentially cause discomfort and urinary complications.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure 2 (Zone 1 and Zone 6) of 4 treatment carts were locked when unattended to limit access to only authorized personnel. Additionally, the facility failed to ensure 3 of 4 treatments carts and 4 of 5 medication carts were free from expired medications/biological's and unopened sterile supplies.

Inspectors wroteBased on review of facility policy, observation, record review, and interview, the facility failed to ensure Resident (R)47 received nutrition via percutaneous endoscopic gastrostomy (PEG) tube. Additionally, while in bed receiving a pleasure tray, the facility failed to position R47 correctly to decrease the potential for aspiration, for 1 of 2 residents reviewed for tube feedings. Findings Include: Review of the facility policy titled, Nutrition Policy and Procedures: Subject: Enteral Feeding-Documentation, with a complete revision date of 08/01/2020 revealed, the resident's head of the bed (HOB) 30 to 45 degrees during administration of the feeding and for one hour after the feeding is completed. [...]