Focused Care at Hogan Park

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 3 of 5 carts (MA Cart Station 1, MA Cart Station 2, Treatment Cart) reviewed for labeling and storage. The facility failed to ensure the MA Medication Carts and the Treatment Cart were locked and secured when staff were not present. This failure could place the residents at risk of gaining access to unlocked medications which were not prescribed to them.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for 5 of 5 residents (Residents #1, #3, #4, #5 and #6) reviewed for wheelchair cleanliness; Resident wheelchairs were dirty and in poor repair. (Residents #1, #3, #4, #5, and #6) This failure could place residents at risk for injury or decreased quality of health related to poor maintenance of resident care equipment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided with reasonable access to receive their mail in a timely manner for 1 of 3 residents (Resident #2) reviewed for resident rights. The facility failed to respect residents' right to privacy and opened their personal mail. (Resident #2) The facility failed to deliver financial mail to residents. (Resident #2) This failure could place residents at risk of a delay in residents' personal correspondence, financial information, or other time-sensitive materials.

Inspectors wroteBased on interview and record review the facility failed to promptly notify the physician or physician's representative when laboratory results fell outside of the clinical reference range in accordance with facility policies and procedures for 1 (Resident #1) of 6 residents reviewed for lab services. The facility failure to relay the test results from Resident #1 to the physician as per facility Lab Monitoring & Lab Orders Policies and Procedures. The failure placed residents at risk of delays in receiving the necessary interventions to treat their medical condition.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the residents' status for 2 of 6 residents (Resident #3 and Resident #4) whose assessments were reviewed:Resident #4's quarterly MDS did not accurately reflect the resident's level of consciousness. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 6 residents (Resident #3) reviewed for medical records. The facility failed to ensure Resident #3's Safe Smoking Assessment record did not accurately document the resident's smoking status. This failure could place residents at risk of inaccurate records with the potential for inadequate care and treatment. Record review of Resident #3's admission Record dated 11/06/25, revealed admission to the facility on [DATE]. Resident #3 was a [AGE] year-old female with diagnoses of acute respiratory failure and Type 2 Diabetes Mellitus (a disease in which the body does not control the amount of sugar in the blood and kidneys). [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #6) of 3 residents reviewed for infection control. 1. The facility failed to ensure CNA A, and the Treatment Nurse turned the water faucets off with a paper towel after washing hands while providing wound care to Resident #6.2. The facility failed to ensure the Treatment Nurse used each 4X4 gauze once while performing wound care to Resident #6. These failures could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. - The facility failed to ensure that prepared food stored in the refrigerator was labeled and dated. - The facility failed to ensure that lids were sealed on spices kept in the dry storage room. - The facility failed to ensure that food stored in the refrigerator and dry storage room was in sealed containers. - The facility failed to ensure the overall cleanliness and sanitation of the kitchen and its storage areas.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 1 facility reviewed for resident rights. The facility failed to ensure all residents had the right to receive visitors between 9:00 PM and 9:00 AM. This deficient practice placed residents at risk of isolation, decreased emotional well-being, and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide reasonable access to the use of a telephone for residents to have private conversations for 1 of 1 facility reviewed for resident rights. The facility failed to provide the residents a telephone where they could talk without being overheard. This deficient practice placed residents at risk of isolation, decreased emotional well-being, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal privacy was provided for 2 (#23 and #37) of 3 residents reviewed for dignity. The facility failed to ensure staff treated Resident #23 with respect and dignity while performing wound care ensuring the door was closed and without the privacy curtain being closed all the way on 01/15/2025. CNA A did not close the window blind while providing incontinent care for Resident #37 on 01/16/2025. These failures could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 6 dumpsters reviewed for food and nutrition services. - The facility failed to ensure that 2 of 6 dumpsters were placed on a concrete slab. - The facility failed to ensure that the area surrounding the dumpsters was free of garbage and other debris. - The facility failed to ensure dumpster doors for 3 of 6 dumpsters were when no staff were disposing of garbage . These failures could lead to an unsanitary environment and encourage the presence of pests.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#21) of 2 residents reviewed for infection control. The facility failed to ensure the Wound Care nurse used PPE during wound care for Residents #21 as the resident was on EBP precautions. These failures could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1 of 11 (Resident #1) residents reviewed for resident call system. The facility failed to provide a working communication system on 10/23/2024 that was easily at reach and that would allow Resident #1 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living.

Inspectors wroteBased on interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 7 of 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for residents rights The facility failed to ensure that staff were answering call lights in a prompt manner. This failure could place residents at risk of decreased feelings of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to manage the personal funds of the residents deposited with the facility for 6 of 6 confidential residents reviewed for personal funds. The facility failed to ensure Residents from a confidential group interview had ready access to their personal funds on the weekends. This failure could place residents whose funds were managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #45, #263 and #24) reviewed for Medicare/Medicaid coverage. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs for 3 of 5 (Resident # 2, Resident #21 and Resident #25) residents reviewed for care plan completion. The facility failed to ensure Resident #2, Resident #21, and Resident #25, comprehensive care plans had measurable objectives and time frames identified to meet residents needs. This failure could place residents at risk for not receiving appropriate supervision.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 5 of 7 (Residents #2, #20, #25, #45 and #262) residents reviewed for smoking safety. The facility failed to ensure Residents #21 assessed as supervised smokers were supervised when smoked. The facility failed to ensure Residents #2, #21, #25, #45, and #262 lighters and cigarettes were not stored on their person. These failures could affect residents who smoke at risk of serious bodily harm, physical impairment, or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to medications in medication cart 1 of 4 and in 2 of 2 medication rooms , and 2 biohazard rooms reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended on 12/5/2023. The facility failed to ensure discontinued medication was locked in medication rooms. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions.

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility's DM met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and placed them at risk for food born illnesses.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators. The facility failed to ensure storage of ice scoop with handle was outside of ice cooler. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 3 (Resident #21, Resident #25 and Resident #262) of 5 residents reviewed for resident records. The facility failed to ensure smoking assessments were completed for Resident #262. The facility failed to ensure smoking assessments were accurate for Resident #21 and Resident #25. This failure could place residents at risk of having errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for two (CNA B and CNA C) of 4 staff reviewed for infection control practices. The facility failed to ensure CNA B and CNA C performed hand hygiene when changing gloves at the appropriate times while providing incontinence care for Resident #9. The facility failed to ensure CNA C performed hand hygiene in between filling ice into resident's pitchers on A hall for multiple residents. These failures could affect the residents by placing them at risk for the spread of infection.

Inspectors wroteDuring an interview on 12/08/2023 at 10:46 AM, the RCN stated the facility staff had done trainings at townhall meetings. That at this time would be when they would catch up on all of the annual trainings for staff. The RCN stated the ADON told the DON she could not find the binder and had no documentation of trainings. She stated the upper management have trained the staff, and also had a clinical educator with corporate that sent all of the trainings to the ADON then follow up with staff. She stated the ADON resigned the previous day or 12/07/2023 thus unable to find the paperwork needed. The RCN stated with staff not having trainings could lead to residents getting sick from illnesses as well as Abuse and/or treating residents with good care. She stated the ADON and IP monitor the trainings for staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its resident for 7 of 18 employees (SW, DM, MS, LVN-H, CNA-J, CNA-K, and HS) reviewed for training. The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to SW, DM, MS, LVN-H, CNA-J, CNA-K, and HS. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement and maintain an effective Infection Control training program for all new and existing staff for 11 of 18 (DON, SW, DM, MS, RN-F, RN-G, LVN-H, CNA-I, CNA-J, CNA-K, HS) personnel files reviewed for training. The facility failed to train for Infection Control for DON, SW, DM, MS, RN-F, RN-G, LVN-H, CNA-I, CNA-J, CNA-K, and HS. These failures placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement and maintain an effective Compliance and Ethics training program for all new and existing staff for 16 of 18 (ADMN, DON, SW, DM, MS, RN-F, RN-G, LVN-D, LVN-H, CNA-I, CNA-J, CNA-K, HS, CNA-L, CNA-M, and CNA-N) personnel files reviewed for training. The facility failed to train for Compliance and Ethics for ADMN, DON, SW, DM, MS, RN-F, RN-G, LVN-D, LVN-H, CNA-I, CNA-J, CNA-K, HS, CNA-L, CNA-M, and CNA-N These failures placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure 7 of 18 (CNA-I, CNA-J, CNA-K, CNA-L, CNA-M, and CNA-N) employees whose in-service records were reviewed had received the required minimum 12 hours annual in-service, and received training that addressed the care of the cognitively impaired for nurse aides providing services to individuals with cognitive impairment. The facility failed to provide the required annual performance care training to CNA-I, CNA-J, CNA-K, CNA-L, CNA-M, and CNA-N. These failures placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' goals and preferences, for 1 of 1 (Resident #10) reviewed for respiratory care. The facility failed to ensure that Resident #10's oxygen tubing had been changed and dated once weekly. This failure placed residents that used oxygen at risk of respiratory complications and/or possible respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served at an appetizing temperature to residents, on 3/9/22. The facility failed to ensure the recipe was followed when prepared pureed Oven Fried Chicken. This deficient practice could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for one (Resident #1) of four residents reviewed, in that: 1. Resident #1's bedroom vertical venetian blinds were missing several slats, and had several slats cut unevenly allowing exposure into resident's bedroom. 2. Resident #1's bedroom inner sliding closet door was off the track. 3. Resident #1's bedroom wall adjacent to the restroom entrance had a 3 ½ by 2-inch hole approximately 12 inches from the floor. These failures could place residents at risk of injury due to closet door potentially falling on resident, risk for pests entering the room through exposed holes in the walls, and lack of dignity of residents' privacy.

Inspectors wroteBased on observation, interview, and record review the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 3 (Resident #15, #16, and #17) out of 8 resident rooms reviewed for environment. -The facility failed to have a working call light that would light up when the residents pushed the call bell for residents' room [ROOM NUMBER] and #44. This failure could place residents at risk of not being able to notify staff when care is needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for three (halls A, B, and D) of four halls reviewed for environment, in that: -Three of four hallways show signs of needing repairs or maintenance with holes in the walls and missing covers. -Several resident bedrooms with holes in the ceiling, walls, and missing covers. These failures could place residents and staff at risk of living in an unsafe, unsanitary, and uncomfortable environment

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective ongoing pest control program for 1 of 1 facility reviewed for pests. The facility failed to have pest control treat the building for rodents and insects. The noncompliance began on 03/03/2023 and ended on 09/19/2023. The facility had corrected the noncompliance before the survey began. These deficient practices could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure when transferring or discharging a resident, documentation was present in the resident's medical record by the resident's physician for 1 (Resident #11) of 3 residents reviewed for discharge requirement. There was no documentation from the physician which indicated the resident had specific needs that could not be met in the facility. This deficient practice could place residents at risk of discharged from the facility without reason. Findings Include: Review of Resident #11's face sheet dated 09/26/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure before transferring or discharging a resident, the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged for 1 (Resident #11) of 3 residents reviewed for discharge requirement. There was no documentation from the physician which indicated the resident had specific needs that could not be met in the facility. This deficient practice could place residents at risk of discharged from the facility without reason. Findings Included: Review of Resident #11's face sheet dated 09/26/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation, in that: 1 Food was moldy. 2. The dishwasher did not get up to a sanitizing temperature 3. The facility was not clean, there were rodent droppings along the walls and under the storage shelves. 4. [NAME] C did not take food temperatures before meal service. 4. Leftovers were not labeled and stored in a manner that prevented contamination. 5. The milk refrigerator was not defrosted and had a build-up of ice on it. This deficient practice could place residents who receive meals prepared from the kitchen and served by facility staff at risk for food borne illness and cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 3 meals (lunch meal observed) for resident rights. Residents sitting at the same table were not served at the same time. This failure could place residents at risk of not being treated in a dignified, respectable manner. CNA B Failed to acknowledge Resident #33 when he asked for his food tray.

Inspectors wroteBased on observation, interview and record review the facility failed to respect the resident's right to personal privacy during care, for 2 of 3 residents (Residents #26) reviewed for privacy, in that: CNA's A and B failed to provide privacy when providing incontinent care to Resident #26 due to no privacy curtain available. During the care Resident #6 was able to observe Resident #26 being changed due to no privacy provided. This failure could place incontinent residents at risk for embarrassment, poor self-esteem, and unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 1 lunch meals reviewed for menus and nutritional adequacy on 10/20/2022 in that: The facility failed to follow the menu and/or recipe for the noon meal on 10/20/22. The facility failed to follow the recommended serving sizes for the noon meal on 10/20/22. These failures could place residents who eat regular foods and residents who eat pureed foods at risk of not having their nutritional needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that menus were followed, and the meals served met the nutritional needs of residents, as evidenced by: Cook C failed to follow the recipe for the noon meal for all residents receiving oral food by not serving pinto beans and ham. Cook C used milk to thin the puree ham. Cook C failed to make puree cornbread for residents. These failures placed residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 5 of 5 resident in the Resident Council Meeting for 1 of 1 Lunch meals tested for nutritive value, flavor, and appearance: The lunch test tray received on 10/20/22 was lukewarm. The puree protein (ham) was made with milk and was unattractive. This deficient practice could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received food that accommodate the preferences for five of five confidential resident group members for accommodation of residents' preferences. - Five confidential group members were not offered a meal substitution of equal nutritional value when they did not like what was being served. -The facility failed to have a meal substitution of equal nutritional value available or listed on the menu for residents. These failures place all residents who consumed food from the facility's kitchen at risk for dissatisfaction, poor intake, weight loss, and declined in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition, for 1 of kitchen reviewed for essential equipment. The facility did not maintain the dishwasher at a working temperature. The facility did not ensure the gas oven was in working order. The knob's paint had worn off so staff could not ensure proper temperature was set. The facility did not have a working toaster. This failure could place residents at risk of being exposed to equipment that does not function properly. Findings Include: Observations and interview of the facility's only kitchen on 10/18/22 between 8:27 a.m. and 9:20 a.m. revealed: There was water pooled in front of the facility's three-compartment sink. The dairy refrigerator had a large buildup of ice on the top of it . The dishwasher reached 100 degrees F. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment in resident rooms and hallways throughout the facility. Resident rooms and other areas accessible to the residents had drywall damage, missing floor tile, missing receptacle covers, missing window blind slats and broken mini blinds. The drain in front of the three-compartment sink did not have a cover on it leaving it completely open. These failures affected the residents and placed them at risk of living in an unsafe and uncomfortable environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident reviewed for accident hazards/supervision (Resident #42). The facility failed to ensure CNA D demonstrated appropriate transfer techniques for Resident #5. These failures could place residents at risk for injuries from inappropriate transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #26) of 2 residents reviewed for infection control incontinent care. The facility failed to ensure CNA A changed her gloves after they became contaminated during incontinent care while assisting Resident #26. This failure could place resident's risk for cross contamination and the spread of infection.