Katherine and Charles Hover Green Houses

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure two (#4 and #28) out of three residents received services and assistance to prevent a reduction in range of motion out of 31 sample residents. Resident #4 was admitted to the facility on [DATE]. According to diagnoses on admission, Resident #4 did not admit to the facility with a contracture to her hands, but based on observations and interviews on 1/26/26 to 1/29/26, the resident was unable to extend her fingers independently and/or without pain. The facility failed to provide the resident interventions to prevent a reduction in the resident's range of motion of her hands. The facility's failure to provide services to maintain the resident's mobility contributed to a decline in the mobility of the resident's left and right hand. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one of one (#2) residents reviewed out of 31 sample residents. Resident #2, who was at risk for falls and had a history of falls, experienced eleven falls since her date of admission of 12/2/25. The interdisciplinary team (IDT) determined Resident #2 had poor safety awareness and was impulsive. On 12/12/25 Resident #2 self-propelled herself outside, where her wheelchair tipped off of the sidewalk. Resident #3 was sent to the hospital and was diagnosed with three rib fractures. On 12/17/25 Resident #2 sustained an unwitnessed fall and was bleeding from her head and was running down her neck. She was sent to the hospital. On 12/20/25 the facility implemented a one-to-one caregiver for Resident #2 from 7:00 a.m. until 7:00 p.m. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an infection prevention and control program was maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of four units. Specifically, the facility failed to: -Implement an effective water management plan to monitor for Legionella-Ensure staff wore the appropriate personal protective equipment (PPE) when providing incontinence care and transfers for Resident #14 and Resident #24, who was on enhanced barrier precautions (EBP) for wounds; and,-Ensure hand hygiene was performed appropriately in the dining areas.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, the facility failed to ensure all staff that were responsible for preparing and cooking meals for the residents were fully educated on proper food handling and food preparation.

Inspectors wroteBased on record review and interviews, the facility failed to notify the one (#41) of six residents or their representative orally and in writing of a charge for an item out of 31 sample residents. Specifically, the facility failed to provide Resident #41 and his representative notification of an accidental charge for Narcan (medication used for reversal of opioid overdose) and how to get reimbursed for the accidental charge in a timely manner.

Inspectors wroteFindings include:I. Facility policy and procedureThe Required Training policy, reviewed on 1/9/26 was provided by the nursing home administrator (NHA) on 1/29/26 at 2:02 p.m. The policy revealed the facility would comply with State and Federal regulations and requirements as they pertain to training. Every employee was also required to complete an annual training curriculum through Care Academy (and/other sources) that would be assigned according to their job responsibilities. It was the responsibility of the employee to complete the required training to maintain employment status. The policy did not address that nursing staff were to demonstrate competency in skills and techniques necessary to care for residents on an annual basis. II. Record reviewOn 1/29/26 at 7:52 a.m. an email request was made to the NHA for the facility's annual competency assessment for CNA #1, CNA #2 and CNA #12. [...]

Inspectors wroteBased on record review and interviews, the facility failed to notify the provider when a resident had a significant change in condition requiring a need to alter treatment for two (#12 and #22) out of five residents out of 20 sample residents. Specifically, the facility failed to inform Resident #12 and Resident #22's provider when medications were not administered according to the physician's orders.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for six of 60 employee files reviewed. Specifically, the facility failed to complete criminal background checks for six employees prior to the employees working with residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity which included proper licensure or certification for one of seven licensed practical nurses (LPN). Specifically, the facility failed to ensure LPN #1 had an active license in the State registration system to ensure the licensure was aligned with the requirement of the State.

Inspectors wroteBased on record review and interviews, the facility failed to ensure each nurse aide had registry verification and had met competency evaluation requirements to provide nursing and nursing related services for five of 42 certified nurse aides (CNA). Specifically, the facility failed to ensure five CNAs (CNA #1, CNA #2, CNA #3, CNA #4 and CNA #5) who were providing resident care were certified in the State registration system.

Inspectors wroteBased on record review and interview, the facility failed to provide training to their staff that at a minimum educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically the facility failed to: -Provide effective initial hire orientation for abuse identification and prevention training or dementia management training for six of eight certified nurse aides (CNA) reviewed; and, -Provide annual abuse identification and prevention training or dementia management training for the five of eight CNAs.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure proper provision of urinary catheter care. Specifically, the facility failed to ensure 1 (Resident #24) of 2 residents' indwelling urinary catheter urine collection bag and tubing were maintained below the level of the resident's bladder to help prevent urinary tract infections.

Inspectors wroteBased on interviews and document review, the facility failed to ensure Payroll-Based Journal (PBJ; an electronic report that contained the number of hours every direct care staff member worked for each day of the quarter) data was reported quarterly to the Centers for Medicaid & Medicare Services (CMS) as required. This deficient practice had the potential to affect staffing information posted on consumer websites and data used in quality rating systems to help consumers understand the level and differences of staffing in nursing homes and, ultimately, had the potential to impact the quality of care delivered to residents who currently resided in the facility.