New Hope Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for 7 of 30 residents reviewed (Resident #11, Resident #12, Resident #26, Resident #29, Resident #54, Resident #66) for diet orders. The facility failed to ensure dietary staff served ground meat on 3/16/2026 for residents on a mechanical soft diet. This failure could place residents on mechanical soft diets at risk of choking and not receiving adequate nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable living environment to help prevent the development of transmission communicable diseases and infections for four (Resident #14, Resident #36, Resident #40, and Resident #68) of seven residents reviewed for infection control. 1. The facility failed to ensure the SW used the proper PPE prior to entering Resident #14's room on 3/16/2026. 2. The facility failed to ensure CNA B did not use the same disposable wipe to cleanse Resident #36's urostomy tubing from the stoma site and out the first time and wiped the suprapubic catheter tubing a second time and then used a clean wipe for the third wipe.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 2 of 8 (Resident #84 and Resident #102) residents reviewed for nail care. The facility failed to ensure Resident #84's and Resident #102's fingernails were trimmed. This failure placed residents at risk for poor grooming, poor personal hygiene, and skin tears.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make sure that drugs are stored properly and only authorized persons have access for 1 of 3 medication carts (MC #1) reviewed for drug storage and labeling. The facility failed to ensure MC #1, was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 6 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 5of 7 residents (Residents #1, Residents #15, Residents #25, Residents #44 and Resident #84) reviewed for respiratory care The facility failed to ensure: 1. Resident #1, Resident #25, Resident #15, and Resident #44's nebulizing mask and tubing were bagged for sanitation when not in use as per the physician's order. 2. The nasal cannula of Resident #84 was uncovered and tucked under the handle of the oxygen concentrator, as observed on 01/27/25. This failure could affect residents who received respiratory services and place them at risk for respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store and label biologicals for 2 (200 and 400 halls and cart for 100 hall) of 6 medication carts reviewed for drug storage. The medication cart for the 200 and 400 halls had three unidentified loose pills. The medication cart for the 100-hall had one loose pill. These deficient practices could affect residents and result in a drug diversion due to medications not being properly disposed and secured.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation. The facility kitchen staff failed to label and date 2 foods and discard of 1 food that was beyond use by date stored in the refrigerator. These failures could place residents at risk for food-borne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 8 residents (Residents #23 and #61) reviewed for care plans. 1. The facility failed to update Resident #23's care plan to reflect current fall prevention interventions including a scoop mattress for fall prevention. 2. The facility failed to update Resident #61's care plan to reflect current advanced directives as Do Not Resuscitate. This failure placed residents at risk of not receiving the appropriate care to meet their current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications for 1 of 2 residents (Resident #84) reviewed for tube feeding. The facility failed to ensure Resident #84's formula bag and tubing set were changed out daily. This failure could place the resident as risk of illness, altered nutrition, and equipment malfunction.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident#40) reviewed for significant med errors . The facility failed to ensure Resident #40's Metoprolol Succinate (prescribed to treat Atherosclerotic heart disease of native coronary artery without angina pectoris) was omitted during medication pass on the morning of 01/27/2025. This failure could place the resident at risk of not receiving the correct/prescribed medications as ordered.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the facility established and maintained an infection prevention program designed to provide a safe environment and to help prevent the transmission of communicable diseases for one of one staff (MA A) observed for infection control MA A failed to disinfect the blood pressure cuff in between Residents #19 and #40's during usage of obtaining their blood pressure readings for medication administration. This failure could place residents at increased risk of healthcare associated infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly for one (Resident #1) of four residents reviewed for change in condition. The facility failed to notify the NP in a timely manner when Resident #1 voiced pain to her left knee, swelling, and heat to the touch was observed by LVN B. LVN B noted swelling and warm to touch on Resident #1's knee at approximately 4:00 PM. LVN B noted they contacted the NP when Resident #1's family was present at approximately 10:00 PM. Resident #1 was sent to the hospital and found to have a fractured left patella (kneecap). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for change in condition. LVN A did not ensure Resident #1, who had a history of a left hip fracture, had a footrest on her wheelchair before transferring her, resulting in a fractured left patella (kneecap). The noncompliance was identified as PNC IJ. The IJ began on 09/04/24 and ended on 09/21/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of not receiving adequate assistance devices, accidents during transfers, harm, sustaining injuries, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for one (Resident #1) of four residents reviewed for pain, in that: The facility failed to provide effective pain management for Resident #1 while on hospice services and comfort measures in place. He was found by his Hospice Nurse on 12/24/23 writhing in pain, thrashing, grimacing, and mouthing help me. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/24/24 at 5:01 PM. While the IJ was removed on 01/25/24 at 2:45 PM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that: The facility failed to follow a changed physician medication order resulting in Resident #1 receiving four times the intended dose of Erleada (a prescription drug used to treat prostate cancer) for approximately five days. This failure was determined to be PNC due to the facility correcting the deficient practice prior (11/17/23) to the investigation. This deficient practice could place residents at risk overdose, could result in worsening or exacerbation of chronic medical conditions, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure Dietary Aide B, Dietary Aide C, and Dietary [NAME] D properly sanitized her hands between tasks. These failures could place residents who were served from the kitchen at risk for health complications, foodborne illnesses, and decreased quality of life.

Inspectors wroteBased on record review and interview, the facility failed to assess each resident quarterly using the Minimum Data Set form specified by the state and approved by CMS not less frequently than once every 3 months for 2 of seven residents (Resident #2 and #63) reviewed for quarterly assessments. The facility failed to ensure a quarterly MDS assessment was completed within 92 days of the previous quarterly assessment for Resident #2 and Resident #63. This failure could place residents at risk for not having their needs meet. Findings Included: Review of Resident #2's Face Sheet dated, 11/13/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a PASRR screening was completed for residents with mental disorder or an intellectual disability for one of three residents (Resident # 11) reviewed for PASRR Level I screenings. The facility failed to ensure an accurate PASRR Level I screening (a preliminary assessment completed for all individuals prior to admission to a Medicaid - certified nursing facility to determine whether they might have a mental illness or intellectual disability) was completed for Resident #11. Resident #11 was readmitted after hospitalization on 2/08/22 with the diagnosis of Bipolar disorder. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services accordance with individually assessed needs.

Inspectors wroteBased on observation, interviews and record review the staff failed to provide daily hygiene and dressing assistance to one of two residents (Resident #30) reviewed for ADL care. Staff failed to provide Resident #30 with a change of clothes for threee days. The facility failed to assist Resident #30, who required staff assistance, to change her clothes for 3 days on 12/12/23, 12/13/23 and 12/14/23. This failure could place residents at risk of not receiving care and services to meet their needs and a decreased quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents who was fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #69) of two reviewed for enteral feeding. LVN A failed to inject air into Resident #69's gastrostomy tube and listen with a stethoscope for air movement. This failure could place residents with gastrostomy tubes at risk of medical complications, and a decline in health due to inappropriate care.