Pope Nursing Home

Inspectors wroteBased on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to provide the services of an RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place on 4 of 92 days during the period of 10/1/25 through 12/31/25.

Inspectors wroteBased on observation, document review, and interview, the facility failed to ensure professional standards of practice were maintained when administering medications for one Resident (#44), out of a total sample of 12 residents and for three Residents (#36, #26, and #25), out of five residents observed during medication administration. Specifically, the facility failed to ensure:1. For Resident #44, an order for Guaifenesin Extended Release (ER) 12-hr 600 milligrams (mg) (extended release expectorant to relieve chest congestion and mucus) twice daily via Gastrostomy Tube (G-Tube: a medical device inserted through the abdominal wall into the stomach to deliver food, fluids, and medications) was clarified to a formula that could be crushed and administered via the G-Tube; and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate of 5% or greater when one of two nurses made five errors out of 33 opportunities, totaling a medication error rate of 15.15%. These errors impacted three Residents (#36, #26, and #25), out of five residents observed. Specifically:1. For Resident #36, Zyprexa (antipsychotic) was omitted and signed as administered;2. For Resident #26, Celexa (antidepressant) and Preservision AREDS (eye vitamins) were omitted and signed as administered; and3. For Resident #25, Artificial Tears and Erythromycin Ointment (antibiotic ointment) were omitted and signed as administered.

Inspectors wroteBased on observations and interview, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to ensure:1. The medication cart was locked when not in direct supervision of the licensed nurse on one of two units;2. Poured medications (prepared for administration/no longer in original labeled containers) were not stored in the medication cart; and3. For Residents #25, #29, and #43, medications were not unsecured at the bedside.

Inspectors wroteBased on observation, interview, and document review, the facility failed to 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. Specifically, the facility failed to ensure:1. For Resident #44, Enhanced Barrier Precautions (EBP) were maintained during wound care; and2. COVID-19 outbreak testing for Residents and Staff was completed after exposure to a staff member that had tested positive for COVID-19.

Inspectors wroteBased on document review and interview, the facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD). Specifically, the facility did not employ a full-time dietician or have a qualified dietary employee in the facility who met the minimum qualifications to serve as FSD from 11/20/24 to throughout the survey period.

Inspectors wroteBased on interviews, the facility staff failed to comprehensively assess the facility resources needed to provide sufficient support and care for the resident population and develop a Facility Assessment as required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Midline Catheter (type of catheter inserted into a peripheral vein, typically in the arm, near the armpit, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#7), out of a total sample of 14 residents. Specifically, the facility failed to: [...]

Inspectors wroteBased on document review and interviews, the facility failed to ensure that licensed nursing staff and nurse aids had appropriate competencies, and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Inspectors wroteBased on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, with no nurse staffing waivers in place as required, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with the provision of resident care. Specifically, the facility failed to provide the services of a RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place on eight occasions for the period of 10/12/24 to 2/8/25 and failed to designate a Registered Nurse to serve as the Director of Nursing (DON) on a full time basis when no staffing waivers were in place.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in a safe and secure manner as required. Specifically, the facility failed to ensure: 1. For Resident #5, that prescribed topical treatment was not left unsecured and unattended at the Resident's bedside; 2. For Resident #92, that prescribed nasal spray was not left unsecured and unattended at the Resident's bedside; and 3. a. medications and treatments were not left at the second-floor nursing station unattended, b. treatment and medication carts were locked when not in direct supervision of the licensed nurse for one of two treatment carts for all days of survey and for one of two medication carts, 4. two of two medication carts were clean and free of loose pills and debris.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure food items were properly dated and stored in two of two kitchenette refrigerators.

Inspectors wroteBased on document review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to: 1. Maintain an accurate surveillance system that reflected potential illnesses and infections in the facility and calculate an accurate facility infection attack rate in accordance with their pre-defined McGeer criteria; 2. Have a facility specific written water management plan to ensure a facility risk assessment was conducted to identify where Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic waterborne pathogens could grow and spread in the facility's water system; and 3. [...]

Inspectors wroteBased on interviews the facility staff failed to ensure a system was in place to monitor that every Certified Nurse Aide (CNA) completed the required 12 hours of in-service training per year.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their abuse policy and procedures when one Resident (#38), and their healthcare proxy (HCP), had reported an allegation of rough care on 4/8/25, resulting in emotional upset, in a total sample of 14 residents. Specifically, after the facility staff were notified of the incident they failed to recognize the allegation as potential abuse, report it to the Director of Nurses (DON) and protect the Resident from further interactions with the accused hospice aide.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that met professional standards of practice for one Resident (#38), out of a total sample of 14 residents. Specifically, the facility failed to ensure that an as needed (PRN) physician order for a supplement juice was complete with dosage frequency, amount and indication for use prior to administering the product.

Inspectors wroteBased on document review and interview, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Residents (#38) with a history of trauma, out of a total sample of 14 residents.

Inspectors wroteBased on document review and interview, the facility failed for one Residents (#38), out of a total sample of 14 residents, to ensure that an as needed (PRN) psychotropic medication, Ativan (Lorazepam - an antianxiety medication) was initially limited to 14 days duration in accordance with the regulatory guideline.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that trash, garbage, and refuse were disposed of properly in the dumpster, from the surrounding area.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to maintain a clean, sanitary, and homelike environment for residents residing on two of two units.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the environment remained free of accident hazards. Specifically, the facility failed to: 1. Ensure residents were provided an environment that was free from hazardous chemicals on one of two units; and 2. Ensure electrical outlets were securely covered.