Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Casa Of Hobart during CMS and state inspections, most recent first.
Hand hygiene was not performed by an LPN after glove removal and after direct resident contact during medication administration and care for four residents. The LPN checked blood sugars for two residents, applied a Lidocaine patch to another resident, and administered meds to a fourth resident without sanitizing her hands at key points, including before glove use, after glove removal, and after handling resident items.
A resident with diagnoses including quadriplegia, anxiety, hypotension, and neurogenic bladder had OTC laxative tablets and a Salonpas pain patch at bedside without a self-administration assessment, care plan, or MD orders. The resident said he used the laxative when constipated and preferred his own pain patches, while the DON stated the resident needed to be assessed to self-administer his meds.
Failure to promptly report an allegation of verbal abuse: A resident reported that an LPN cursed at her and spoke to her in a rude, insulting manner after she asked for medication. The resident became upset, cried, and vomited, while another CNA observed her distress and a second CNA later reported the concern to an LPN. The LPN considered the report to be abuse and said she verbally informed RN and DON, but the Administrator and DON were not aware of the allegation despite policy requiring immediate reporting of suspected abuse.
Failure to provide timely nail care for two dependent residents. One resident with DM2 and a cervical spinal fusion history, and another resident with DM2, stroke, and aphasia, were both assessed as needing staff help with personal hygiene and grooming. Despite care plan directions and task records showing ADL care, survey observations found their fingernails remained long over multiple checks, and both residents indicated they wanted shorter nails.
A resident with Alzheimer's disease, anxiety, stroke, repeated falls, and psychoactive medication use displayed anxious and disruptive behaviors on the memory care unit, including standing up, grabbing items, crying, and swearing. Staff responded by telling her to sit down or stop cussing, moving her wheelchair, and removing a book from her hands without offering individualized redirection or other interventions. The record showed no dementia care plan with individualized approaches for her behaviors, and the Unit Manager confirmed none was in place.
Medication labels did not match current physician orders for two residents during med pass. An LPN prepared Pregabalin for one resident and Bumetanide for another, but each medication card showed directions that differed from the active order, and there was no label indicating an order change. One resident had polyneuropathy and the other had edema.
Incomplete Supplement Documentation and Inaccurate Dental Assessments: The DON failed to ensure records were complete and accurate for two residents. One resident with Alzheimer’s disease, dementia, CKD, and other diagnoses had a high-calorie liquid supplement ordered BID, but the MARs documented it as administered without recording the amount consumed. Another resident with dysphagia, HF, and dementia had dental assessments that stated no issues with teeth or oral problems, despite records showing the resident was edentulous and a dental exam documenting no teeth; the DON stated the admission dental assessments were not accurate.
Failure to Notify Responsible Party of Change in Condition: A resident with vascular dementia and mild agitation became exit-seeking, verbally aggressive, and was placed on 1:1 supervision after repeated attempts to open the back door and leave to get a pop. The record showed the MD notification was not dated and timed, and there was no documentation that the family/RP was notified of the behavior change and 1:1 status until later notes.
A facility failed to give ordered insulin as prescribed for a resident with diabetes, with multiple held doses documented without an order for blood sugar parameters and some missing blood sugar readings. The facility also failed to document follow-up after a resident had markedly elevated BP and later showed stroke-like symptoms, with no documented physician notification or BP rechecks before EMS transport. In addition, a resident with diarrhea and dialysis dependence had no documented follow-up or active anti-diarrheal order after reporting loose stools and refusing dialysis.
A resident with a suprapubic catheter, quadriplegia, and bladder dysfunction was found with a scabbed stoma, bloody drainage, dried drainage on the tubing, and no dressing over the site. The resident said staff were not doing daily catheter care and the catheter had not been changed for over a month, despite MD orders for monthly catheter changes and catheter care every shift. The TAR showed care documented as completed by a Wound Nurse and QMA, but the Wound Nurse admitted signing for care he did not perform, and the DON stated QMAs could not change a suprapubic catheter.
A resident with dementia, heart failure, dysphagia, HTN, and syncope did not receive timely dental and vision services. The record showed the resident was edentulous and later had a first dental exam documenting no teeth and no current concerns, while the first optometrist exam found hypermetropia, myopia, and bilateral cataracts with a new glasses Rx. SS notes did not document the visits, whether eyeglasses were ordered, or whether the family was notified about the dental exam, and SS staff stated she was unsure why the resident was not seen sooner and was unaware of the glasses Rx and cataract findings.
A resident receiving IV vancomycin for cellulitis had an initial vancomycin trough level that was low, and nursing documentation indicated a follow-up trough was to be obtained on a specified later date. However, no corresponding physician order for the follow-up trough was entered, and there was no evidence the lab test was completed. During interview, the ED and DON stated that a nurse had filled out a lab requisition but failed to enter the order, resulting in the vancomycin trough not being performed, while the resident had multiple comorbidities including DM, atrial fibrillation, and osteoarthritis.
Two residents dependent on staff for ADLs, including bathing, did not receive scheduled showers as required by their care plans. Documentation showed multiple missed showers without records of refusals or attempts, and interviews with the DON and Nurse Consultant confirmed the expectation for at least two showers per week.
An LPN was observed opening a Gabapentin capsule with bare hands and emptying its contents into a medication cup with other crushed medications for a resident, without using gloves. The ADON and DON both acknowledged the concern, with the DON stating the LPN thought it was acceptable to touch the capsule exterior.
A glucometer was not sanitized after use by an LPN before being stored, contrary to facility policy. In a separate incident, a CNA provided incontinence care to a resident on Enhanced Barrier Precautions for dialysis without wearing the required gown, despite clear signage and care plan instructions. Both actions failed to meet infection prevention and control protocols.
A resident with kidney failure, hypotension, and heart failure did not receive prescribed Midodrine on several occasions due to elevated BP readings, but there was no documentation that the physician was notified when the medication was held. An RN expressed uncertainty about administering the medication without clear parameters, and the DON acknowledged the issue.
An LPN failed to follow professional standards during a medication pass by preparing medications for one resident but administering them to another, without informing the surveyor of the switch. The error occurred after the LPN placed multiple residents' medication cups in the cart and later administered the wrong set, despite facility policy requiring medications to be given immediately after preparation and not pre-poured.
A resident with end stage renal disease, stroke history, and total dependence for ADLs did not receive timely incontinent care after activating the call light. The call was not answered for over 30 minutes, during which the resident remained soiled. The care plan indicated a risk for skin breakdown and required staff assistance for incontinence, but the delay in response resulted in a failure to provide prompt care.
Three residents did not receive care and treatment as ordered, including missed blood sugar checks, insulin doses not given, lack of documentation for omitted treatments, and administration of blood pressure medication despite low readings. The DON confirmed these lapses, and facility policy required adherence to prescriber orders.
Surveyors found that a medication cart contained multiple medications, including Albuterol sulfate inhalation packets and inhalers, that were not properly labeled or stored. An RN was unable to identify the intended residents for some medications, and some items lacked administration instructions. The DON confirmed a recent pharmacy audit but could not explain the labeling deficiencies.
A resident with multiple medical conditions and increased confusion had physician orders for a urinalysis due to suspected UTI. Despite education and attempts, the resident refused straight cath and a bedpan attempt was unsuccessful, with poor documentation of further attempts or refusals. The resident was later hospitalized with acute cystitis, and the DON confirmed documentation was lacking.
The facility failed to ensure proper medication storage and handling. An LPN left a medication cart unattended with pre-poured medications and keys on top. Pre-filled saline syringes were improperly stored in a resident's room. Unlabeled and undated insulin pens, loose pills, and unlabeled syringes were found in a medication cart, violating facility policy.
A long-term care facility was found deficient in infection control practices. An IV nurse improperly handled soiled gloves, a Nurse Practitioner failed to perform hand hygiene after glove removal, an LPN disposed of a lancet incorrectly, and a CNA did not follow Enhanced Barrier Precautions. These actions violated the facility's infection prevention policies, potentially compromising resident safety.
The facility was found to have multiple environmental deficiencies, including smeared feces on a room divider, feces-stained bed linen, marred walls, and missing toilet paper holders. Additionally, hot water temperatures exceeded safe levels, and a call light was not functioning. These issues were observed across all units during an environmental tour with the Maintenance Director.
A facility failed to assess a resident for self-administration of medication and did not have a physician's order for the resident to self-administer an Albuterol inhaler. The resident, who used the inhaler daily for rescue breathing, was cognitively intact but had no documented assessment or authorization for self-administration, contrary to facility policy.
A resident's privacy was compromised when an NP assessed their peg tube in a hallway, exposing the resident's stomach in a common area. The resident, who has a peg tube and complex medical history, was not moved to a private area for the assessment. The incident was reported to the NP's physician supervisor by the DON.
A resident reported a missing teal blue outfit to multiple staff members over two months, but no grievance form was filed, and the issue was not resolved. The resident, who is cognitively intact and uses a wheelchair due to hemiplegia, spoke with laundry staff who acknowledged the missing item but did not take further action. The DON confirmed that a grievance should have been filed.
A facility failed to inform a resident, who was cognitively intact, about new medications prescribed for high blood pressure and flu prophylaxis. Despite the resident's multiple health conditions, there was no documentation that they were made aware of changes in their medication regimen. Interviews with staff confirmed the oversight.
The facility failed to provide scheduled showers for two residents and supervised eating for another resident. One resident, who was cognitively intact, did not receive showers twice a week as required. Another resident, dependent on staff for ADLs, also missed scheduled showers. A third resident, requiring supervision for eating due to visual impairment and confusion, was observed eating unsupervised, posing a choking risk.
The facility failed to monitor and assess non-pressure skin conditions, post-surgical care, and blood pressure parameters for residents. A resident experienced double vision post-cataract surgery without documented follow-up, while another had a soiled bandage on a renal abscess drain site that was not changed as needed. Additionally, blood pressure medication was administered outside prescribed parameters.
A facility failed to administer pressure ulcer treatments and IV antibiotics as ordered for a resident with multiple medical conditions, including sepsis and pressure ulcers. Observations and records showed missed IV antibiotic doses and incomplete documentation of wound care treatments. Staff interviews confirmed the expectation to follow physician orders, but documentation gaps and missed treatments led to the deficiency.
A resident with end-stage renal disease and diabetes expressed multiple times that his toenails were too long and needed trimming. Despite being cognitively intact and aware of his needs, his requests were ignored, and his toenails remained unkempt. The last podiatry assessment was months prior, and no podiatry visits were recorded for January, with no documentation of a missed or rescheduled appointment.
The facility failed to secure smoking materials for two residents, who were found with vapes and cigarettes in their rooms, contrary to policy. Additionally, a resident with a history of falls did not have the prescribed bed halos installed, despite a recent fall. Both deficiencies were confirmed by staff interviews.
Two residents in an LTC facility experienced deficiencies in catheter care and infection control. One resident had a Foley catheter bag improperly positioned and tubing on the floor, with a CNA failing to perform hand hygiene and wear an isolation gown. Another resident reported inadequate catheter drainage and site care, with observations confirming a dirty catheter and dried blood. The facility's policies on catheter care and infection prevention were not followed, leading to potential risks for the residents.
The facility failed to document and provide adequate nutrition for two residents with weight loss histories. One resident, with multiple health issues, reported inadequate meal portions and significant weight loss, while another resident's meal consumption was not properly monitored, despite requiring a therapeutic diet and supplements. The facility did not adhere to its policy of documenting meal and supplement intake.
A facility failed to monitor a fluid restriction for a resident requiring dialysis. The resident, with conditions including end-stage renal disease, had a physician order limiting fluid intake to 1200 cc per day. However, there was no documentation of monitoring this restriction in the records for December and January. The DON confirmed the lack of documentation, despite the facility's policy requiring fluid management for such residents.
A resident with a history of anxiety, depression, kidney failure, and hypertension did not receive necessary dental services for decayed and broken teeth. Despite a dentist's recommendation for extractions over a year ago, there was no follow-up or dental care plan. The Social Service Director and DON confirmed the lack of follow-up.
A resident with depression and visual impairments was not provided with a personalized activity program, leading to distress and lack of engagement. Observations showed the resident often without stimulation, such as music or television, and no activity care plan was in place. The DON acknowledged the oversight.
A facility failed to offer a resident their prescribed inhaler during medication administration. An LPN administered five tablets but did not provide the inhaler, citing the resident's usual refusal. The DON stated the inhaler should have been offered, allowing the resident to choose whether to accept or refuse it.
A facility failed to monitor and document a resident's ongoing sexual behaviors adequately, leading to a deficiency in behavioral health care. The resident, with multiple diagnoses, exhibited inappropriate sexual actions, but documentation was inconsistent, with only one entry in POC charting and two Behavior Observations in 2024. Staff interviews revealed daily occurrences of inappropriate behaviors, yet behavior charting was lacking in the MAR and Nursing Notes.
The facility failed to provide timely medications for two residents. A resident did not receive prednisone as it was thought to be unavailable, though it was in the Capsa machine. Another resident was out of Miralax, which was not stocked in the Capsa machine, and the DON indicated it should be resident-specific. The physician was notified in both cases, and administration was approved upon medication arrival.
A facility failed to document a resident's discharge against medical advice (AMA) and did not provide necessary information for continuation of care. The resident, who had undergone cervical surgery, signed an AMA form but there was no record of notifying the physician, the resident's status at discharge, or if medication orders were provided. Staff interviews revealed communication and documentation lapses, with the facility's policy indicating no further obligation once a resident leaves AMA.
A resident's dignity was compromised when their foley catheter drainage bag was left uncovered and visible from the doorway on multiple occasions. Despite having a care plan due to chronic kidney disease and a pressure ulcer, the facility did not use a dignity bag to cover the drainage bag, as confirmed by a nurse consultant.
A facility failed to ensure a Physician's Order and assessment for self-administration of medications for a resident. An LPN left a medicine cup with Methadone pills for the resident, who self-administered the medication without an order. The resident's record showed no self-administration orders or assessments, despite facility policy requiring IDT determination for self-administration.
A facility failed to provide timely incontinence care for a resident dependent on staff for ADLs. The resident reported not being changed all day, and observations confirmed a saturated brief and wet blanket. The resident, with diagnoses including morbid obesity and heart failure, was cognitively intact but dependent on staff for toileting. Staff interviews revealed reliance on the resident to request changes, and the DON acknowledged the need for more timely care.
A facility failed to follow treatment orders for a resident with a non-pressure skin condition. The resident had a hydrocolloid bandage applied without an order, contrary to the physician's instructions to cleanse the area and apply betadine. The resident, who was cognitively intact and dependent on staff, had a history of morbid obesity, cellulitis, and heart failure. The Director of Nursing confirmed the treatment should have been completed as ordered.
A resident with a history of falls was observed with their bed at medium height instead of the lowest position as required by their care plan. The resident, who was moderately impaired and dependent on staff for mobility, had previously fallen out of bed and sustained injuries. Staff indicated the bed could be lowered further but was not due to concerns about the resident's foley catheter drainage bag touching the ground.
A resident with a history of UTIs and a suprapubic catheter had their drainage bag placed on the floor multiple times, despite requests for a wash basin to prevent this. The resident's care plan did not address this issue, and the facility failed to ensure the bag was properly positioned, leading to a deficiency.
A facility failed to ensure complete and accurate documentation of insulin administration for a resident with type 2 diabetes and vascular dementia. The resident's MAR showed missing signatures for insulin administration on several dates. The DON indicated that a QMA was unable to administer the insulin, and the nurse on duty did not sign the MAR as required by facility policy.
The facility failed to ensure employees reported allegations of abuse by an employee towards residents in the Memory Care Unit to the Administrator. Employee 7 was accused of making fun of residents, using derogatory names, and threatening staff to prevent reporting. Terminated Employee 6 claimed her hours were cut after reporting to the DON, who denied receiving any reports. The Administrator was only informed on the day of the interview and initiated an investigation.
Hand Hygiene Not Performed After Glove Removal and Resident Contact
Penalty
Summary
The facility failed to ensure infection control practices were in place and implemented when an LPN did not perform hand hygiene after glove removal and after direct resident contact during medication administration and care activities for four residents. During observation on 4/6/26, the LPN checked Resident 93’s blood sugar with a glucometer and did not sanitize her hands before putting on gloves or after removing them. The same occurred when she checked Resident J’s blood sugar with a glucometer later that evening, with no hand hygiene before glove use or after glove removal. The LPN also applied a Lidocaine 4% patch to Resident 25’s left shoulder while wearing gloves, then removed the gloves and left the room without sanitizing her hands before or after glove removal. Later, while preparing and administering medications to Resident 85, the LPN did not sanitize her hands before preparing the medications, and after the resident took the medications and she handled the resident’s cup and items from the overbed table, she left the room without sanitizing her hands. During interview, the Administrator stated the LPN should have sanitized her hands after glove removal and after direct resident contact. The facility’s Hand Hygiene policy stated hand hygiene should be performed before and after direct contact with intact skin, after contact with inanimate objects in the immediate vicinity of the patient, and after glove removal.
Failure to Assess Self-Administration of Medications and Obtain Orders
Penalty
Summary
The facility failed to ensure a resident was assessed to self-administer medications and failed to have physician's orders for medications found at the bedside. During multiple observations, a bubble pack of over-the-counter generic laxative medication and a Salonpas medicated pain patch were seen on Resident C's over-bed table. Resident C stated he used the laxative when he was constipated and preferred using the pain patches instead of what the facility provided. Resident C's record showed diagnoses including neuromuscular dysfunction of the bladder, anxiety, quadriplegia, and hypotension. The resident's quarterly MDS indicated he was cognitively intact for daily decision making and had an indwelling Foley catheter. There was no care plan for self-administration of medications and no self-administration assessment completed. There were also no physician's orders for the Salonpas patch or the over-the-counter laxative tablet. A nurse's note documented that the resident refused the facility's Lidoderm patch because he had his own patch and refused what the facility offered. The Unit Manager stated she was unaware the resident had his own medicated pain patches and laxative medication, and the DON stated the resident needed to be assessed to self-administer his own medications.
Failure to Promptly Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was promptly reported when a resident reported that an LPN cursed at her and spoke to her in a rude and insulting manner after she asked for her medication. The resident, who had diagnoses including chronic pancreatitis, depression, and anxiety, was cognitively intact for daily decision making and dependent in ADLs. She stated that the interaction on the unit left her physically ill, caused her to vomit into a garbage can, and made her cry and shut down. The record contained no documentation about the staff/resident interaction on the date of the event. CNA 2 observed the resident upset and crying when delivering her dinner tray, but did not witness the interaction. CNA 1 later saw the resident upset and crying and reported the concern to LPN 2. LPN 2 stated she considered the resident’s report to be abuse and verbally reported it to RN 1 and the DON, but the Administrator and DON stated they were not aware of the allegation. The Administrator, who was the Abuse Coordinator, stated staff had been educated to contact her directly for suspected abuse, and the facility policy required employees and volunteers to report any incident, allegation, or suspicion of abuse, neglect, exploitation, mistreatment, or misappropriation immediately to the administrator or an immediate supervisor.
Failure to Provide Timely Nail Care for Dependent Residents
Penalty
Summary
The facility failed to ensure ADLs were completed for dependent residents related to nail care for 2 of 7 residents reviewed. Resident 4, who had diagnoses including type 2 diabetes and a history of cervical spinal fusion, was assessed as cognitively intact and in need of supervision or touching assistance for personal hygiene. His care plan directed staff to assist with personal hygiene, including dressing and grooming as needed. Although the record documented showers, bed baths, and nail care on several dates, the resident stated he wanted his fingernails shorter, and survey observations over multiple days showed his fingernails remained long on both hands. The DON later indicated the resident's fingernails would be cut and he did not have to wait for activity staff. Resident 5, who had diagnoses including type 2 diabetes, stroke, and aphasia, was assessed as cognitively impaired and dependent on staff for personal hygiene. His care plan also directed staff to assist with personal hygiene, including dressing and grooming as needed. The task record documented showers, bed baths, and nail care on specific dates, but survey observations showed the fingernails on his left hand and right thumb were extremely long and remained long on subsequent observation. During interview, the resident indicated he wanted his fingernails shorter, and the Administrator stated the resident had his fingernails cut the afternoon of 3/31/26.
Failure to Provide Individualized Dementia Care Interventions
Penalty
Summary
The facility failed to provide individualized services and other interventions related to dementia care for a resident on the memory care unit. Resident 89 had diagnoses including Alzheimer's disease, anxiety disorder, stroke, repeated falls, and high blood pressure. The 3/5/26 Quarterly MDS indicated she was not cognitively intact for daily decision making, had behaviors toward others such as hitting or scratching, and received an antipsychotic and an antidepressant. The record also showed an order for Abilify 2 mg daily and that she was receiving services from an outside behavioral center, but there was no care plan for dementia care with individualized interventions or approaches for her behaviors. During observations, the resident was seated in the activity/dining room and displayed anxious and disruptive behaviors, including turning her wheelchair away from the table, standing up, mumbling curse words, trying to grab books from the activity aide, crying, rubbing her eyes, and repeatedly attempting to stand. Staff responses consisted of telling her to sit down or stop cussing from across the room, moving her wheelchair without speaking to her, and taking a book away from her without offering another item or other intervention. On one occasion, a nurse entered and stated the resident probably needed a change of scenery and wheeled her out of the room. The Unit Manager stated there was no care plan regarding the resident's dementia with approaches or interventions when she had behaviors, and the DON stated the memory care unit, behaviors, and structured activities were being reviewed because changes were needed in how staff helped residents with behaviors.
Medication Labels Did Not Match Physician Orders
Penalty
Summary
Prescription medications were not properly labeled for 2 of 8 residents observed during medication administration. On 4/6/26 at 9:41 a.m., an LPN prepared medications for Resident 104 and dispensed one 75 mg Pregabalin capsule into the medication cup. The medication card label indicated the resident was to receive one capsule every 12 hours, but the Physician's Order dated 3/31/26 directed Pregabalin 75 mg three times a day. The medication label did not match the order, and there was no label on the medication card showing that the order had been changed. Resident 104's record also listed polyneuropathy among the diagnoses. On 4/6/26 at 9:56 a.m., the same LPN prepared medications for Resident 12 and dispensed two 1 mg tablets of Bumetanide into the medication cup. The medication card label indicated 1 mg daily, while the Physician's Order dated 3/26/26 directed Bumetanide 2 mg daily. The label on the medication did not match the medication order, and there was no label on the medication card indicating the order had been changed. Resident 12's diagnoses included edema. During an interview on 4/7/26 at 11:30 a.m., the Nurse Consultant stated the pharmacy would be contacted regarding the labeling of the medications.
Incomplete Supplement Documentation and Inaccurate Dental Assessments
Penalty
Summary
The facility failed to ensure clinical records were complete and accurately documented for dietary supplement consumption for Resident 20. Resident 20 had diagnoses including Alzheimer's disease, adjustment disorder, dementia with psychotic disturbance, vascular dementia, high blood pressure, atrial fibrillation, and chronic kidney disease. The 12/31/25 quarterly MDS indicated the resident was moderately impaired for daily decision making and had no oral problems or weight loss. A physician's order dated 3/5/26 directed a high-calorie liquid supplement twice daily for weight, and the 3/2026 and 4/2026 MARs showed the supplement was signed out as administered, but the amount consumed was not documented. The DON stated during interviews that the amount consumed should have been documented on the MAR. The facility also failed to maintain an accurate dental assessment for Resident B. Resident B had diagnoses including dysphagia, heart failure, dementia without behaviors, high blood pressure, and syncope. The 12/1/25 annual MDS indicated the resident was not cognitively intact for daily decision making and staff were unable to examine the resident's mouth for dental, while the 3/3/26 quarterly MDS indicated no oral problems. However, the hospital history and physical dated 11/13/24 documented the resident as edentulous, the nursing admission assessment dated 11/23/24 stated there were no issues with teeth, the readmission nursing assessment dated 5/27/25 also stated no issues with teeth, and a dental exam note dated 11/5/25 documented no teeth in the upper and lower right and left quadrants. The DON stated the nursing admission dental assessments were not accurate, and the resident's son stated the resident's dentures were lost at the hospital and she had no natural teeth.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to ensure a resident’s responsible party was notified of a change in condition related to increased behaviors and placement on one-to-one supervision. Resident D had diagnoses including vascular dementia with mild agitation and muscle weakness, and the Quarterly MDS dated 12/27/25 indicated the resident was cognitively impaired for daily decision making. On 2/6/26, the resident was observed ambulating in the dining room, pushing on doors, setting off the back door alarm, and repeatedly attempting to exit the area while stating she was going down the street to get a pop. Staff redirected the resident back to her wheelchair, but she became resistive and verbally aggressive, and one-to-one care was initiated after she was assisted to her room and put herself to bed. The Behavior Observation Form dated 2/6/26 documented the resident as exit-seeking and wanting to go to the store to get a pop, but there was no date and time showing when the physician was notified. The resident’s name was listed as family or responsible party notified, but no date and time was documented, and there was no documentation in the nurses’ notes on 2/7/26 and 2/8/26 that the family was notified of the behaviors and one-to-one care. A later behavior note on 2/9/26 stated the resident remained on 15-minute checks and that the family and physician were made aware, with a urinalysis ordered due to the behaviors. During interview, the Bakersfield Unit Manager stated the resident’s family was not notified of the resident’s behavior and being placed on 1:1 on 2/6/26.
Failure to Administer Ordered Insulin and Document Follow-Up for Elevated BP and Diarrhea
Penalty
Summary
The facility failed to ensure insulin was administered as ordered for a resident with type 2 diabetes and bipolar disorder without psychotic features. The resident had physician orders for Insulin Aspart 5 units subcutaneously with meals and Glargine Insulin 22 units subcutaneously at bedtime. The March 2026 MAR showed multiple instances where both insulins were held because the resident's blood sugar was documented as being outside of parameters, but there was no order authorizing holding the insulin based on blood sugar values. In several instances, blood sugar levels were not documented at all when the insulin was held. The Nurse Consultant stated the standing insulin orders did not include parameters and the insulin should have been given as ordered. The facility also failed to document follow-up after elevated blood pressures for a resident with dysphagia, heart failure, dementia without behaviors, high blood pressure, and syncope who was not cognitively intact for daily decision making. Blood pressures were recorded as 191/78 and 174/106, and the resident's isosorbide mononitrate was signed out as administered. However, there were no nursing progress notes before the resident was transferred to the hospital, no documentation that the physician was notified of the high blood pressures, and no documentation that the blood pressures were rechecked. A change in condition report later documented neurological signs of a stroke, and nursing notes indicated the resident had left-sided facial droop and slurred speech before EMS transport. The facility further failed to document follow-up regarding an anti-diarrheal medication for a resident who was cognitively intact and dependent on dialysis. The resident reported diarrhea to staff and refused dialysis because of it. An LPN documented that the resident did not have any active anti-diarrheal orders, that the resident's wife planned to bring medication from a previous hospital stay, and that the PCP was notified and agreed the medication would need to be communicated for charting and safety purposes. The record showed diarrhea or loose stool on multiple dates, additional incontinent stool episodes without documented stool consistency, and no documentation of follow-up or an anti-diarrheal order.
Suprapubic Catheter Care and Change Not Completed as Ordered
Penalty
Summary
The facility failed to ensure appropriate suprapubic catheter care was provided and that the catheter was changed as ordered for one resident with a suprapubic catheter. The resident had diagnoses including neuromuscular dysfunction of the bladder, anxiety, quadriplegia, and hypotension, and was cognitively intact for daily decision making. A care plan identified the resident as at risk for complications related to the suprapubic catheter. A physician’s order dated 1/26/26 directed that the 18 French suprapubic catheter with a 30 cc balloon be changed every month and as needed on the 8th of each month, and another order directed catheter care every shift. During observations, the resident stated staff did not provide catheter care every day and that the catheter had not been changed for over a month. The suprapubic catheter site was observed with a scabbed stoma, moderate bloody drainage around the catheter, no bandage over the stoma, and later dried drainage on the tubing with no bandage covering the site. The record showed the catheter had not been changed since 2/22/26, despite the monthly order. The TAR indicated catheter care and catheter changes were documented as completed by staff, including the Wound Nurse and QMA, but the resident stated the Wound Nurse had never performed catheter care. The Wound Nurse acknowledged signing out treatments without completing them, and the DON stated QMAs were not able to change a suprapubic catheter and that the Wound Nurse should not have signed out care he did not perform.
Delayed Vision and Dental Services
Penalty
Summary
The facility failed to ensure medically related social services were provided in a timely manner for Resident B, specifically related to vision and dental care. Resident B had diagnoses including dysphagia, heart failure, dementia without behaviors, high blood pressure, and syncope, and was not cognitively intact for daily decision making on both the annual and quarterly MDS assessments. The record showed the resident was edentulous and had no oral problems noted on assessments, while vision was documented as adequate initially and later with corrective lenses. Care conference notes indicated referrals were sent to the dentist and optometrist, and the family wanted the resident to be put on the list to see the eye doctor. The resident did not see a dentist until the first dental exam, which documented no teeth in the upper and lower quadrants and that there were no concerns at that time. The resident did not see an eye doctor until the first optometrist exam, which found hypermetropia in the right eye, myopia in the left eye, and cataracts in both eyes, with a new eyeglasses prescription left by the optometrist. A later dental exam again documented the resident was edentulous and not a candidate for dentures, and a later optometrist exam repeated the same findings. There was no documentation in Social Service progress notes about the visits, whether eyeglasses had been ordered, or whether the family had been notified about the dental exam. During interviews, the SS staff member stated she was responsible for ancillary services, was unsure why the resident was not seen sooner, and was unaware the eyeglass prescription had been written or that the resident had cataracts. She later learned the glasses had been ordered after the prescription was resent and that the resident's son had not returned calls for consent to order them.
Failure to Complete Ordered Vancomycin Trough Laboratory Test
Penalty
Summary
The facility failed to ensure that ordered laboratory tests were completed as required when a vancomycin trough level was not obtained for one resident receiving IV vancomycin for cellulitis. The resident, who had diagnoses including cellulitis, diabetes mellitus, atrial fibrillation, and osteoarthritis and was cognitively intact with a need for moderate assistance with transfers, had a physician’s order dated 1/14/26 for vancomycin 1 gram IV daily. A lab result from the same date showed a vancomycin trough of less than 3.0, and a nurse’s note on 1/15/25 documented that the trough result was communicated to the pharmacy and that the next vancomycin trough should be done on 1/19/26. However, there was no corresponding physician’s order for the follow-up trough in the record and no indication that the trough was completed on 1/19/26. During interview, facility leadership reported that the nurse had filled out a lab requisition for the test but had not entered the order, and the test was not performed. The resident was later discharged to the hospital on 1/20/26 due to abnormal labs.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs), specifically bathing, were completed for dependent residents. For one resident with diagnoses including epilepsy, psychotic disorder, hypertension, and alcohol dementia, records showed the resident was not cognitively intact and was dependent on staff for bathing. The care plan required staff assistance with ADLs, and the resident was scheduled to receive showers twice weekly. However, documentation revealed that showers were missed on multiple scheduled dates. Another resident, with diagnoses such as osteomyelitis, diabetes, COPD, asthma, and hypertension, was also dependent on staff for bathing, toileting, personal hygiene, and oral hygiene. The care plan specified assistance with bathing, offering showers at least twice weekly, and providing a bed bath on non-shower days or upon refusal. Documentation indicated that this resident did not receive showers on numerous dates, and there was no record of refusals or attempts to offer showers. Interviews with the DON and Nurse Consultant confirmed the expectation for at least two showers per week and acknowledged the lack of documentation for missed showers.
Failure to Use Gloves During Medication Administration
Penalty
Summary
During a medication administration observation, an LPN was seen opening a Gabapentin 300 mg capsule with her bare hands and emptying the powder contents into a medication cup along with another crushed medication for a resident who received medications in crushed form. The LPN did not use gloves while handling the medication capsule. The Assistant Director of Nursing acknowledged awareness of the concern but did not provide additional information. The Director of Nursing also acknowledged the issue, noting that the LPN believed it was acceptable to touch the outside of the capsule as long as the inside contents were not touched.
Failure to Sanitize Glucometer and Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of communicable diseases and infections. During an observation, an LPN performed a glucometer test on a resident and, after completing the test, did not sanitize the glucometer before placing it back in the medication cart. The LPN acknowledged that the glucometer should be sanitized after each use, and the facility's policy confirmed that cleaning and disinfecting between each resident test was required. Additionally, a CNA provided incontinence care to a resident who was under Enhanced Barrier Precautions (EBP) without donning the required gown, despite a sign indicating EBP was necessary. The CNA was unsure which resident required EBP and proceeded with care using only gloves. The resident's records indicated diagnoses including end stage renal disease and dialysis, with care plans and physician orders specifying the need for EBP, including gown and gloves for high-contact care activities. The facility's EBP protocol also required these precautions during dressing, bathing, and other high-contact activities.
Failure to Notify Physician When Medication Was Held
Penalty
Summary
The facility failed to notify a resident's physician when a prescribed medication, Midodrine, was held on multiple occasions. The resident, who had diagnoses including kidney failure, hypotension, and heart failure, was cognitively intact and had a physician's order for Midodrine 5 mg three times daily for hypotension. On specific dates, the medication was not administered due to elevated blood pressure readings, as documented in the Medication Administration Record and nurses' notes. Despite the medication being withheld, there was no documentation that the resident's physician was informed of these omissions. During interviews, an RN expressed uncertainty about administering the medication due to the absence of specific parameters and confirmed that the dose was held when the resident's blood pressure was in the 150s. The Director of Nursing acknowledged the concern but did not provide additional information.
Failure to Ensure Medication Administration Met Professional Standards
Penalty
Summary
During a medication pass observation, an LPN prepared morning medications for one resident, which included potassium, a multivitamin, Cinacalcet, vitamin D, amlodipine, clonazepam, and hydrocortisone. After preparing the medications and placing them in a plastic cup, the LPN locked the cup in the medication cart to retrieve a glucometer. Upon returning, the LPN took a medication cup from the cart and administered the medications to the resident in the bed closest to the door, giving approximately half the medications at a time. The LPN then checked the resident's blood sugar and documented the administration in the Medication Administration Record (MAR). A subsequent review revealed that the resident who received the medications was not the intended recipient for whom the medications were prepared. The LPN had previously set up medications for another resident and, upon returning to the cart, mistakenly administered those medications instead. The LPN did not inform the surveyor of the switch during the observation. Facility policy required adherence to the five rights of medication administration and specified that medications should be administered at the time they are prepared and not pre-poured. The LPN had completed orientation to the medication pass routine prior to the incident.
Delay in Responding to Call Light for Dependent Resident Needing Incontinent Care
Penalty
Summary
A deficiency was identified when a dependent resident did not receive timely assistance with incontinent care. Observation showed that the resident's call light was activated at 5:15 a.m., but was not answered until 5:47 a.m. by the DON, who found the resident had experienced a bowel movement and required care. A CNA began providing care at 5:49 a.m. The resident's medical record indicated diagnoses including end stage renal disease requiring dialysis and a history of stroke, with a care plan noting risk for skin breakdown and the need for assistance with incontinent care. The resident was documented as always incontinent of bowel and bladder and dependent for all ADLs. The DON confirmed that care was provided after the call light was answered and had no further information regarding the delay.
Failure to Administer Medications and Monitor Blood Sugars as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs for three residents with diabetes and hypotension. For one resident with insulin-dependent diabetes, there were multiple instances where blood sugar levels were not monitored as ordered, insulin doses were not administered, and there was a lack of documentation explaining these omissions. In several cases, when blood sugar readings were outside of the prescribed parameters, there was no evidence that the physician was notified, and in at least one instance of low blood sugar, there was no documentation of treatment, rechecking, or physician notification as required by facility guidelines. Another resident with diabetes had physician orders for blood sugar checks and insulin administration based on a sliding scale. The record showed that on several occasions, midday blood sugars were not checked and insulin was not administered, with no documentation in the nurses' notes to explain these omissions. The Director of Nursing confirmed that these required checks and treatments were not completed as ordered. A third resident with a diagnosis of hypotension had a physician order to hold a specific blood pressure medication if the blood pressure was below a certain threshold. Despite this, the medication was administered on multiple occasions when the resident's blood pressure was below the ordered limit. The Director of Nursing acknowledged that the medication should not have been given under these circumstances. The facility's medication administration policy required medications to be given in accordance with prescriber orders, which was not followed in these cases.
Improper Labeling and Storage of Medications on Medication Cart
Penalty
Summary
Surveyors observed that the Cherry Lane medication cart contained multiple medications that were not properly labeled or stored. Specifically, nine Albuterol sulfate inhalation packets in the bottom drawer lacked any labeling, and the RN present was unable to identify which residents they belonged to. Additionally, two inhalers in the top drawer had no name or label, and another inhaler was labeled only with a resident's name and room number but lacked administration instructions. An additional Albuterol sulfate inhalation packet in the top drawer was also found without a label. The RN was unsure why these medications were not labeled, despite a recent audit of the cart, and the DON confirmed that the pharmacy had recently audited all medication carts but could not provide further information.
Failure to Obtain and Document Ordered Urinalysis for Resident with Suspected UTI
Penalty
Summary
The facility failed to ensure that a urinalysis (UA) was collected as ordered for a resident with diagnoses including cellulitis, diabetes, and heart failure, who was cognitively intact. The resident's daughter reported increased confusion and suspected a urinary tract infection (UTI). Multiple physician orders were placed to obtain a UA due to the resident's altered mental status and increased confusion. Documentation shows that the resident was educated on the need for a urine sample and refused a straight catheterization, agreeing only to use a bedpan. Attempts to collect a sample were unsuccessful, including a bedpan spill and further refusals of straight catheterization. There was a lack of documented attempts, refusals, or notifications regarding obtaining the urine sample during several days in the period when the UA was ordered. The Director of Nursing acknowledged that refusals and education provided to the resident were not well documented. The resident was later admitted to the hospital with a primary diagnosis of acute cystitis. The deficiency centers on the facility's failure to ensure timely collection and documentation of the ordered laboratory test and communication with the practitioner.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and handling, as observed during a survey. On one occasion, an unattended medication cart was found with pre-poured medications labeled only with residents' first names, medication cart keys, and various medications left unsecured on top of the cart. An LPN admitted to leaving these items unattended while using the bathroom, acknowledging the error in pre-pouring medications. The Director of Nursing confirmed that pre-pouring medications was against facility policy. Additionally, pre-filled saline syringes were improperly stored in a resident's room, contrary to the facility's medication storage policy, which mandates that all medications be stored in a locked cart. Further observations revealed unlabeled and undated insulin pens, loose pills, and unlabeled syringes in a medication cart. The Director of Nursing indicated that these items needed to be disposed of and confirmed that insulin pens should be labeled with the resident's name and date opened, as per the facility's policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented, as evidenced by multiple observations of staff not adhering to established protocols. In one instance, an IV nurse was observed leaving a resident's room wearing soiled gloves, walking down the hallway, and discarding them improperly at the nurses' station. This occurred despite the resident being on contact isolation due to an ESBL infection. The nurse's actions were contrary to the facility's infection prevention and control program, which mandates the appropriate disposal of personal protective equipment before leaving a resident's room. Another deficiency was noted when a Nurse Practitioner (NP) failed to perform hand hygiene after glove removal while examining a resident's PEG tube. The NP donned gloves without sanitizing her hands, touched the resident's PEG tube, and discarded the gloves without performing hand hygiene. This was a direct violation of the facility's policy, which requires hand hygiene before and after glove use, especially when moving from a contaminated to a clean site. Additionally, an LPN improperly disposed of a used lancet in a resident's room garbage can instead of a sharps container, as required by the facility's policy. Furthermore, a CNA failed to follow Enhanced Barrier Precautions (EBP) while emptying a resident's Foley catheter, neglecting to wear an isolation gown despite the resident being on EBP due to the presence of wounds and a PICC line. These actions demonstrate a lack of adherence to infection control protocols, potentially compromising resident safety.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents, staff, and the public, as observed during an environmental tour with the Maintenance Director. Issues identified included smeared feces on a room divider shared by two residents, feces-stained bed linen in a shared room, and marred walls in various rooms. Additionally, several rooms had marred and dirty heat registers, missing toilet paper holders, and cracked ceiling tiles. A call light was found not working, and hot water temperatures exceeded 120 degrees in multiple units, posing potential safety risks. The Maintenance Director acknowledged these deficiencies during the tour, noting that the hot water heater had been set higher due to a recent pipe burst in the kitchen. The report highlights that these issues were present across all five units of the facility, including Cherry Lane, Cherry Court, Blueberry Lane, Apple Lane, and Bakersfield Lane. The citation tag relates to specific complaints, indicating that these environmental concerns were part of ongoing issues within the facility.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and had a physician's order to self-administer medication. During multiple observations, an Albuterol hand-held inhaler was seen on the over-bed table of a resident, identified as Resident G, who used it for rescue breathing at least daily. Despite the resident's cognitive intactness for daily decision-making, as indicated in the 11/14/24 Quarterly Minimum Data Set assessment, there was no documented self-administration assessment or physician's order allowing the resident to self-administer the inhaler. The resident's medical history included COPD, acute respiratory failure, Alzheimer's disease, anxiety disorder, high blood pressure, and bipolar disorder. The care plan, revised on 5/14/24, noted the resident's risk for complications due to COPD and included approaches for administering bronchodilators as ordered. However, the facility's policy required the Interdisciplinary Team (IDT) to determine the resident's capacity to self-administer medications, which was not done in this case. The Director of Nursing had no additional information to provide regarding the oversight.
Resident Privacy Breach During Medical Assessment
Penalty
Summary
The facility failed to maintain the privacy of a resident during a medical assessment conducted by a Nurse Practitioner (NP). The incident involved Resident C, who was observed in a common area when the NP assessed the resident's peg tube in the hallway, exposing the resident's stomach and peg tube to public view. This assessment was conducted without moving the resident to a private area, compromising the resident's privacy. Resident C has a complex medical history, including a peg tube for nutrition, falls, dysphagia, type 2 diabetes, palliative care, Parkinson's disease, psychotic disorder, severe dementia with agitation, high blood pressure, restlessness, and agitation. The resident is not cognitively intact and relies on staff for most activities of daily living. The NP did not provide additional information during an interview, and the Director of Nursing reported the incident to the NP's physician supervisor.
Failure to Address Resident Grievance for Missing Personal Items
Penalty
Summary
The facility failed to honor a resident's right to voice grievances without discrimination or reprisal, as required by regulations. Resident 23, who is cognitively intact and uses a wheelchair due to hemiplegia, reported a missing teal blue outfit to multiple staff members over a period of more than two months. Despite her efforts, no grievance form was filed, and the issue was not resolved. The resident had spoken with laundry staff, who acknowledged the missing item but did not take further action to file a grievance or replace the clothing. The Director of Nursing confirmed that a grievance should have been filed for the missing items.
Failure to Inform Resident of New Medications
Penalty
Summary
The facility failed to ensure that residents were involved in decisions about their care, specifically regarding the communication of new medications. Resident D, who was cognitively intact and required assistance with daily activities, reported not being informed about new medications or physician's orders. The resident's medical record, reviewed on January 22, 2025, showed multiple diagnoses, including acute respiratory failure, COPD, type 2 diabetes, heart failure, high blood pressure, chronic kidney disease, osteoarthritis, and depression. Despite new physician's orders for medications such as Amlodipine, Losartan Potassium, and Tamiflu, there was no documentation indicating that Resident D was informed of these changes. Interviews with the Unit Manager and the Director of Nursing confirmed the lack of documentation regarding the resident's awareness of the new medication regimen.
Failure to Provide Scheduled Showers and Supervised Eating
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for dependent residents, specifically in providing showers and assistance with eating. Resident D, who was cognitively intact and required substantial assistance with bathing, reported not receiving showers on scheduled days. The record review confirmed that Resident D did not receive showers at least twice a week for several months. Similarly, Resident C, who was not cognitively intact and dependent on staff for ADLs, did not receive the scheduled showers twice a week as documented in the care plan. Resident E, who was cognitively intact but required supervision for eating due to impaired visual function and other health issues, was observed eating unsupervised, resulting in a potential choking hazard. The resident was experiencing increased confusion and had a recent physician's order for IV antibiotics due to a urinary tract infection. The Director of Nursing acknowledged that Resident E should have had supervised meal consumption. These deficiencies were identified during a complaint investigation.
Deficiencies in Resident Monitoring and Care
Penalty
Summary
The facility failed to ensure proper monitoring and assessment of non-pressure skin conditions, blood pressure parameters, and post-surgical care for residents. Resident G, who had undergone cataract surgery, reported experiencing double vision but there was no documentation of her surgery or any post-operative assessment and monitoring in her clinical record. Despite having physician's orders for post-surgery eye drops, there was no evidence of a care plan for her vision or any follow-up assessments after her surgeries. Resident 82 was observed with a soiled and foul-smelling bandage on his lower back, indicating a lack of proper wound care. The bandage, which covered a drain site for a renal abscess, had not been changed or monitored as required. The Wound Nurse confirmed that the bandage had not been changed prior to the observation, and the treatment was scheduled on an as-needed basis, which led to it being overlooked. The resident's medical records showed multiple instances where the drain site was not monitored as per the physician's orders. Additionally, the facility failed to adhere to blood pressure medication administration guidelines for Resident 82. The resident was prescribed Midodrine with specific blood pressure parameters, but the medication was administered even when the resident's blood pressure readings exceeded the prescribed limits. This oversight was not addressed by the Unit Manager, and there was no additional information provided regarding the medication administration issue.
Failure to Administer Pressure Ulcer Treatments and IV Antibiotics as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments and intravenous (IV) antibiotics were administered as ordered for a resident with multiple medical conditions, including sepsis, osteomyelitis, and pressure ulcers. Observations revealed that the resident, who had a peripherally inserted central catheter (PICC) line, did not receive IV antibiotics as scheduled. Specifically, there were instances where the IV antibiotics were not administered, and the medication administration record (MAR) was not signed to indicate that the antibiotics were given. The resident's care plan, which was revised to address skin impairments and the need for IV medication, was not followed as prescribed. The treatment administration record (TAR) showed multiple instances where pressure ulcer treatments were not documented as completed. The resident had several stage 3 pressure ulcers that were present on admission and had not healed, requiring specific wound care treatments that were not consistently administered. Interviews with facility staff, including the wound nurse and unit manager, confirmed that treatments and IV antibiotics were expected to be administered as ordered by the physician. However, the facility's failure to adhere to these orders was evident in the documentation gaps and missed treatments. The facility's policy required staff to initial the electronic TAR after each treatment, which was not consistently done, leading to the deficiency.
Failure to Provide Necessary Podiatry Care
Penalty
Summary
The facility failed to provide necessary foot care for a resident, identified as Resident 69, who was reviewed for podiatry care. On multiple occasions, the resident expressed a desire to have his toenails cut, indicating that they were too long and unkempt. Despite his repeated requests to staff members, his toenails remained untrimmed. The resident, who was cognitively intact, emphasized that he was aware of his needs and felt his requests were being ignored. Observations confirmed that his toenails were indeed long and unkempt. The resident's medical record revealed diagnoses including end-stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic nephropathy. The last podiatry assessment, dated several months prior, indicated that the toenails were trimmed and debrided to the resident's tolerance, with a recommendation for recall as medically necessary but no sooner than 60 days. However, there were no podiatry visits recorded for January 2025, and the Social Service Consultant confirmed the absence of documentation for a missed or rescheduled podiatry appointment during that time.
Failure to Secure Smoking Materials and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that smoking materials were securely stored and not kept in residents' rooms, as observed with two residents. Resident G was found with a vape on her bed, which she admitted to keeping with her at all times, despite facility policy requiring smoking materials to be stored by the facility. Resident F was observed with two vapes, three packs of cigarettes, and two lighters in his nightstand drawer, even though he was not currently smoking due to cold weather. Both residents were cognitively intact, and their records indicated a need for the facility to store their smoking materials, yet these items were found in their possession. Additionally, the facility failed to implement necessary fall prevention measures for Resident H, who had a history of repeated falls. The resident's bed was observed without the prescribed halos, a bed mobility assist device, despite a recent fall where the resident slid out of bed. The interdisciplinary team had identified the need for halos as a new intervention to prevent further falls, but this intervention was not in place during observations. The Director of Nursing confirmed that the halos should have been installed to prevent falls.
Deficiencies in Catheter Care and Infection Control
Penalty
Summary
The facility failed to ensure proper care and maintenance of Foley catheters and adherence to Enhanced Barrier Precautions (EBP) for two residents. Resident 82 was observed multiple times with a Foley catheter bag improperly positioned on the arm of a wheelchair, above the waist, and with tubing on the floor. A CNA was observed emptying the catheter without performing hand hygiene and using inappropriate equipment, such as a wash basin instead of a urinal. The CNA also failed to wear an isolation gown despite the resident being on contact isolation due to ESBL in the urine. The resident's care plan indicated the need for contact isolation and proper positioning of the catheter bag, which was not followed. Resident 49 reported that staff did not drain his catheter bag regularly and had to call 911 for catheter exchange due to obstruction. Observations revealed a dirty catheter with dried blood around the insertion site, indicating a lack of proper site care. The resident's care plan required catheter care every shift, which was not adhered to, as evidenced by the resident's complaints and the condition of the catheter site. The Treatment Administration Record (TAR) indicated that catheter care was signed off as completed, despite evidence to the contrary. Interviews with the Director of Nursing and Unit Manager confirmed the deficiencies in catheter care and adherence to infection control protocols. The facility's policies on urinary catheter care and infection prevention were not followed, leading to potential risks for the residents involved. The lack of proper catheter care and failure to maintain EBP contributed to the deficiencies observed during the survey.
Deficiency in Nutritional Monitoring and Documentation
Penalty
Summary
The facility failed to ensure proper documentation and provision of food and supplements for residents with a history of weight loss, specifically affecting two residents. Resident F, who had multiple diagnoses including sepsis, osteomyelitis, and pressure ulcers, reported significant weight loss and inadequate meal portions, particularly at breakfast. Despite a physician's order for double portions, meal consumption logs showed numerous instances where meals were not documented, indicating a lack of monitoring and recording of the resident's nutritional intake. This oversight contributed to Resident F's weight dropping from 112 pounds to 92 pounds over a short period. Similarly, Resident 82, who had conditions such as acute myocardial infarction and end-stage renal disease, was observed with an untouched lunch tray, suggesting a lack of consumption monitoring. The resident's care plan required a therapeutic diet and renal liquid supplements, yet the meal logs frequently lacked documentation of meal consumption, and the Medication Administration Record did not specify the amount of supplement consumed. The facility's policy required detailed documentation of meal and supplement intake, which was not adhered to, leading to deficiencies in nutritional monitoring for both residents.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to monitor a fluid restriction for a resident who required dialysis. Resident 82, who was admitted with diagnoses including acute myocardial infarction, renal dialysis, and end-stage renal disease, was identified as being at risk for altered fluid balance due to dialysis and fluid restriction. A physician order dated 12/8/24 specified a daily fluid intake limit of 1200 cc, divided between dietary and nursing. However, there was no documentation in the Medication Administration or Treatment Administration Records for December 2024 and January 2025 to indicate that the nursing staff monitored or accounted for the fluid restriction. During an interview, the Director of Nursing confirmed the absence of documentation regarding the monitoring of the fluid restriction, despite the facility's policy requiring such management for residents with fluid restrictions.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services for decayed and broken teeth. Resident 73, who is cognitively intact and has a medical history including anxiety disorder, depression, kidney failure, and hypertension, reported that the facility was supposed to follow up with a dentist after she cracked her tooth. Although a dentist had recommended an extraction over a year ago, there was no follow-up. The resident's record showed a Dental Note from November 2023 indicating the need for an oral surgeon for extractions, but no dental care plan was in place. A Social Service Note from December 2023 mentioned awaiting a response from the oral surgeon, but by January 2025, there was no documentation of any follow-up appointment. Interviews with the Social Service Director and the Director of Nursing confirmed the lack of follow-up and additional information.
Failure to Provide Personalized Activity Program for Resident
Penalty
Summary
The facility failed to provide a personalized activity program for a cognitively impaired and dependent resident, identified as Resident 81. Observations over several days revealed that the resident was often left without any form of stimulation, such as television or music, and was not actively engaged in activities. The resident was seen crying, rocking back and forth, and screaming, indicating distress and a lack of engagement. Despite the presence of an Activity Director, there was no evidence of a personalized activity care plan for the resident, and the last documented one-on-one activity session occurred several days prior to the observations. The resident's medical history included depression, muscle weakness, cataracts, and encephalopathy, and she required varying levels of assistance with daily activities. Despite being cognitively intact for daily decision-making, the resident was not provided with adequate stimulation or invited to participate in activities, as confirmed by both family interviews and staff acknowledgment. The Director of Nursing recognized the oversight, noting that music or television should have been provided to the resident.
Failure to Offer Prescribed Inhaler to Resident
Penalty
Summary
The facility failed to ensure that a resident was given the opportunity to participate in their treatment, specifically regarding medication administration. During an observation, an LPN prepared and administered five tablets to a resident but did not offer the resident their prescribed inhaler, Anora Ellipta, which is used to treat chronic obstructive pulmonary disease. The LPN noted that the resident always refused the inhaler and therefore did not offer it. However, the Director of Nursing indicated that the inhaler should have been offered to the resident, allowing them the choice to accept or refuse it. This incident was related to a specific complaint investigation.
Inadequate Monitoring and Documentation of Resident's Sexual Behaviors
Penalty
Summary
The facility failed to adequately monitor and document the behaviors of a resident with ongoing sexual behaviors, leading to a deficiency in providing necessary behavioral health care and services. Resident C, who had diagnoses including multiple sclerosis, tachycardia, and mood disorder, exhibited inappropriate sexual behaviors, such as entering another resident's room and engaging in inappropriate actions. Despite being cognitively intact and requiring supervision for certain activities, the resident's behaviors were not consistently documented in the Medication Administration Record (MAR) or Nursing Notes, as required. The facility's documentation was insufficient, with only one entry related to sexual inappropriateness in the POC charting from 11/5/24 to 12/18/24, and only two Behavior Observations recorded in 2024. Interviews with staff revealed that the resident's inappropriate behaviors occurred almost daily, yet there was a lack of consistent behavior charting. The Regional Nurse Consultant indicated that behavior charting should be documented in the MAR or Nursing Notes, but the Director of Nursing noted that behaviors were charted in the aides' POC charting. The deficiency was highlighted by the lack of documentation and monitoring of the resident's behaviors, despite the resident's ongoing sexually inappropriate actions and the need for psychiatric monitoring and stabilization.
Medication Availability Issues for Two Residents
Penalty
Summary
The facility failed to ensure timely availability of medications for two residents during medication administration. For Resident G, a Qualified Medication Aide (QMA) discovered that the resident was out of prednisone 5 mg tablets. The QMA indicated she would notify the nurse. Later, a Licensed Practical Nurse (LPN) confirmed that prednisone was available in the Capsa machine, but the resident had not received it. The Director of Nursing (DON) was informed and ordered the medication from the pharmacy, notifying the physician who approved administration upon arrival. For Resident H, the QMA found that Miralax was unavailable and planned to inform the nurse. The LPN mentioned that Miralax was usually kept as house stock in the medication room, but the DON stated it should be resident-specific and was not stocked in the Capsa machine. A medication note indicated that the physician was notified and approved administration upon arrival. The facility's current medication administration policy requires notification of the attending physician, resident, and responsible party if a drug is unavailable.
Failure to Document AMA Discharge and Provide Continuation of Care Information
Penalty
Summary
The facility failed to properly document a resident-initiated discharge against medical advice (AMA) and did not provide necessary information for the resident's continuation of care. Resident B, who had undergone an anterior cervical discectomy and fusion, was admitted to the facility and later signed a Release of Responsibility for Discharge Against Advice form. However, there was no documentation indicating that the attending physician was notified of the resident's request for an AMA discharge. Additionally, there was no record of the resident's status at the time of discharge, with whom the resident left, or if current medication orders were provided for the resident's continued care. Interviews with facility staff revealed a lack of communication and documentation regarding the AMA discharge. The Director of Nursing (DON) acknowledged the absence of documentation in the progress notes and confirmed that the physician had not been informed of the impending discharge. LPN 1, the nurse on duty, was not aware of the discharge until the following day and indicated that Unit Manager (UM) 2 was supposed to handle the documentation, which UM 2 denied. The facility's policy stated that once a resident leaves AMA, the facility is under no further obligation, and all medications should be returned to the pharmacy. This incident was related to a specific complaint, IN00442760.
Failure to Cover Foley Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident H, by not covering the foley catheter drainage bag, which was visible from the doorway. Observations were made on multiple occasions over three consecutive days, where the resident was seen in their room with the catheter drainage bag containing yellow urine clearly visible. This lack of coverage was noted during observations at various times of the day, indicating a consistent oversight in maintaining the resident's dignity. Resident H's medical record indicated diagnoses of chronic kidney disease and a pressure ulcer of the sacrum, necessitating the use of a foley catheter. The resident was assessed as moderately impaired for daily decision-making and had an indwelling catheter as per the Quarterly Minimum Data Set assessment. A care plan was in place due to the risk of complications from the catheter use. Despite these considerations, the facility did not ensure the catheter drainage bag was covered, as confirmed by a nurse consultant who acknowledged that a dignity bag should have been used to cover the drainage bag.
Failure to Ensure Physician's Order for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a Physician's Order for self-administration of medications and an assessment to self-administer medications was completed for Resident B. On the specified date, an LPN was observed leaving a medicine cup with 14 white circular pills on the bedside table in Resident B's room and then walked out, allowing the resident to self-administer the medication. During an interview, Resident B confirmed that the pills were Methadone and that they always took the medication independently. The LPN admitted to walking away from the resident during medication administration and acknowledged that there was no self-administration order for the resident. Resident B's medical record indicated diagnoses including end-stage renal disease, diabetes, hypertension, and renal dialysis, with a cognitive status noted as intact. A Physician's Order dated prior to the incident specified the administration of Methadone HCl, a narcotic pain medication, but did not include any orders for self-administration. Additionally, there were no assessments completed for the resident's self-administration of medications. The facility's policy required that self-administration of medications be determined by the Interdisciplinary Team, which was not adhered to in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff for activities of daily living. During an interview, the resident reported not being checked or changed every two hours and stated they had not been changed all day. Observations confirmed that the resident's brief was saturated with urine, and the bath blanket underneath was wet. The resident indicated that this was the first time they were changed for the day, with the last change occurring around 2:00 a.m. The resident's record showed diagnoses including morbid obesity, cellulitis, and heart failure, and the resident was cognitively intact but dependent on staff for toilet transfers and frequently incontinent. The care plan required assistance with ADLs, including toileting. Interviews with staff revealed that the assigned CNA had not provided incontinence care, relying on the resident to request changes. The Director of Nursing acknowledged that care should have been provided more timely, and the facility's policy required necessary services for toileting and elimination.
Failure to Follow Treatment Orders for Non-Pressure Skin Condition
Penalty
Summary
The facility failed to ensure that treatments were completed as ordered for a resident with a non-pressure skin condition. During an observation, it was noted that the resident had a hydrocolloid bandage on the left ischial area, which was dated a day prior. The CNA and LPN present confirmed the date on the dressing. However, the resident's medical record indicated a physician's order for a different treatment: cleansing the area with normal saline or wound cleanser, applying betadine, and leaving it open to air daily. This treatment was documented as completed on the day the hydrocolloid dressing was observed, despite no order for such a dressing being present. The resident, who was cognitively intact and dependent on staff for toilet transfers, had a history of morbid obesity, cellulitis, and heart failure. The wound was identified as non-pressure and resulting from trauma, with specific instructions for betadine application. A subsequent review by the wound physician led to a new order for hydrocolloid dressing, but this was after the initial observation. The Director of Nursing acknowledged that the treatment should have been completed as originally ordered.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to ensure fall interventions were in place for a resident with a history of falls. Resident H, who was moderately impaired for daily decision-making and dependent on staff for transfers and bed mobility, was observed in their room with the bed positioned at medium height instead of the lowest position as required by their care plan. The care plan, dated 1/22/24 and reviewed on 6/1/24, indicated that the bed should be in the lowest position to prevent falls. However, observations on 8/14/24 and 8/15/24 showed the bed was not consistently in the low position, and the resident was able to adjust the bed height on their own. The resident had a history of falls, including an incident on 7/29/24 where they fell out of bed while reaching for the trash can. On 8/3/24, the resident was found on the floor with a one-inch laceration next to the left eyelid, requiring emergency room evaluation and sutures. During an interview, CNA 2 indicated that the bed could go lower but was not lowered all the way to prevent the resident's foley catheter drainage bag from touching the ground. Nurse Consultant 1 acknowledged that the bed should be in a low position and mentioned updating the care plan to reflect the resident's ability to adjust the bed height.
Improper Placement of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, leading to a deficiency. Resident F, who has a history of urinary tract infections and uses a suprapubic catheter, was observed with their catheter drainage bag placed on the floor on multiple occasions. The resident reported that the midnight shift did not empty the drainage bag or remove it from the floor. Despite the resident's request for a wash basin to prevent the bag from resting on the floor, this was initially denied. Observations on consecutive days confirmed that the drainage bag was either full or had been emptied but remained on the floor. The resident's medical records indicated a diagnosis of acute pyelonephritis and neuromuscular dysfunction of the bladder, with a care plan that included positioning the catheter bag below the bladder level. However, there was no specific care plan addressing the issue of the drainage bag being placed on the floor. The resident was receiving antibiotic treatment for a urinary infection, and nurses' notes documented the resident's preference for placing the bag on the floor for better drainage. The Director of Nursing acknowledged the lack of prior documentation regarding the resident's request for a wash basin.
Incomplete Insulin Administration Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented regarding insulin administration for a resident with type 2 diabetes and vascular dementia. The resident's care plan indicated a risk for complications related to diabetes, with interventions including diabetes medication as ordered by the physician. A physician's order specified that the resident was to receive Lantus insulin 10 units at bedtime. However, the Medication Administration Record (MAR) for July 2024 showed that the insulin was not signed out as administered on four specific dates. During an interview, the Director of Nursing (DON) revealed that a Qualified Medication Aide (QMA) was working the hall and could not administer the insulin, and the nurse on duty who administered the insulin did not sign it out on the MAR. The facility's medication administration policy required the individual administering the medication to initial the MAR after giving each medication.
Failure to Report Allegations of Abuse in Memory Care Unit
Penalty
Summary
The facility failed to ensure that employees reported allegations of abuse by an employee towards residents in the Memory Care Unit to the Administrator. This failure potentially affected 18 residents. During interviews, it was revealed that Employee 7 was accused of making fun of residents, using derogatory names, and threatening other staff members to prevent them from reporting her actions. Terminated Employee 6 reported that Employee 7 would use foul language, refuse to provide care, and make residents feel unwanted by their families. Despite these allegations, Terminated Employee 6 claimed that when she reported the abuse to the DON, her hours were cut, and her holiday pay was removed, and she was told to report it to the DON instead of the Administrator. The DON denied receiving any reports of abuse from Terminated Employee 6 and stated that any reported abuse would have been escalated to the Administrator and the Indiana Department of Health for investigation. The Administrator confirmed that she was only made aware of the allegations on the day of the interview and had initiated a full investigation. The facility's abuse policy requires employees to report any incidents or suspicions of abuse to the Administrator immediately, without fear of retaliation, and allows them to report directly to the state survey agency. The report relates to specific complaints filed against the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,090 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hobart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Hobart Skilled Nursing Facility, The | 2 mi | ★★★★★ | 0 | 0 |
| Aperion Care Tolleston Park | 4.3 mi | ★★★★★ | 31 | 0 |
| Lincolnshire Health & Rehabilitation Center | 4.5 mi | ★★★★★ | 38 | 0 |
| Spring Mill Health Campus | 5 mi | ★★★★★ | 21 | 0 |
| Brickyard Healthcare - Merrillville Care Center | 5.1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.