Hobart Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a comprehensive assessment accurately reflected wandering/exit seeking behavior for 1 (#1) of 3 sampled residents reviewed for comprehensive assessments. The DON identified 37 residents resided in the facility.Findings:On 04/23/26 at 1:26 p.m., Resident #1 was observed in their room in bed. A housekeeper was observed seated outside of the resident's room providing one on one supervision with a clip board to document the resident's one on one supervision.On 04/28/26 at 1:36 a.m., Resident #1 was observed in their room in bed. Driver #1 was observed outside the room in a chair to perform one on one supervision with a log on a clip board to document the resident's location hourly. A nurses note for Resident #1, dated 03/25/26, showed the resident attempted to exit the facility and had to be redirected back to their room. A comprehensive assessment for Resident #1, dated 03/29/26 showed the resident had a BIMS score of 4 which indicated their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have an adequate hot water supply to ensure showers were conducted as scheduled for 3 (#2, 6, and #7) of 3 sampled residents reviewed for showers. The DON reported 35 residents resided in the facility. Findings: A Resident Showers policy, dated 04/15/24, read in part, Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. 1. Resident #2 had diagnoses which included paraplegia. The resident was admitted to the facility on [DATE]. The resident discharged from the facility on 02/23/25. A monthly shower record for December 2024 showed 13 scheduled showers. The shower record showed three showers were given (12/03, 12/10, and 12/12), eight showers were not given (12/05, 12/07, 12/14, 12/17, 12/24, 12/26, and 12/28) and two showers were refused (12/19 and 12/21). A quarterly assessment, dated 01/25/25, showed Resident #2's cognition was intact with a BIMS score of 15. The assessment showed they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide adequate supervision and interventions to prevent elopement for 1 (#1) of 3 sampled residents reviewed for elopement. The DON reported 35 residents resided in the facility. The elopement book at the nurses station identified seven residents at risk for elopement. Findings: A policy titled Elopements, dated 08/01/21, read in part,Staff shall investigate and report all cases of missing residents. Resident #1 was admitted to the facility on [DATE] with diagnoses which included dementia and depression. An elopement risk assessment, dated 02/28/25, showed no risk for elopement. A progress note, dated 03/02/25 at 8:35 a.m., showed Resident #1 was found outside sitting in the grass across from the parking lot. The note showed the resident was assisted back into the facility. The note also showed the resident had scrapes on both knees and a red area to the right cheekbone. A incident report, dated 03/02/25, showed Resident #1 was observed outside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to maintain a home like environment by ensuring: a. the tile was in good repair around a toilet to prevent odors; b. the wall was in good repair; and c. the lighting was sufficient in one bathroom of 16 bathrooms observed for a homelike environment. The DON identified 38 residents resided in the facility. Findings: A Homelike Environment policy, revised 05/17, read in part, .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility and reflect a personalized, homelike setting, these characteristic include .Clean, sanitary, and orderly environment .Pleasant, neutral scents .Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable, and home like environment. The lighting design emphasizes: a. Sufficient general lighting in resident-use areas . On 03/24/24 at 10:46 a.m., the following observations were made in a room on the 200 hall: a. the tile around toilet was cracked, raised, and soft to the touch with a strong…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure a qualified staff administered a resident's breathing treatment for one (#140) of one sampled resident observed for breathing treatments. The DON identified 38 residents resided in the facility. Three residents had orders for nebulizer breathing treatments in the facility. Findings: Resident #140 had diagnoses which included chronic obstructive pulmonary disease and chronic diastolic heart failure. A physician's order, dated 03/18/24, documented albuterol sulfate inhalation nebulization solution 2.5 mg per 3 ml give 1 vial via mask every four hours related to chronic obstructive pulmonary disease. On 03/24/24 at 10:18 a.m., Resident #140 had their call light on to start their breathing treatment. CNA #1 walked in and turned on the Resident's nebulizer machine. They left the room. A mist started flowing through the Resident's handheld mouthpiece. On 03/24/24 at 10:20 a.m., Resident #140 stated the nurse had put the medication in the handheld device earlier that morning. Resident #140 coughed multiple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to care plan and ensure a resident was assessed for the use of bed rails prior to installation for one (#29) of four sampled residents reviewed for physical restraints. The DON identified 38 residents resided in the facility and 19 residents used bed rails or assist bars. Findings: The Proper Use of side Rails policy, revised 12/16, read in part, .An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails .The use of side rails as an assistive device will be addressed in the resident care plan . Resident #29 had diagnoses which included dementia and cerebral infarction. On 03/25/24 at 9:16 a.m., Resident #29 was observed in bed with full upper bed rails up on each side of the bed. A Care Plan, dated 01/01/24, did not document the the use of bed rails. On 03/26/24 at 11:05 a.m., LPN #2 stated Resident #29's bed rails were up. They stated the bed rails were used for positioning. On 03/26/24 at 11:06 a.m., LPN #2 stated there should be a resident assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure medications were locked when not attended for two (treatment carts) of four carts observed for medication storage. The DON identified two medication carts and two treatment carts. Findings: A Medication Storage In The Facility policy, revised 01/18, read in part, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations .The medication supply is accessible only to licensed nursing personnel .or staff members lawfully authorized to administer medications . On 03/24/24 at 9:21 a.m., two carts were observed unlocked on a hallway. One cart had insulin medications, insulin needles, insulin syringes and glucometers. The other cart had pain topical creams, breathing treatments, and wound care supplies. There were five residents in the vicinity of the two carts and no staff present. On 03/24/24 at 9:28 a.m., CNA #1 went by the two carts and locked them. CNA #1 stated the two carts were unlocked. On 03/24/24 at 9:30 a.m., LPN #1 stated the two carts were treatment carts.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure residents were informed, with a signed acknowledgment from the resident, of items and services for which the resident might be charged for skilled services, for three (#2, #19 and #37) of three residents sampled for beneficiary notification review. The Administrator reported 18 residents who had discharged from skilled services in the last six months. Findings: The clinical record for Resident #2 documented the resident was admitted to skilled services on 08/02/22 and was discharged on 12/16/22. The Advanced Beneficiary Notice (ABN), form CMS-10055, was not signed by the resident or their representative. The clinical record for Resident #19 documented the resident was admitted to skilled services on 01/06/23 and was discharged on 01/31/23. The ABN, form CMS-10055, was not signed by the resident or their representative. The clinical record for Resident # 37 documented the resident was admitted to skilled services on 07/21/22 and was discharged on 12/16/22. The ABN. form CMS-10055, was not signed by the resident or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a discharge summary for one (#42) of one resident reviewed for discharge. The Resident Census and Conditions of Residents, documented a census of 38 residents. Findings: Resident #42 was admitted to skilled services on 12/01/22. The record documented the resident was discharged to home on [DATE]. A physician progress note, dated 12/06/22, documented the resident lived alone but would like to get strong enough to go home. The clinical record was reviewed and no documentation of a discharge summary was found in the record. On 02/09/23 at 4:13 p.m., the regional Registered Nurse reviewed the clinical record and reported a discharge summary was not completed as required.

Based on record review and interview, the facility failed to reduce a psychoactive medication, per physician orders, for one (#16) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: A facility policy, Medication Monitoring and Management, revised on January 2018, documented in parts, .During the first year in which a resident is admitted on a psychopharmacological medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has initiated such medication, the facility attempts a GDR [gradual dose reduction] during at least two quarters (with at least one month between the attempts), unless clinically contraindicated . The clinical record for Resident #16 documented the resident was admitted with a diagnosis of insomnia. Resident #16's Physician Orders, dated 10/07/22, included Trazodone HCL (hydrochloride) tablet 50 mg (milligram), give one tablet at bedtime by mouth, related to insomnia. A Consultant Pharmacist/Physician Communication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.