Inspection Reports for
Naomi Heights Nursing & Rehabilitation Center

The facility was found deficient in multiple areas including failure to deliver resident mail on Saturdays, inadequate care for residents unable to perform ADLs (specifically nail and oral care), hot water temperatures exceeding safe limits in multiple bathrooms, failure to ensure proper dialysis communication and assessment, improper food storage and labeling, and failure to administer influenza vaccine to a resident upon admission.

The complaint investigation revealed Resident #2 did not receive incontinence care from 10:40 a.m. until 6:44 p.m. on 01/13/2025, violating physician orders and care plans. Additionally, Resident #1 fell from a mechanical lift on 03/27/2025 due to improper sling size and incorrect sling attachment by CNAs, resulting in serious injury. The immediate jeopardy was abated after corrective actions including staff training, counseling, and monitoring.

The facility failed to provide incontinence care every two hours to Resident #2 as ordered, resulting in minimal harm. Additionally, the facility failed to ensure proper use of a mechanical lift during transfer of Resident #1, resulting in a fall causing a displaced femur fracture and subarachnoid hemorrhage, constituting immediate jeopardy. Corrective actions were implemented and the immediate jeopardy was abated.

The facility failed to timely transmit a Minimum Data Set (MDS) assessment for one resident, did not provide adequate grooming assistance to a resident, failed to maintain proper food storage practices, and did not implement required Enhanced Barrier Precautions or proper hand hygiene during wound care for several residents.

The facility failed to ensure that resident care equipment, specifically feeding pumps, was kept clean for one resident receiving tube feeding. Additionally, the facility failed to implement the care plan for another resident by not assisting with meals and not providing Ensure as ordered.

The facility failed to ensure a safe, clean, and homelike environment for 3 of 5 sampled residents, including cluttered rooms with unmade beds and broken window sills. Additionally, the facility failed to resolve grievances for 1 of 5 sampled residents, with no grievance forms documented despite family complaints.

The complaint investigation substantiated that Resident #5 was physically abused by S4 CNA on 02/01/2023. Resident #5 suffered physical injuries and psychosocial harm. The facility took corrective actions including staff in-service, termination of the CNA, notification of responsible parties, and implementation of monitoring procedures.

The facility failed to protect Resident #5 from physical abuse by S4 CNA, resulting in actual harm including a scalp laceration, abrasion, bruising, and psychosocial harm. The abuse was confirmed through interviews, clinical record reviews, and physical evidence. Corrective actions were implemented prior to the State Agency's investigation.

The visit was complaint-related due to multiple incidents of resident elopement and failure to notify appropriate parties and supervise residents at risk. Immediate jeopardy was identified and later removed after corrective actions.

The facility failed to immediately notify physicians and family members after elopement incidents for multiple residents, failed to report elopements to the State Survey Agency timely, failed to properly assess elopement risk for Resident #1, and failed to adequately supervise residents at risk for elopement, resulting in multiple unsupervised exits from the facility. Immediate jeopardy was identified and later removed after the facility implemented corrective actions including staff in-services, monitoring, and changes to the wander alert system.