Inspection Reports for
The Waters of Hobart Skilled Nursing Facility

The facility failed to ensure medications were properly labeled and stored on two medication carts and in resident rooms. Additionally, the facility did not follow proper infection control procedures for cleaning a shared glucometer before and after use.

The facility had multiple deficiencies including failure to ensure proper medication orders and assessments for self-administration, incomplete physician notification of medication refusals, inaccurate Minimum Data Set assessments, inadequate care for dependent residents, delayed medical follow-up, improper respiratory care oxygen flow rates, incomplete monitoring of unnecessary medications, improper medication labeling and storage, unsafe food storage and sanitation practices, incomplete infection monitoring documentation, inadequate infection control practices for glucometer cleaning, and environmental maintenance issues.

The inspection relates to Complaints IN00440342 and IN00443034, involving issues with pressure ulcer care, feeding tube care, dialysis communication, medical record documentation, and infection control.

The facility failed to provide appropriate pressure ulcer treatment, ensure feeding tube placement checks and documentation, maintain communication with dialysis centers, accurately document medical records, and enforce infection prevention protocols including proper use of Personal Protective Equipment (PPE).

This visit was triggered by complaints IN00440342 and IN00443034. Deficiencies cited were related to allegations in these complaints, including pressure ulcer care, feeding tube management, dialysis communication, medical record documentation, and infection control.

The facility was found deficient in multiple areas including failure to provide appropriate treatment for pressure ulcers, failure to follow physician orders for feeding tube care, lack of communication with dialysis center regarding resident location, incomplete and inaccurate medical record documentation, and failure to ensure proper use of personal protective equipment for residents on Enhanced Barrier Precautions.

The facility was found not in compliance with Life Safety Code requirements due to deficiencies including missing ceiling tiles in the maintenance storage room, annular space around sprinkler heads in a resident bathroom, smoke passage issues with medicine room doors, exposed electrical wiring and unsecured electrical panels. Corrective actions were taken promptly and plans for ongoing monitoring were established.

The facility had multiple deficiencies including failure to ensure proper medication self-administration orders, inadequate assistance with activities of daily living, improper medication administration, lack of appropriate assessments and care plans, incorrect oxygen flow rates, improper catheter care, and environmental cleanliness issues.

The facility was found deficient in multiple areas including medication self-administration orders, transfer and discharge notices, ADL care, quality of care related to bruising and medication administration, foot care, range of motion management, bowel/bladder catheter care, tube feeding management, respiratory care, nurse staffing posting, and environmental conditions.

This citation relates to Complaint IN00428486.

The facility failed to ensure physician's orders for monitoring an external cardiac device were followed for one resident. Additionally, the facility failed to ensure infection control guidelines were implemented, including proper use of personal protective equipment (PPE) in isolation rooms for residents with infectious diseases.

Complaint IN00428486 was substantiated with federal/state deficiencies cited at F684 related to the allegations.

The facility failed to ensure physician's orders for monitoring an external cardiac device were followed for 1 resident. Additionally, infection control guidelines were not properly implemented, including failure to wear required PPE and perform hand hygiene in isolation rooms.

The citation relates to Complaint IN00424611 concerning medication administration errors and pharmacy service failures.

The facility failed to ensure pharmacy services were provided as ordered for one resident, resulting in missed pain medication doses. Additionally, the medication error rate exceeded 5%, with errors observed during medication passes. Infection control deficiencies were also noted related to hand hygiene during medication administration and wound care.

Complaint IN00424611 was substantiated with federal and state deficiencies cited at tags F755 (pharmacy services) and F759 (medication errors).

The facility was found deficient in pharmacy services related to failure to provide scheduled pain medication for one resident, a medication error rate exceeding 5% for two residents during medication pass, and failure to implement proper infection control measures including hand hygiene during medication administration and wound care.

Complaint IN00421593 was investigated and no deficiencies related to the allegations were cited. An unrelated deficiency regarding pain management was cited.

The facility failed to ensure adequate pain management for one resident (Resident B), including lack of monitoring for signs of narcotic withdrawal, incomplete pain assessments, and lack of non-pharmacological interventions. The resident's opioid medication was discontinued without adequate follow-up on pain control or withdrawal symptoms.

The complaint investigation found that the resident's pain was not adequately managed, with substantiated issues including discontinued opioid medication without proper monitoring, lack of non-pharmacological interventions, and incomplete pain assessments.

The facility failed to ensure appropriate pain management for one resident, including lack of monitoring for narcotic withdrawal signs, ineffective medication management, absence of non-pharmacological interventions, and incomplete pain assessments.

This visit was triggered by multiple complaints (IN00409913, IN00411506, IN00412700, IN00413008, IN00413907, IN00415513, IN00416438) alleging various deficiencies related to resident care, medication administration, fall management, pressure ulcer care, and pharmacy services.

The facility was found deficient in multiple areas including honoring resident medication preferences, timely assistance with activities of daily living, quality of care related to falls, pressure ulcer care, intravenous fluid management, and pharmacy services including narcotic medication documentation.

The inspection relates to multiple complaints including IN00409913, IN00412700, IN00413008, IN00411506, IN00415513, IN00416438, and IN00413907. Complaints involved medication administration timing, incontinence care, fall management, pressure ulcer care, IV catheter monitoring, and narcotic medication documentation.

The facility failed to honor a resident's medication timing preference, provide timely incontinence care, promptly assess and notify physicians after falls, ensure proper pressure ulcer treatment, monitor and maintain IV catheter care, and maintain accurate narcotic medication documentation. These deficiencies affected multiple residents and posed risks of harm.

The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code requirements including means of egress obstructions, exit door impediments, hazardous area door self-closing devices, fire alarm and sprinkler system policies, ceiling penetrations affecting sprinkler operation, unsecured electrical panels, HVAC corridor return air issues, and improper use of power strips.

The facility was found deficient in multiple areas including medication self-administration assessments and orders, care for activities of daily living, resident-centered activities, treatment and monitoring of diabetic ulcers and bruises, respiratory care including oxygen administration, pain management, medication management including insulin administration and monitoring, laboratory result notification, kitchen sanitation, and infection prevention and control related to COVID-19 screening.

The facility was found deficient in multiple areas including medication self-administration, ADL care, activities programming, quality of care related to skin and respiratory treatments, pain management, unnecessary drug use, lab services notification, food safety, and infection control including COVID-19 protocols.

The investigation was triggered by Complaints IN00385701 and IN00396036. Complaint IN00385701 related to medication self-administration assessment failure. Complaint IN00396036 related to pressure ulcer care and treatment deficiencies.

The facility failed to ensure a medication self-administration assessment was completed before leaving medications at the bedside for one resident. Additionally, care plan interventions and treatment orders for pressure ulcers were not in place or updated for two residents at risk or with pressure ulcers.

Complaint IN00385701 related to medication self-administration assessment failure. Complaint IN00396036 related to inadequate pressure ulcer care and assessment.

The facility failed to ensure a medication self-administration assessment was completed before leaving medications at the bedside for one resident. Additionally, the facility did not provide appropriate pressure ulcer care or update care plans for residents at risk, failing to assess and treat new pressure ulcers for two residents.