Casa of Hobart

In the surveyor’s words

From the most serious findings on record at Casa of Hobart, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 23, 2026

  Based on record review and interview, the facility failed to initiate and update effective resident-specific interventions to prevent the elopement from the facility of a recently admitted resident with a diagnosis of schizophrenia, a court-appointed guardian and history of running away for 1 of 4 residents reviewed for elopement risk. The resident signed out of the building and exited through the main front door entrance. The nursing staff was unaware of the resident's whereabouts. The resident ambulated approximately 1.5 miles from the facility on a highly traveled road that had no sidewalks. The fire department was dispatched to a private residence after the resident knocked on their door and transported the resident to the hospital. […]

• Immediate jeopardy, isolatedF693Dec 12, 2023

  Based on record review and interview, the facility failed to implement measures to ensure a moderately impaired dependent resident was not lying flat in bed while an enteral (administered into the gastrointestinal tract) tube feeding was infusing, which led to labored breathing, audible crackle lung sounds, projectile vomiting, unresponsiveness, intubation, and ultimately death for 1 of 3 residents reviewed for tube feeding. (Resident B) The immediate jeopardy began on [DATE] when the resident was observed several times by staff during the early and late morning hours with the head of bed flat and the enteral tube feeding infusing. […]

• Actual harm, isolatedF686Mar 27, 2024

  Based on observation, record review and interview, the facility failed to ensure services to prevent the development of pressure injuries were effectively provided to Resident D, who was admitted to the facility without a pressure ulcer and developed a facility-acquired unstageable pressure ulcer (pressure ulcer known but not stageable due to coverage of wound bed by slough and/or eschar) and also failed to ensure services were provided to Resident E, who developed a facility-acquired stage three (full thickness tissue loss) pressure ulcer, in accordance with the physician orders, for 2 of 3 residents reviewed for pressure ulcers. […]

• Actual harm, isolatedF686Jul 2, 2021

  Based on observation, record review, and interview, the facility failed to ensure pressure relieving devices were in place and the resident's foot was repositioned from against the foot board which resulted in an acquired deep tissue injury pressure ulcer to the bottom of the left lateral foot for 1 of 3 residents reviewed for pressure ulcers. (Resident 23) Finding includes: On 6/27/21 1:45 p.m., Resident 23 was observed in bed. At that time, his left foot was pressed against the foot board of the bed and was laying directly on the mattress. His foot was not elevated, nor was there any pressure relieving devices under the foot. The resident had a specialty air mattress on his bed. On 6/28/21 at 10:00 a.m., the resident was observed in bed. […]

• No harm, potential for more than minimal, widespreadF867Nov 2, 2023

  Based on record review and interview, the facility failed to identify unresolved quality deficiencies, some of which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process, as evidenced by the number of repeated deficiencies cited for pressure ulcers related to not completing treatments as ordered and not completing weekly wound assessments. This deficient practice had the potential to affect 94 of 94 residents residing in the facility. […]