Pope Nursing Home

In the surveyor’s words

From the most serious findings on record at Pope Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Apr 9, 2026

  Based on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to provide the services of an RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place on 4 of 92 days during the period of 10/1/25 through 12/31/25. […]

• No harm, potential for more than minimal, widespreadF801Apr 22, 2025

  Based on document review and interview, the facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD). Specifically, the facility did not employ a full-time dietician or have a qualified dietary employee in the facility who met the minimum qualifications to serve as FSD from 11/20/24 to throughout the survey period. Findings include: During an interview on 4/17/25 at 10:23 A.M., the Line [NAME] said the Certified Dietary Manager (CDM) had been out on leave for approximately four months now. The Line [NAME] said she was just a cook and did not possess the education or training to be the interim CDM while the CDM was out. She said the Dietician was only part-time and worked two days a week. […]

• No harm, potential for more than minimal, widespreadF838Apr 22, 2025

  Based on interviews, the facility staff failed to comprehensively assess the facility resources needed to provide sufficient support and care for the resident population and develop a Facility Assessment as required. Findings include: During an interview on 4/18/25 at 12:32 P.M., the Administrator said he was unable to find a Facility Assessment document. He said he doesn't know if there is one because they have never reviewed it in their Quality Assurance Performance Improvement meetings. During an interview on 4/22/25 at 2:21 P.M., the Director of Nursing said she and the Administrator had thoroughly searched all of their documentation and said the facility had not conducted and developed a Facility Assessment document.

• No harm, potential for more than minimal, patternF658Apr 9, 2026

  Based on observation, document review, and interview, the facility failed to ensure professional standards of practice were maintained when administering medications for one Resident (#44), out of a total sample of 12 residents and for three Residents (#36, #26, and #25), out of five residents observed during medication administration. Specifically, the facility failed to ensure:1. For Resident #44, an order for Guaifenesin Extended Release (ER) 12-hr 600 milligrams (mg) (extended release expectorant to relieve chest congestion and mucus) twice daily via Gastrostomy Tube (G-Tube: a medical device inserted through the abdominal wall into the stomach to deliver food, fluids, and medications) was clarified to a formula that could be crushed and administered via the G-Tube; and 2. […]

• No harm, potential for more than minimal, patternF759Apr 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate of 5% or greater when one of two nurses made five errors out of 33 opportunities, totaling a medication error rate of 15.15%. These errors impacted three Residents (#36, #26, and #25), out of five residents observed. Specifically:1. For Resident #36, Zyprexa (antipsychotic) was omitted and signed as administered;2. For Resident #26, Celexa (antidepressant) and Preservision AREDS (eye vitamins) were omitted and signed as administered; and3. For Resident #25, Artificial Tears and Erythromycin Ointment (antibiotic ointment) were omitted and signed as administered. […]