The Nicol Home

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 28, 2022

  The facility identified a census of 26 residents, with three reviewed for falls. Based on observation, record review, and interview the facility failed to ensure Resident (R) 1 was free from falls when facility staff failed to follow R1's care plan for two staff assistance with bathing. On 11/16/22 at approximately 07:05 PM, Certified Nurse's Aide (CNA) M assisted R1 in the shower. R1 was in the shower chair when CNA M turned to get wash cloths and left R1 alone on the shower chair, which led to R1 falling off of the shower chair and sustaining a laceration to the top of her scalp measuring 2.2 centimeters (cm) by 2.3 cm. R1 was transported to the emergency department and it was determined that R1 sustained a subdural hematoma (collection of blood on the surface of the brain). […]

• No harm, potential for more than minimal, widespreadF851Jul 31, 2024

  The facility had a census of 30 residents. The sample included 13 residents. Based on the interview and record review, the facility failed to submit complete and accurate information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit accurate staffing hour date for all direct care personnel as required. This placed the residents at risk for unidentified issues with inadequate staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2024 Quarter 2 documented the metric for Registered Nurse (RN) hours and Licensed Nurse (LN) Coverage 24hours/Day was suppressed for the facility and quarter. […]

• No harm, potential for more than minimal, widespreadF881Mar 31, 2021

  The facility had a census of 29 residents. Based on interview and record review, the facility failed to consistently utilize an antibiotic stewardship program that included tracking and monitoring of infections and antibiotic use. Findings included: - Review of the facility's January, February, and March 2021 Infection Control Surveillance log and infections mapping revealed they had not been completed. The log contained columns for the identified resident, the resident room, infection site, notification to family and physician, lab or x-rays involved, organism name, antibiotic name and start, type of infection precautions, catheter use, community or facility acquired, and if the infection met criteria for treatment. […]

• No harm, potential for more than minimal, patternF628Jun 10, 2026

  Based on observation, record review, and interview, the facility failed to provide a written notice for a transfer for Resident (R)5, R7, and R26 (or their representatives) when they were transferred to the hospital or the bed hold policy. The facility also failed to complete a discharge summary with a recapitulation (a concise medical document required during discharge from a long-term care facility or nursing home. It summarizes the resident's course of treatment, diagnoses, and medical progress) of R33's stay when R33 was discharged from the facility. […]

• No harm, potential for more than minimal, patternF656Jul 31, 2024

  The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan that addressed the individual resident needs for Resident (R)17, R12, R5, R13, and R26. This placed the residents at risk for impaired care due to uncommunicated needs. Findings included: - R17's Electronic Medical Record (EMR) documented diagnoses of muscle weakness, fluency (speech) disorder following nontraumatic subarachnoid hemorrhage (bleeding in the space just outside the brain), atrial fibrillation (rapid, irregular heartbeat), major depressive disorder (major mood disorder which causes persistent feelings of sadness), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made… […]