Homestead Rehabilitation & Health Care Center

NJ Complaint#: NJ0018771Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident abuse between Certified Nursing Assistant (CNA #1) and Resident #29 that occurred on 2/2/25 and a Licensed Practical Nurse (LPN#1) that appeared intoxicated when reporting to work on 7/2/25. This deficient practice was identified for 1 of 2 reported complaints reviewed.On 6/26/25 the NJDOH received an anonymous complaint from an employee of Homestead Rehabilitation and Health care Center. The employee claimed there was an issue with quality of care specifically citing, an allegation of staff to resident abuse from a CNA (name detached) which had resulted in injury as well as a nurse being intoxicated when reporting to work.On 7/17/25 at 10:04 AM, the surveyor reviewed the employee files for CNA#1 and LPN#1. A review of CNA#1's employee file revealed a Facility Reported Incident dated 5/23/25 at 3:00 PM revealed a staff member reported to the Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint #: NJ184361 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure care plan interventions were implemented for a resident's skin integrity. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #67), and was evidenced by the following:The surveyor reviewed the closed medical record for Resident #67. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia, heart failure, need for assistance with personal care, and major depressive disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/11/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated a severely impaired cognition. A further review revealed that the resident needed partial assistance from another person to complete activities of daily living (ADLs).A review of the individualized comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and review of pertinent facility documents, the facility failed to ensure a resident who required assistance for bathing received a shower upon admission to the facility and on their scheduled shower day. This deficient practice was identified for 1 of 3 residents reviewed for activities of daily living (Resident #67), and was evidenced by the following:The surveyor reviewed the closed medical record for Resident #67. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia, heart failure, need for assistance with personal care, and major depressive disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/11/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated a severely impaired cognition. A further review revealed that the resident needed partial assistance from another person to complete activities of daily living (ADLs). A review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during wound care treatment for 1 of 2 Residents (Resident #2) reviewed for care and services for pressure ulcers.This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to (a) ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing and (b) ensure a system was in place for the accurate acquiring, receiving, and dispensing of medications in accordance to professional standards of practice. This deficient practice was identified for 2 (two) of 4 (four) residents (Resident #33 and Resident #42) observed during the medication observation pass and had the potential to affect all residents. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: The surveyor reviewed the closed medical record for Resident #67.A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia, heart failure, need for assistance with personal care, and major depressive disorder.A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated a severely impaired cognition. A further review revealed that the resident needed partial assistance from another person to complete activities of daily living (ADLs).A review of the individualized comprehensive care plan (ICCP) included a focus area dated effective [DATE], for requiring increased assistance with ADL function due to debility due to recent hospitalization, impaired mobility, cognitive deficit with poor safety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop and maintain an infection prevention and control program (IPCP) that included all of the required elements, the facility failed to review the IPCP policy on an annual basis b.) failed to follow infection control procedures with 2 of 3 residents on Oxygen (O2) Therapy. This deficient practice was identified for 2 of 3 residents (Resident #4 and #8) reviewed for O2 therapy.This deficient practice was evidenced by the following: 1.The Surveyor reviewed the facility's IPCP policy which reflected that the policy did not include A system of surveillance which is designed to identify possible infections before they spread to other residents in the facility; who possible infections should be reported to; and failed to document the requirements for the isolation of a resident. A review of the facility's IPCP policy reflected that it was last reviewed January 2024. On 7/24/25 at 10:15 AM, during an interview with the surveyor, the Director of Nursing (DON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure handrails were secure and intact on 1 of 2 resident units (observed on 3rd floor nursing unit). This deficient practice was evidenced by the following:On 07/21/25 at 9:12 AM, the surveyor was observing medication administration pass on the 3rd floor low-side and observed two handrails that were missing the return part (end part of the handrail) which was located next to room [ROOM NUMBER] and room [ROOM NUMBER]. The missing return part of the handrail exposed a screw and metal components that attached the handrail to the wall.On 07/22/25 at 10:30 AM, the surveyor interviewed a Licensed Practical Nurse (LPN#1) on the 3rd floor low side, who in the presence of the surveyor observed the handrail missing the return part. At that time, LPN#1 stated that the handrail that was missing the return part was a potential hazard to the resident's because it exposed the residents to a sharp object (screw…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ #00174902; NJ00174912; NJ00174921 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe and comfortable room temperature levels for residents in 2 of 3 nursing units (Second and Third Floor). This deficient practice was identified on 06/20/24 and was evidenced by the following: 1.On 06/20/24 at 9:51 a.m., the surveyor in the presence of the Maintenance Person (MP) checked the temperatures on the Second floor and the following were obtained: room [ROOM NUMBER] - room temperature of 82.4 degrees Fahrenheit; occupied; resident has a working desk fan; air conditioner (AC)/radiator working with low air coming out; resident not in distress. room [ROOM NUMBER] - room temperature of 83.3 degrees Fahrenheit; occupied; resident has a working desk fan; AC/radiator working with low air coming out; water pitcher at bedside; resident not in distress. room [ROOM NUMBER] - room temperature of 84.2 degrees Fahrenheit; occupied;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to assure that the physician responsible for supervising the care of residents completed monthly progress notes . This deficient practice continued over several months for 15 of 16 residents reviewed, Resident #18, #19, #58, #117, #10, #20, #38, #56, #61, #64, #42, #50, #1, #12 and #16 reviewed for physician progress notes and current physician orders. This deficient practice was evidenced by the following: 1. On 3/07/24 at 10:41 AM, the surveyor reviewed Resident #18's hybrid medical records. Review of Resident #18's admission Record (AR) reflected that Resident #18 was admitted to the facility with medical diagnoses that included but were not limited Systemic Lupus Erythematosus, Sepsis, Major Depressive Disorder, Cirrhosis of Liver, and Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris Review of the Medical Progress Notes (PN) written by Physician #1, from 2/8/24 to 3/7/24 were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store, label, and discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 3/4/24 at 09:25 AM, the surveyor in the presence of the Certified Dietary Manager (CDM) observed the following during the kitchen tour: 1. During the kitchen inspection, the surveyor observed on the inside of the 3 door refrigerator, individual 2 ounce (oz) condiment cups with parmesan cheese without open or use by labels. The surveyor also observed a gallon of whole milk as well as a gallon of fat-free milk and a 1/2 gallon of 2% milk container, all opened without open or use by dates. The CDM explained that the facility goes by the expiration dates printed on the large containers of parmesan cheese and the use by dates on the milk containers to evaluate their freshness. The CMD agreed that all products when opened should have an open and use by date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility staff interviews and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) had completed specialized training in infection prevention and control and was qualified by certification and experience for 1 of 1 staff member reviewed in accordance with Center for Medicare and Medicaid Services (CMS) and New Jersey State guidelines. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following: ii. Required Core Practices for Infection Prevention and Control: Facilities are required to have one or more individuals with training in infection prevention and control employed or contracted on a full-time basis or part-time basis to provide on-site management of the Infection Prevention and Control (IPC) program. The requirements of this Directive may be fulfilled by: a. An individual certified by the Certification Board of Infection Control and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices to decrease the possibility of spreading infection during medication administration and failed to ensure that the sharps container (SC) that were filled with contaminated sharps/needles were disposed properly, for 3 of 3 units reviewed for infection control practices. This deficient practice was evidence by the following: 1. On 3/7/23 at 10:06 AM, the surveyor observed Licensed Practical Nurse # 2(LPN#2) perform a wound treatment to Resident #1. LPN #2 went to wash her hands at the sink in the resident's room after entering the resident's room. LPN #2 turned on the faucet, wet her hands with water from the sink, applied soap, lathered her hands for 16 seconds outside the running water prior to rinsing, dried her hands with a paper towel from the dispenser on the wall and used another paper towel to turn off the faucet. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, it was determined that the facility failed to maintain dignity during mealtime for a resident who needed assistance with eating. This deficient practice was observed for 2 of 5 second floor dining room residents reviewed, Resident #10 and Resident #24 and was evidenced by the following: 1. On 3/4/24 at 12:16 PM, the surveyor observed Resident #10 in the second floor dining room seated in a Broda chair (chair that provides safe, comfortable long-term seating that can reduce the number of falls for residents) being fed their lunch. The surveyor observed that the resident's hospice Certified Nursing Aide (CNA) was standing behind the resident while reaching over the resident's right side to feed them. The surveyor interviewed the hospice CNA on 3/4/24 at 12:21 PM who stated, she was aware that any staff should be seated in eye to eye level while feeding any resident. The hospice CNA further stated that it was not appropriate to stand while feeding. A review of the admission Record for Resident #10 revealed that the resident was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility staff failed to follow acceptable standards of clinical practice for 1. not accurately documenting the resident's refusal of a medication, 2. not adequately documenting in the Administration Record to indicate that the daily weights were done according to physician's order (PO) to 2 of 16 residents reviewed, Resident #11 and Resident #18. This was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. On 3/8/24 at 8:06 AM, the State Surveyor observed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

REPEAT DEFICIENCY Based on observation, interview, and record review it was determined that the facility failed to provide care and services consistent with professional standards of practice for a resident with a pressure ulcer. This deficient practice was identified in 1 of 2 residents, Resident #1, reviewed for pressure ulcer care and prevention. The deficient practice was evidenced by the following: On 3/4/24 at 11:25 AM, the surveyor observed Resident #1 lying in bed in their room. Resident #1 was alert, verbally responsive, and conversant. Resident #1 stated they had a wound on their backside that was treated daily by the nurses and a wound doctor would visit weekly. On 3/7/24 at 10:06 AM, the surveyor observed Licensed Practical Nurse (LPN) #2 provide wound treatment to Resident #1's sacral wound. LPN #2 provided the surveyor a copy of the resident's treatment order. The physician order dated 1/11/24 read, Cleanse Sacral Wound and R [right] Buttocks with NS [normal saline] apply Triad to peri wound Medihoney, to Calcium Alginate Cover with large foam dressing BID [two times a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY An onsite revisit was conducted on 5/14/24 to verify the facility's plan of correction (POC) with a completion date of 3/28/24. The facility's POC indicated that the Director of Nursing (DON)/Designee will do a root cause analysis review on all incident and accidents reported after the completion of the incident/accident investigation to ensure that care plan (CP) will have an appropriate intervention monthly. Based on interview, record review, and review of the POC, it was determined that the facility failed to ensure the residents who had a fall incident, were accurately investigated for falls root cause analysis. This deficient practice was identified for 1 of 3 residents reviewed for falls, Resident #3. 1. On 5/14/24 at 10:35 AM, the surveyor observed Resident #3 in the hallway outside of their room in a wheelchair. The surveyor observed the resident's bed the lowest position with bed rails up and call light within reach. A review of the admission Record for Resident #3 revealed that the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to: a) ensure appropriate storage of oxygen (O2) equipment in accordance with facility and infection control policies, b) ensure a resident received oxygen as ordered by the physician. This deficient practice was identified in 3 of 3 residents (Resident #11, #12 and #58), reviewed for respiratory care. The deficient practice was evidenced by the following: 1. On 3/4/24 at 11:14 AM, during the initial tour in Resident #11's room, the surveyor observed an oxygen tubing connected to the resident's tracheostomy and oxygen concentrator dated 2/7. The resident was observed with eyes closed with the tracheostomy in place. A review of the admission Record (AR) for Resident #11 reflected that the resident was admitted to the facility with diagnoses that included but not limited to Chronic Respiratory failure with hypoxia; Respiratory Syncytial virus pneumonia; Sepsis and Anoxic brain damage. A review of the Resident #11's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that narcotic medication shift to shift sign in and out sheet was accurately signed. This deficient practice was identified for 1 of 3 units inspected during the facility unit inspection process. This deficient practice was evidence by the following: On 3/4/24 at 1:00 PM, the State Surveyor inspected the 2nd floor medication Cart A. During the inspection the State Surveyor reviewed the Narcotic Inventory book. All Narcotics stored in the medication cart were in order and The Narcotic Count shift to shift sign in sheet was found to have empty areas. Review of the Narcotic Count Shift to Shift sign in sheet was found to lack nurse's signatures on 3/1/24 Outgoing Nurse 11:00 PM, 3/3/24 Incoming Nurse 3:00 PM and 3/4/24 Outgoing Nurse 11:00 PM. On 3/4/24 at 1:10 PM, the State Surveyor interviewed the Registered Nurse (RN#1) who stated that the sheet should be signed by every incoming and outgoing nurse on each shift. The surveyor reviewed the Narcotics Accountability Policy with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined that the facility failed to maintain a medication error rate below 5%. The surveyor observed 2 nurses administer 26 doses of medication to 3 residents and there were 3 errors which resulted in a medication error rate of 11.54 %. The deficient practice was evidenced by the following: On 3/8/24 at 8:06 AM, the State Surveyor observed the start of medication pass with the Licensed Practical Nurse (LPN#1) on the 3rd floor. 1. On 3/8/24 at 8:14 AM, LPN#1 administered Multi-Vitamin with Minerals to Resident #19. The surveyor noted that the computer screen reviewed by LPN#1 documented Multivitamin 50 Plus on the electronic medical administration record (eMAR). After Resident #19 medication administration was completed the surveyor interviewed LPN#1. LPN#1 stated that Multi-Vitamin with Minerals was the same as Multivitamin 50 Plus. Review of the March 2024 Physician's Order (PO) revealed an order for Multivitamin 50 Plus tablet that began on 2/9/24. On 3/8/24 at 12:00 PM, the surveyor interviewed the Licensed Nursing Home…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined that the facility failed to properly store and refrigerate medication at the required temperature. This deficient practice was observed for 1 of 2 facility units inspected during the initial facility unit inspection. The deficient practice was evidenced by the following: On 3/4/24 at 1:00 PM, the State Surveyor accompanied by the RN#1 inspected the 2nd floor locked medication refrigerator located in the locked medication room. The thermometer located inside the refrigerator was found to be 32 degrees Fahrenheit (F) upon inspection. The State Surveyor inspected the medication that was in the refrigerator at the time: 1. 17x10 milliliter (ml) Insulin Pens 2. 1x3.7 (ml) Calcitonin Salmon Nasal Spray 3. 3x2.5 ml Latanoprost Ophthalmic Solution 0.005% 4. 1x1ml Tuberculin Purified Protein Derivative Diluted Aplisol 5. 1x30 ml opened Lorazepam Intensil Oral Concentrate 2mg/ml 6. 1x30 ml sealed Lorazepam Intensil Oral Concentrate 2mg/ml Upon inspection all the medications seemed to be in good condition The State Surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility documentation, it was determined that the facility failed to prepare vegetables in the proper consistency for 2 of 4 residents (Resident #5 and #36) reviewed on a modified diet. This deficient practice was evidenced by the following: On 3/5/24 at 11:30 AM, the surveyor observed the lunch tray line. The Certified Dietary Manager (CDM) requested a mechanical soft diet tray (mechanical soft diet is a type of diet that involves foods that are physically soft, making them easier to eat without the need for extensive chewing), which contained three whole fish sticks, regular mixed vegetables (carrots, broccoli, and cauliflower) and mashed potatoes. The Surveyor interviewed the CDM in reference to the fish sticks and vegetables served whole for a mechanical soft diet. The CDM explained, they do serve mechanical soft residents whole fish stick and regular mixed vegetables because they are considered fork mash-able or fork tender. The CDM identified that the CNA or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policies, it was determined that the facility failed to provide full visual privacy for 2 of 18 residents reviewed, Resident #72 and Resident #2. The deficient practice was evidenced by the following: On 5/10/22 at 9:46 AM, the surveyor observed the Phlebotomist enter Resident # 72's room and he left the door opened. From the hallway, the surveyor observed the Phlebotomist set up his supplies and attempted to draw the resident's blood. There was no privacy afforded to the resident during this procedure. At 9:54 AM, the surveyor interviewed the Phlebotomist who stated that he should have provided privacy to the resident while performing blood draws for a resident. At 10:01 AM, the surveyor interviewed the Licensed Practical Nurse # 1 (LPN #1) who stated that the Phlebotomist should have provided privacy while doing blood draws. The surveyor received and reviewed the policy titled Residents Privacy dated 12-28-21, which revealed that during treatments and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to notify resident families or resident representatives (RR), and the Ombudsman's office in writing for a facility-initiated transfer to the hospital for 2 of 2 residents (Resident #74 and #39) reviewed for hospitalization. The deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) that revealed facility-initiated hospital transfers had occurred without written notification to the families and Ombudsman's office for the following residents: 1. According to the Discharge Minimum Data Set (MDS) an assessment tool dated 3/7/22, Resident #74 was transferred to the hospital with return not anticipated to the facility. There was no documentation that the facility had notified the resident's family or RR in writing regarding the reason for transfer and bed hold policy. On 5/9/22 at 11:22 AM, the surveyor interviewed the Social Worker (SW) who stated that she was new in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care plan for a resident receiving oxygen therapy, Resident # 7, who was 1 of 21 residents reviewed for comprehensive care plans. The deficient practice was evidenced by the following: On 5/4/22 at 10:39 AM, the surveyor observed Resident #7 receiving oxygen via a nasal cannula (NC-plastic prongs attached to a tube, inserted into the nostrils that oxygen flows through) that was attached to an oxygen concentrator (an oxygen delivery system). The oxygen concentrator was set at 2 LPM (liters per minute). The surveyor reviewed the electronic medical record (EMR) of Resident #7 which revealed the following: The Resident Face Sheet, which listed diagnoses that included Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. The Quarterly Minimum Data Set (MDS) assessment, dated 5/5/22, which indicated the facility assessed the resident's cognitive status using a Brief Interview for Mental Status. The resident scored a 10 out of 15 which indicated that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to provide care and services consistent with professional standards of practice during a wound treatment. This was found with Resident #7, who was 1 of 3 residents reviewed for pressure ulcer care and prevention. The deficient practice was evidenced by the following: On 5/9/22 at 10:30 AM, the surveyor spoke with Resident #7 who stated, I have a wound by the spine and that the nurses provided treatment to the wound. Resident #7 said, I think it's some type of cream they [nurses] put and they [nurses] say it's getting better. On 5/9/22 at 11:23 AM, the surveyor observed a Licensed Practical Nurse (LPN) perform a wound treatment to the sacrum of Resident #7. The LPN applied Triad paste (a zinc-oxide-based topical paste) to the resident's wound. The LPN did not cleanse the wound site prior to applying the topical treatment. On 5/9/22 at 1:22 PM, the surveyor interviewed the LPN about the wound care procedure and the observation of the wound site not being cleansed prior to applying the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, it was determined that the facility failed to ensure that all DEA [Drug Enforcement Administration] 222 forms were completed with sufficient detail to enable accurate accountability and reconciliation for controlled medications for 3 of 3 DEA FORM-222 provided. This deficient practice was evidenced by the following: On 5/10/22 at 11:15 AM, the surveyor reviewed the DEA 222 forms provided by the Administrator. The surveyor noted the following: 1. A DEA FORM-222 dated 3/9/22, which included an order for Hydromorphone 2 mg (milligrams) tablets, oxycodone/APAP 5/325 mg tablets, and morphine sulfate oral solution 20 mg/ml (milligram per milliliter). The number received for the order and the supplier DEA number was not documented on the form. 2. An undated DEA FORM-222, which included an order for Oxycontin 10 mg tablets, Oxycontin 15 mg tablets, oxycodone/APAP 5/325 mg tablets, and oxycodone IR (Immediate Release) 5 mg tablets. The number received and date received for the order and the supplier DEA number was not documented on the form. 3. A DEA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection for 1 of 1 Phlebotomist observed. This deficient practice was as evidenced by the following: On 5/10/22 at 9:46 AM, the surveyor observed the Phlebotomist enter Resident # 72's room and he left the door opened. From the hallway, the surveyor observed the Phlebotomist perform hand hygiene and put on gloves. With his gloved hands, the Phlebotomist grabbed the bedside table and pushed it away from the resident's bed. Then, with his gloved hands, the Phlebotomist picked up and moved the paperwork from the bedside table, pushed a button on the side of the resident's handrail to raise the bed up and grabbed his laboratory supplies from his rolling bag and placed them on the bed next to the resident. The surveyor observed the Phlebotomist, with his gloved hands place a tourniquet on the resident's arm and wiped the resident's skin with an alcohol preparation pad. The Phlebotomist inserted a needle into the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.