Homeland Center

Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure each resident the right to be free from physical abuse for one of three residents reviewed (Resident 1).Findings Include:Review of facility policy, titled Resident Abuse, Neglect, and Exploitation, with a revised date of July 2023, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.Review of Resident 1's clinical record revealed diagnoses that included intracranial injury (Traumatic Brain Injury [TBI] -an injury to the brain caused by an external force) and Parkinson's Disease (a progressive, neurodegenerative disorder of the central nervous system…

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 policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to provide the highest practical well-being by not following physician orders for three of 22 residents reviewed (Residents 3, 8, and 84).Findings include: Review of Resident 3's clinical record revealed diagnoses that included dependence on renal dialysis (an artificial process for removing waste products and excess fluids from the body that is needed when the kidneys are not functioning properly), hypertension (high blood pressure), and weakness. Review of Resident 3's physician orders revealed an order for Midodrine HCl Oral Tablet 5 mg, Give 2 tablets by mouth every 8 hours as needed for hypotension (low blood pressure), give for SBP (systolic blood pressure) less than 120, with a start date May 5, 2025. Review of Resident 3's clinical record revealed a document titled Physician Orders with an order dated May 5, 2025, that read, Change Midodrine to 10 mg PRN (as needed) for SBP <120. Further review of Resident 3's clinical record revealed her SBP measure 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 facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for two of two residents reviewed (Residents 6 and 64).Findings include: Review of facility policy, titled Activities of Daily Living (ADLs), with a last review date of January 2025, revealed Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; and 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 6's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), Parkinson's disease (long term degenerative disorder of the central nervous system that mainly affects…

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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the preparation and administration of medications for two Residents observed (Residents 3 and 55).Findings include: Review of facility policy, titled IIB2: Oral Medication Administration, with a last review date of January 2025, revealed C. For solid medications: 1) Pour or push the correct number of tablets or capsules into the souffle cup, taking care to avoid touching the tablet or capsule, unless wearing gloves. During a medication pass observation on August 20, 2025, between 9:22 AM and 9:30 AM, Employee 6 was observed preparing and administering medications to Residents 3 and 55. When preparing medications, Employee 6 was observed using an ink pen to poke a hole in the back of the pill pouch on each blister pack, and then used the ink pen to poke the pill through from the front of the blister pack into the medication cup. She prepared and administered six medications to Resident 3, and 10 medications to…

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 policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two of nine residents reviewed for limited range of motion (Residents 30 and 40). Findings include: Review of facility policy, titled Restorative Nursing Programs, dated April 16, 2022, read, in part, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form. Review of Resident 30's clinical record revealed diagnoses that included cerebrovascular accident (CVA- poor blood flow to the brain that causes cell death), hemiplegia (one-sided paralysis or weakness caused by brain or spinal cord problems), and muscle weakness. Interview with Resident 30 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 19 residents reviewed (Residents 28 and 66). Findings Include: Review of Resident 28's clinical record revealed diagnoses that included chronic kidney disease (CKD - when a disease or condition impairs kidney function, causing kidney damage to worsen over several months or years) and heart failure (when the heart muscle doesn't pump blood as well as it should). Observation of Resident 28 on September 9, 2024, at 10:09 AM, revealed Resident 28 sitting in her room with a CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while you sleep) on her bedside table. Resident 28 revealed she uses it daily. Review of Resident 28's clinical record revealed a progress note dated July 27, 2024, at 7:23 AM, indicating Resident 28 slept with her CPAP 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 observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for three of 21 residents reviewed (Residents 13, 16, and 61). Findings include: Review of facility provided policy, titled Homeland Center Infection Prevention and Control Manual, Transmission-Based Precaution, dated 2021, revealed, It is essential both to communicate transmission-based precautions to all health care personnel and for personnel to comply with requirements. Pertinent signage (i.e., isolation precautions) and verbal reporting between staff can enhance compliance with transmission-based precautions to help minimize the transmission of infections within the facility. Review of Resident 13's medical record revealed diagnoses that included urinary tract infection (UTI - an infection in any part of the urinary system) and Chronic obstructive…

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, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 21 residents reviewed (Residents 70 and 85). Findings include: Review of Resident 70's clinical record revealed diagnoses that included Alzheimer's with early onset (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Observation of Resident 70 on October 30, 2023, at 9:39 AM, revealed her wandering throughout the nursing unit. Review of Resident 70's current plan of care revealed that she had a care plan for elopement, where it was noted that she is a wanderer and wanders aimlessly. This information was updated to Resident 70's care plan on October 2, 2023. Review of Resident 70's behavior tracking documentation revealed that she exhibited wandering behavior on October 4, 2023. Review of Resident 70'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.

Based on observation, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 16). Findings Include: Review of facility policy, titled Wound Care and Dressing Change, revised January 2020, revealed Clean portion of surface before placing supplies on table. Wash hands and don gloves .Undress wound, assess area and cleanse and appropriately dispose of soiled dressing. Remove gloves and sanitize hands. [NAME] new gloves. Apply new treatment as ordered. Review of Resident 16's clinical record revealed diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and stage 4 pressure ulcer of the sacrum (localized damage to the skin and/or underlying soft tissue usually over a bony prominence; stage 4 is full-thickness skin and tissue loss).…

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.