Future Care Homewood

Inspectors wroteBased on record review and interview, it was determined that the facility failed to prevent an avoidable fall with injury when they failed to follow the resident's plan of care to provide two staff person assistance with bed mobility. This resulted in actual harm to Resident #103. This was evident for 1 complaint (#3096869) of 4 complaints reviewed during a complaint survey. Corrective measures were put in place prior to the start of the complaint survey, so this citation is past noncompliance with the compliance date of 6/30/26.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to report an incident of resident injury related to staff action that caused a resident serious bodily injury. This was evident for 1 complaint (#3096869) of 4 complaints reviewed during the complaint survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure meals were served to residents at an appealing and palatable temperature. This was evident for 1 out of 1 test tray temperature observation. This practice has the potential to affect all residents who eat the food prepared by the facility.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure food items were properly labeled and stored to maintain their integrity and prevent the use of outdated food. This was evident during the initial tour of the kitchen, and this finding had the potential to affect all residents who received food prepared by the facility.

Inspectors wroteBased on interview, observation, and record review, it was determined that the facility failed to promote and maintain residents' dignity by serving meals on paper trays with disposable plastic utensils for an extended period without a documented clinical or regulatory justification. This was evident for 2 (Residents #39 and #9) of 3 residents reviewed for dignity during the recertification and complaint survey.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to protect the privacy of a resident's clinical information. This was evident for 1 (Resident #86) out of 45 residents that were in the survey sample.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure a resident's psychotropic drug regimen was free from unnecessary medications by failing to timely act upon a pharmacist's recommendation to evaluate, add a duration, or implement a stop date for an active as needed (PRN) anxiolytic medication. This was evident for 1 (Resident #18) of 5 Resident records reviewed for unnecessary medication during the recertification survey process. The Findings Included:A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. [...]

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident's annual Minimum Data Set (MDS) was accurate. This was evident for 2 (Resident #10 and Resident #17) out of 30 residents reviewed for MDS assessment during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed ensure physician orders were obtained and implemented in accordance with their assessed needs and individualized care plans by: 1) failing to obtain and implement physician orders for turning and repositioning dependent residents; and 2) failing to obtain a physician order that included the clinical indication for a resident's chronic urinary catheter. This was evident for 2 (Resident #1 and #6) of 3 residents reviewed for positioning and mobility, and for 1 (Resident #1) of 3 residents reviewed for urinary catheter management during the annual and complaint survey.

Inspectors wroteBased on record review ad interview, it was determined that the facility failed to ensure that a resident with a pressure ulcer received treatment in accordance with the wound physician's recommendations to promote healing. This was evident for 1 (Resident #1) of 2 residents reviewed for pressure ulcer during the recertification and complaint survey.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to 1) ensure that oxygen was administered as ordered, and 2) ensure residents' oxygen tubing was labelled and placed in the resident's nose as ordered. This was evident for 2 (Resident #17 and Resident #98) out of 3 residents sampled for oxygen use during the recertification/complaint survey.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to document attempts at non-pharmacological interventions prior to a resident being administered a pain medication. This was evident for 3 (Resident #124, Resident #18, and Resident #10) out of 5 residents sampled for unnecessary medications during the recertification/complaint survey.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to lock a medication cart. This was evident for 1 (Resident #86) out of 45 residents that were in the survey sample.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide or obtain from an outside resource routine dental service to meet the needs of each resident. This was evident for 1 (Resident #19) of 1 resident reviewed for dental services during the recertification survey process. The Findings Included:On 06/24/2026 at 11:20 AM, during Resident #19's interview the resident revealed that he/she would like to see a dentist because his/her dentures were not fitting well. The surveyor observed that the resident had no teeth in his/her mouth. [...]

Inspectors wroteBased on clinical record review, resident interview, and staff interview it was determined that the facility staff failed to ensure a resident's showers were documented accurately. This was evident for 1 (Resident #8) out of 1 reviewed for showers during the recertification/complaint survey.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to follow enhanced barrier precautions. This was the result of a random observation during the recertification/complaint survey.

Inspectors wroteBased on review of facility policy, observations, and interviews, the facility failed to provide a functional, sanitary and comfortable environment for two (2) out of 21 sampled residents (Resident [R] #6 and R#19) when housekeeping staff failed to clean the residents' room and bathroom which had a strong smell of urine; and general housekeeping duties were not completed across three (3) units (Units #4, #5, and #6). Intakes #2608459 and #2599200 are directly related to these findings.

Inspectors wroteBased on observations, record reviews, and staff interviews, it was determined that the facility failed to provide appropriate pain management for residents. This was evident for 2 resident (Resident #137 and Resident #410) of 3 residents who were reviewed for pain management during the recertification/complaint survey.

Inspectors wroteBased on a review of staff personnel files and staff interview, it was determined that the facility staff failed to ensure nursing staff are retrained on an annual basis. This was evident for 3 (Staff #6, #34, #37) out of the 5 nurses reviewed for skills and competencies.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to maintain food trays and dinnerware in good condition and failed to store and serve food in a manner that prevents food borne illness to the residents. This was evident during the initial and subsequent kitchen observations conducted during the recertification/complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and NOMNC (Notice of Medicare Non-coverage) was provided to the residents who were discharged from Medicare Part A services but had benefit days remaining. This was evident for 2 (Resident #30 and Resident #420) of 3 randomly selected residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification during the recertification/complaint survey.

Inspectors wroteBased on observation, record reviews and interviews, it was determined that the facility failed to develop a person-centered comprehensive care plan for each service and treatment provided. This was evident for 1 (Resident #14) of the 28 sample size resident records reviewed during the survey process. Findings Included: BiPAP (Bilevel Positive Airway Pressure) is a non-invasive respiratory treatment that uses air pressure to assist with breathing, particularly for conditions like sleep apnea, COPD, and other respiratory problems. On 05/12/25 at 11:48 AM, an observation of Resident #14's room revealed that the resident was on oxygen via nasal cannula with oxygen concentrator and the resident also had a Bi PAP machine at bedside. In an interview with Resident #14, he/she reported that he/she requires oxygen at all times and uses the Bipap machine to sleep. [...]

Inspectors wroteBased on a medical record review, observation, and interviews, it was determined that the facility failed to: 1) revise care plans quarterly, 2) the inter-disciplinary team (IDT) failed to attend care plan meetings at the time of the quarterly revision, and 3) revise care plans with a change in the resident's condition. This was evident for 3 (Resident #2, #130, #46 ) of the 75 Residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on a complaint incident MD00195763, record review, and interviews with residents and staff, it was determined that the facility failed to ensure that a resident receive their showers on scheduled shower days. This was evident for 1(Resident #96 ) of 5 residents reviewed for activities of daily living during the recertification/complaint survey.

Inspectors wroteBased on medical record review, resident and staff interviews it was determined that the facility staff failed to provide fingernail grooming for a dependent resident. This was evident for 1 (Resident #31) of 2 residents investigated for Activities of Daily Living (ADL) during the survey process.

Inspectors wroteBased on a review of the resident medical records and interviews with facility staff, it was determined that the facility failed to: 1) ensure that a resident received prescribed medication for 5 days, 2) ensure that a physician's order for a wound consultation was followed timely and 3) clarify a physician's order. This was evident for 3 (Resident # 389, #416 and #394) of 75 residents reviewed during this recertification/complaint survey.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure that a resident with limited range of motion received treatment and services as ordered. This was evident for 1 (Resident #130) of 1 resident investigated for position and mobility during the recertification/complaint survey.

Inspectors wroteBased on a review of the complaint and medical records, and staff interviews, it was determined that facility staff failed to provide/document appropriate and sufficient services, treatment, and care for a resident with an indwelling urinary catheter. This was evident for one (Resident #288) of two residents reviewed for urinary catheter care during this recertification/complaint survey.

Inspectors wroteBased on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure drug records were maintained in a manner that allowed for reconciliation of dispensed and administered medication. This failure was evident for one resident (Resident #410) out of two residents reviewed for narcotic medication administration during this recertifiation/complaint survey.

Inspectors wroteBased on observation, medical record review and interview, it was determined the facility failed to maintain a medication error rate of less than 5%. This was evident for two (2) errors identified out of 26 opportunities for error during medication pass observation.

Inspectors wroteBased on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure resident received dental services. This was evident for 1 (Resident #24) out of the 42 residents that were part of the survey sample.

Inspectors wrote3) A review of Resident #120's clinical record on 5/15/25 revealed staff charted that they provided daily and sometimes twice daily showers for the resident. The first floor Unit Manager (Staff #22) was interviewed on 5/15/25 at 11:58 AM. Asked him if the resident gets showers each week. He replied at least two every week and we try for more. He said the resident sometimes refuses but gets a bed bath once or twice a day. This surveyor showed him the set of shower sheets where it shows two to three showers a day. He said No way. It takes two and sometimes three staff to give a shower and never a tub bath. He said it is an education error. New staff are probably clicking 'yes' because they are in a hurry and probably only seeing the word bath not tub bath. The Regional Clinical Services Manager (Staff #4) was interviewed on 5/19/25 at 8:50 AM. [...]

Inspectors wroteBased on medical record review and interview, it was determined that 1) the facility failed to offer the administration of the pneumococcal vaccine to 1 (Resident #6) out of 5 Residents reviewed for immunizations; and 2) provide education about the risk and benefits to resident who refused the pneumococcal vaccine. This was evident for 1 (Resident #2) out of 5 Residents reviewed for immunizations during the survey.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to ensure that every resident had access to a communication system to call for staff assistance, if needed. This is evident for 3 (Resident #100, #87, #40) of 8 resident's call bell accessibility observed during the recertification/complaint survey. Findings Included: On 05/21/25 at 08:45 AM, a surveyor conducted an audit for call bell accessibility and function, during the audit the following concerns were identified: In an interview with Resident #95, he/she was asked if there was any concerns about the call light system, Resident #95 stated that his/her call bell was in good working condition, but the roommate's (Resident #100) call bell stop working a while ago. Resident #100 was not present for an interview; however, the surveyor attempted to use Resident #100's call bell and it was in-operable. [...]

Inspectors wroteBased on a review of staff personnel files and staff interview, it was determined that the facility staff failed to ensure geriatric nursing assistants (GNA) are retrained on an annual basis. This was evident for 1 out of the 1 GNA's reviewed for skills and competencies.

Inspectors wrote5. Review of Resident #37's medical record on 7/28/22 revealed the Resident was admitted to the facility on [DATE]. The Resident was discharged from the facility to the hospital on 3/31/22. Further review of the Resident's medical record failed to reveal any documentation that a notice regarding the transfer had been provided to the Resident or the Resident's responsible party. Interview with Regional Nurse #1 on 7/29/22 at 7:45 AM confirmed the facility had no evidence Resident #37 and the Resident's responsible party had been given written notification of the transfer to the hospital and the reason for the transfer. Based on medical record review and interview with staff it was determined the facility staff failed to provide written notice for emergency transfers to the residents, and residents' representative. [...]

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to develop comprehensive care plans for residents (Resident #37, #64, #89, #113). This was evident for 4 out of 66 residents reviewed during an annual survey.

Inspectors wroteBased on resident council members meeting and interviews It was determined that the facility failed to provide residents with enough nurse staffing.

Inspectors wroteBased on observations during the survey it was determined that the facility staff failed to post staffing information at the entrance to the facility. This was evident from the start of the survey until 8/5/22. The evidence is: During tours of the facility and observation when the surveyors entered and left the facility it was noted that there was no posting of the current nurse staffing information at the entrance for visitors and residents to see. Regional Nurse #1 was interviewed on 8/5/22 at 1:50 PM and informed of the findings.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure that medication regimens were free from unnecessary medications (Residents #103, #315, #31 and #110). This is evident for 4 of 66 residents selected for review during the survey process.

Inspectors wroteBased on observation and staff interviews it was determined that the facility staff failed to ensure that food was served and handled in sanitary manner during lunch meal service and failed to ensure that food was stored in accordance with professional standards for food service safety. This practice has a potential of effecting all residents in facility.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for residents (Resident #31, #89, #110 and #226). This was evident for 4 of 66 residents reviewed during the annual survey.

Inspectors wroteBased on resident interview, family interview, staff interview, and clinical record review it was determined that the facility nursing staff failed to ensure residents received at least two showers each week (#26, #31, and #102). This was evident for 3 out of the 66 residents reviewed as part of the survey process.

Inspectors wroteBased on record review and interview, the facility failed to properly manage the funds of a resident (Resident #109). This was evident for 1 out of 3 residents reviewed during an annual survey.

Inspectors wroteBased on review of facility documents and staff interview it was determined the facility failed to timely report an allegation of abuse to the State Survey Agency which is the Office of Health Care Quality (OHCQ). This was evident for 2 (#218 and #317) of 12 residents reviewed for abuse.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to provide wound treatments as ordered by the physician for residents (Resident #37 and #315). This was evident for 2 out of 7 residents reviewed for skin conditions during the annual survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers for a resident (Resident #37). This is evident for 1 of 7 residents reviewed for pressure ulcers during an annual survey. A pressure ulcer also known as pressure sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. [...]

Inspectors wroteBased on medical record review, observation, and interviews with facility staff it was determined the facility staff failed to provide evidence of adequate care to residents with indwelling urinary catheters (Residents #103). This was evident for 1 of 5 residents reviewed for indwelling urinary catheters during the annual survey.

Inspectors wroteBased on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure a resident's physician was notified about weight loss (#102), failed to recognize a resident's weight loss, reweigh and provide a dietary consult in a timely manner (#5), and failed to obtain ordered weights (#61). This was evident for 3 residents out of the 66 sampled as part of the survey. The evidence is: 1. A review of Resident #102's clinical record revealed that the resident has had a 22% weight loss since admission a year ago. There was no mention in the clinical record of the physician being contacted regarding this weight loss. A review of the resident's clinical record revealed that on 8/2/21 the dietician wrote a note Resident readmitted after short stay hospital . [...]

Inspectors wroteBased on observation, medical record review and interview, it was determined the facility staff failed to provide oxygen therapy consistent with professional standards of practice for a resident (Resident #37). This was evident for 1 out of 3 residents reviewed for oxygen therapy during an annual survey.