Homeplace Manor Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property for 2 of 3 employees (RN and DON) reviewed for employability. The facility failed to ensure evidence that the criminal history was checked prior to the DON and RN being hired or having access to the residents. The facility failed to ensure evidence that the Employee Misconduct Registry or Nurse Aide Registry was checked prior to RN being hired or having access to the residents. The failure could place residents at risk of receiving care from someone who was unemployable, which increased the risk of abuse, neglect, and exploitation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #1) of 3 residents reviewed for PASRR Level 1 screenings. The facility failed to ensure the accuracy of the PASRR Level 1 Screening for Resident #1. The PASRR Level 1 Screening dated 11/13/25 did not indicate a diagnosis of mental illness, although the diagnosis post-traumatic stress was present upon Resident #1's admission on [DATE]. This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation, individualized care, or special services to meet their needs.

Inspectors wroteBased on interviews and record review, the facility failed to provide the appropriate treatment and facility services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for a resident with Post Traumatic Stress Disorder (PTSD) for 1 (Resident #1) of 3 residents reviewed for behavioral health care services. The facility failed to ensure Resident #1, who was diagnosed with depression, anxiety, and post-traumatic stress disorder (PTSD), received the care and services needed in the most appropriate setting, after the resident began to display increased behaviors on 4/15/2026 and requested outpatient psychiatric services. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to utilize the services of a RN for 8 consecutive hours 7 days a week and designate a RN as a DON on a full-time basis for 1 of 1 facility reviewed for nursing services. The facility failed to ensure an RN worked for 8 consecutive hours for 28 of 79 days reviewed in October and November 2025 until December 18th 2025. The facility failed to designate an RN as a DON on a full-time basis for 2 of 3 months reviewed in October and November 2025 until December 18th 2025. These failures placed all residents at risk for their clinical needs not being met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure freezer and refrigerator temperatures were tracked daily2. The facility failed to ensure foods were labeled properly. 3. The facility failed to ensure food temperatures were taken before serving. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 14 of 45 employees (AIT, SW, DM, Maint D, ADON, AD, DOR, RN A, LVN B, LVN C, LVN D, CNA E, CNA F, and CNA G) reviewed for employability. The facility failed to ensure evidence that the criminal history was checked prior to the AIT, SW, DM, Maint D, ADON, AD, DOR, RN A, LVN B, LVN C, CNA E, CNA F, and CNA G being hired or having access to the residents. The facility failed to ensure evidence that the EMR was checked prior to the AIT, AD, DM, Maint D, CNA E, CNA F, and CNA G being hired or having access to residents. The facility failed to ensure evidence that the NAR was checked prior to CNA E, CNA F, and CNA G being hired or having access to the residents. [...]

Inspectors wroteBased on interview and record review, within 14 days after a facility completes a resident's assessment, the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System for 14 (Residents #1, #4, #5, #7, #10, #11, #13, #14, #16, #19, #20, #21, #23, and #24) of 24 reviewed for resident assessments, in that: 1. Resident #1's admission MDS assessment, dated 03/11/2025 and Quarterly MDS's, dated 05/29/2025, 08/26/2025,09/11/2025, and 11/10/2025 were completed but not transmitted to CMS as of 12/18/2025. 2. Resident #4's admission MDS, dated [DATE] and Quarterly MDS's, dated 05/29/2025, 08/26/2025,09/11/2025, and 11/10/2025 were completed but not transmitted to CMS as of 12/18/2025. 3. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to complete a performance review of each CNA at least once every 12 months, for 2 of 3 (CNA F & CNA G) reviewed for nursing services. The facility failed to complete annual CNA competency evaluations for CNA F and CNA G, based on the personnel file review results. This failure could affect residents by placing them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 5 (Resident #9, Resident #10, Resident #19, Resident #20, and Resident #23) of 5 residents reviewed for hospice services. 1. The facility failed to maintain the required hospice forms and documentation, that included the Hospice Election Form, for Resident #10, Resident #19, and Resident #20 Resident #23 were. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, 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 development and transmission of communicable diseases and infections for 2 of 2 (CNA-E and CNA-I) staff observed during incontinent care, and the storage of ice scoop for 1 of 1 ice chest reviewed for infection control. 1. The facility failed to ensure CNA E and CNA I performed appropriate hand hygiene during peri-care for Resident #24. 2. The facility failed to ensure the ice scoop for the ice chest was stored outside of the ice chest. These failures placed residents of the facility at risk of infection spread from cross contamination of ice in ice chest and improper hand hygiene.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on HIV, restraint reduction and prevention of falls. The facility failed to implement and maintain a training program that ensured the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H received required HIV training upon hire. The facility failed to implement and maintain a training program that ensured the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H received required restraint reduction training upon hire. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to include effective communications as mandatory training for direct care staff all new and existing staff for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on effective communication. The facility failed to ensure communication training was provided to the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H upon hire. This failure could place residents at risk of not understanding their total health status and not effectively being provided notice of rights and services both orally and in writing in a manner that the resident understands.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staff members were educated on the rights of the resident and the responsibilities of a facility to properly care for its residents. for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on resident's rights. The facility failed to ensure that the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on the rights of the resident, and the responsibilities of the facility to properly care for its residents upon hire. This failure could place residents at risk of their rights not being honored by uninformed staff.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide training to their staff that at a minimum educates staff on (1) activities that constitute ANE and misappropriation of resident property: (2) procedures for reporting incidents of ANE or misappropriation of resident property; (3) dementia management and resident abuse prevention for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on abuse, neglect, and exploitation and training for dementia management. The facility failed to ensure the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on abuse, neglect and exploitation & dementia management upon hire. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff on the elements and goals of the facility QAPI program for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on QAPI. The facility failed to ensure that the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on the facility's QAPI program upon hire. This failure could place residents at risk of their quality of care not being improved upon when a known issue had occurred from staff not being informed on the goals and various elements of the QAPI program.

Inspectors wroteBased on interviews and record reviews, the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for all new and existing staff for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on infection control. The facility failed to ensure the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on infection control upon hire. This failure could place residents at risk of contracting facility acquired infections from staff not being informed on proper infection prevention and control practices when performing resident care activities that pertain to that staff member's role.

Inspectors wroteBased on interviews and record reviews, the facility failed to include as part of its compliance and ethics program (1) an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program; (2) annual training if the operating organization operates 5 or more facilities for all new and existing staff for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) reviewed for training on compliance and ethics. The facility failed to ensure that the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on compliance and ethics upon hire. This failure could affect residents and place them at risk of being uninformed of compliance and ethics program due to lack of staff training.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide behavioral health training consistent with the requirements at 483.40 (behavioral health services) and as determined by the facility assessment for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on behavioral health. The facility failed to ensure that the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on behavioral health upon hire. This failure could place residents diagnosed with a mental, psychosocial, or substance use disorder at risk of not receiving the care specific to their individual needs.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives to meet resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #10 and Resident #15) of 12 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of hospice services for Resident #10. 2. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of insulin and diabetes for Resident #15. This failure could place the residents at risk for decreased quality of life and not having their needs met.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a therapeutic recreation specialist or an activity professional for 1 of 1 activity director (AD) reviewed for qualifications. The facility failed to ensure the AD, hired on 9/29/2025, was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 1 lunch meal reviewed. This facility failed to follow the menu when preparing lunch meal on 09/02/2024. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety of 1of 1 kitchens reviewed. The facility failed to ensure items stored in 1 of 1 freezer were properly stored and labeled. The facility failed to ensure current temperature logs of 1 of 1 freezer and 2 of 2 refrigerators were maintained daily. The facility failed to ensure dietary staff (1 of 2) wore hair nets when preparing, serving meals. These failures could place resident that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 7 of 19 employees (DON, DM, MAINT, CNA C, TRNS, COTA, and HSKP F) reviewed for training. The facility did not ensure effective communication training was completed by the DON, MAINT, TRNS, and COTA during orientation. The facility did not ensure effective communication training was completed by the DM, CNA C, and HSKP F annually. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff members were educated on the rights of the resident and the responsibilities of the facility to properly care for its residents for 5 of 19 staff (DM, LVN G, HSKP E, TRNS, and HSKP F) reviewed for training requirements in that: The facility failed to ensure five staff which included: DM, LVN G, HSKP E, TRNS, and HSKP F received the required training on resident rights timely. This failure could place residents at risk of receiving care from staff who were insufficiently trained.

Inspectors wroteBased on interview and record review the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and dementia management for 2 (DM and HSKP F) of 19 employees reviewed for staff training. The facility failed to have documentation for DM and HSKP F on what constitutes abuse, neglect, exploitation, misappropriation of resident property and how to report the above. These failures could place residents at risk of injury or harm due to being cared for by untrained staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure standards, policies, and procedures for an infection prevention and control program was completed for 3 of 19 staff (DM, HSKP E, and HSKP F) reviewed for training. The facility failed to ensure five staff which included the DM, HSKP E, or HSKP F received the required training on infection control timely. These failures could place residents at risk of illness due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #24) of 14 residents reviewed for care plan completion. 1. The facility failed to complete Resident #24's baseline care plan within the required 48-hour timeframe. 2. The facility failed to provide Resident #24 a summary of their baseline care plan after completion. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.

Inspectors wroteBased on interview and record review the facility failed to complete a performance review of each CNA at least once every 12 months, for 1 of 3 (CNA C) reviewed for annual competency evaluations. The facility failed to complete annual CNA competency evaluations for CNA C, based on the personnel file review results. This failure could affect residents by placing them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent survey of the facility including any plans of correction without identifying information about complainants or residents reviewed for resident rights. The facility failed to ensure the three preceding years of any surveys, certifications, and complaint investigations with plan of correction were posted for residents, family members, and visitors to review without identifying information about complainants or residents. The failure placed residents and their family members and representatives at risk for violation of the right to review the findings from State surveys and investigations conducted in the facility without asking to review the reports.

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (October 2023, November 2023, and December 2023) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, 7 days a week for the months of October 2023, November 2023, and December 2023 (Saturday's and Sunday's) for a total of 22 days. This failure could place the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for 1(Resident #1) of 3 residents reviewed for infection control practice. CNA (Certified Nurse Aide) A failed to perform hand hygiene and change her gloves at the appropriate times while providing incontinence care for Resident #1. These failures could place residents at risk for the spread of infection.

Inspectors wroteBased on interviews and record reviews the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week or designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day. The facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. These failures placed all residents at risk of their clinical needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to appropriately label, date, seal/close items stored in pantry, refrigerator, and freezer. The failure could place residents at risk for food-borne illness from food contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents care plans were reviewed and revised by the interdisciplinary team after each assessment for 6 of 13 Residents (Residents #1, # 12, #19, #22, #24, #25) reviewed for comprehensive care plans, in that; The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #1's comprehensive assessment on 07/11/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #12's comprehensive assessment on 06/30/2023. The facility failed to develop a comprehensive care plan without conducting a care plan conference within 7 days of Resident #19's comprehensive assessment on 07/01/2023. [...]

Inspectors wroteBased on interview and record reviews the facility failed to maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 6 of 7 months reviewed for antibiotic stewardship. The facility failed to maintain a system to monitor antibiotic use during the months of January 2023 through June 2023. These failures placed residents at risk of adverse outcomes associated with the inappropriate use of antibiotics.

Inspectors wroteBased on observation and interview the facility failed to post, in an area of the facility that is readily available to residents, employees, and visitors five of 33 postings. The facility failed to display the Facility admission Policy, a description of the protection of personal funds, how to apply for and use Medicare and Medicaid benefits, and how to receive funds for previous payments covered by such benefits. This failure could affect all residents who reside in the facility by placing them at risk of incomplete or inaccurate information.

Inspectors wroteBased on interview and record reviews the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program for 1 of 1 facility's reviewed for QAPI. The facility failed to maintain documentation of QAPI meetings prior to February of 2023. This failure placed residents at risk of maintaining and improving safety and quality of life.

Inspectors wroteBased on interviews and record reviews the facility failed to assure the security of all personal funds of residents deposited with the facility for 1 of 1facility reviewed for the surety bond. The facility failed to have a surety bond that exceeded the average balance of the trust fund. This failure placed residents at risk of a loss of personal funds.

Inspectors wroteBased on interview, and record review, the facility failed to provide the required 80 square foot of usable living space per resident in 8 multiple occupancy resident rooms (16, 17, 18, 19, 20, 21, 22, and 23) of 31 rooms reviewed for room classification. The rooms measured less than the 80 square feet of usable living space per resident in multiple occupancy resident rooms. This failure could impede the ability of residents to live in these rooms.