Homestead Rehabilitation & Health Care Center

Inspectors wroteBased on interviews, record review, and review of pertinent facility documentation on 7/16/26, it was determined that the facility failed to initiate an investigation into an incident of alleged abuse of a resident (Resident #1). This deficient practice was evidenced in 1 of 3 residents' records reviewed for incident investigation and was evidenced by the following: A review of Resident #1's Face Sheet (FS), an admission record summary revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to chronic multifocal osteomyelitis of the left ankle and foot (bone infection), adult failure to thrive, severe protein-calorie malnutrition, ulcerative colitis with intestinal obstruction, epilepsy, and malignant neoplasm of the bone. [...]

Inspectors wroteComplaint #:3008822 and 3013216 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure their Licensed Nursing Home Administrator (LNHA) a.) maintained the facility in a safe operable condition including maintaining and testing their fire sprinkler system; b.) ensured the administrator, as well as all staff, implemented facility policies and procedures including conducting a fire watch accurately; c.) and ensured all local and state officials were notified that the facility's fire sprinkler system was in-operable since [DATE]. An interview with the LNHA on [DATE] at 4:38 PM, revealed that the facility's fire sprinkler system was in-operable and he was only made aware of it on [DATE]. [...]

Inspectors wroteBased 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 9 of 11 residents reviewed, Resident #2, #4, #7, #8, #10, #11, #39, #59, and #67 reviewed for physician progress notes. This deficient practice was evidenced by the following:1. On 7/16/24 at 10:57 AM, the surveyor reviewed Resident #8's hybrid medical records (combination of electronic and paper chart). Review of Resident #8's admission Record (AR) reflected that Resident #8 was admitted to the facility with medical diagnoses that included but were not limited severe protein-calorie malnutrition, chronic obstructive pulmonary disease, hypothyroidism and hypertension. [...]

Inspectors wroteBased on interview, review of Nurse Staffing Report sheets, and other pertinent facility documents, it was determined that the facility failed to ensure a Registered Nurse worked seven days a week for at least 8 consecutive hours a day for 5 of 14 days reviewed. This deficient practice was evidenced by the following:On 7/16/25 at 10:29 AM, during the entrance conference, the surveyor requested the Nurse Staffing Report to be completed for the following weeks: 6/29/25 through 7/5/25; 7/6/25 through 7/12/25 and 3/2/25 through 3/8/25. The surveyor reviewed the Nursing Staffing Reports, which revealed there was no Registered Nurse (RN) to work eight consecutive hours on the following dates: 1. No RN on 7/4/25; the last RN was scheduled on 7/3/25 2. No RN on 7/5/25; the last RN was scheduled on 7/3/25 3. No RN on 7/6/25; the last RN was scheduled on 7/3/25 4. No RN on 7/9/25; [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to evaluate the performance of all Certified Nursing Assistants (CNA) on an annual basis. This deficient practice was identified for 5 of 5 CNA's whose personnel records were reviewed and was evidenced by the following: On 7/24/25 at 10:17 AM, the surveyor reviewed the personnel files for 5 CNAs:1. CNA#1, with a date of hire of 8/17/22, no recent employee evaluation was completed.2. CNA#2, with a hire date of 8/23/23, no recent employee evaluation was completed.3. CNA#3, with a hire date of 7/2/24, no recent employee evaluation was completed.4. CNA#4, with a hire date of 10/1/24, no recent employee evaluation was completed.5. [...]

Inspectors wroteBased on interview, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening (HS) when there was more than 14 hours between dinner and breakfast mealtimes. This deficient practice was identified for 3 of 3 residents (Resident #15, #38, and #42) during the 7/21/25 resident council group meeting and evidenced by the following:On 07/21/2025 at 10:33 AM, the surveyor conducted the resident council meeting with three residents (Residents #15, #38 and #42) who were alert and oriented and selected by the facility to attend the group meeting. The residents stated that they received dinner between 5:00 PM-5:30 PM, and breakfast was delivered between 8:00 AM-8:30 AM. All three residents stated that they were not offered nor received snacks in the evening. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following:On 7/16/2025 at 10:01 AM, the surveyor in the presence of the chef toured the kitchen and observed the following:1. In the 3-door standing refrigerator, the surveyor observed 10, 2oz cups of sliced pickles dated 7/7/25 -7/12/25 and 12, 2oz cups of grated cheese with a use by date of 7/15/25. The chef was unable to state why those items had not been disposed of by the use-by date. 2. In the 6-door standing refrigerator, the surveyor observed a round container of grape jelly covered with plastic wrap, labeled opened on 7/11/25. [...]

Inspectors wroteBased on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris. This deficient practice was evidenced by the following:On 7/16/2025 at 10:01 AM, the surveyor, in the presence of the chef, toured the kitchen and garbage area and observed the following:There was garbage debris that included food wrappers, food containers, cups, gloves, paper products, and medication cups around the dumpster and surrounding areas. The chef said that the maintenance and dietary departments should have cleaned the area. On 7/17/2025 at 9:35 AM, the surveyor interviewed the Food Service Director (FSD), who stated that the garbage areas are a shared area; [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to ensure the medical director: a.) implemented the facility's policies and procedures for resident care including physician visits documented at the time of visit and b.) ensure facility policies and procedures were reviewed and updated as needed. This deficient practice has the potential to affect all residents, and was evidenced by the following:Refer F 711A review of the undated facility provided Director Roles and Responsibilities for the Medical Director's job description included:Physician Leadership: Help the facility ensure that patients have appropriate physician coverage and ensure the provision of physician and health care practitioner services. Provide guidance for physician performance expectations; [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement (QAPI) Program was being implemented to ensure sustainability with previously cited deficiencies. The facility was cited during last standard survey on 3/12/24, and was evidenced by the following:Refer to F686, F711, F755, F880 During the entrance conference on 7/16/24 at 10:29 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) a copy of the facility's QAPI program plan and the 2024 and 2025 quarterly sign-in sheets and QAPI notebook. [...]

Inspectors wroteBased on interview, and review of facility documentation, it was determined that the facility failed to ensure that Certified Nurse Assistant (CNA) received at least 12 hours of mandatory in-service training for 5 of 5 CNA's education reviewed, (CNA#1, CNA#2, CNA#3, CNA#4, and CNA#5). This deficient practice was evidenced by the following: On 7/24/25 at 10:17 AM, the surveyor requested the personnel education files for 5 CNA's1. CNA#1, with a date of hire of 8/17/22 no record of education was provided.2. CNA#2, with a hire date of 8/23/23 no record of education was provided.3. CNA#3, with a hire date of 7/2/24 no record of education was provided.4. CNA#4, with a hire date of 10/1/24 no record of education was provided.5. CNA#5, with a hire date of 7/22/23 no record of education was provided. On 7/21/25 at 12:20 PM, the survey requested CNA education from the Director of Nursing (DON). [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner on 1 of 3 Nursing Units (Unit 3). The deficient practice was evidenced by the following:On 7/21/25 at 11:25 AM, during a tour of the 3rd floor nursing unit, the surveyor observed cracked floor tiles and chipped paint throughout the unit on the low and high sides. The surveyor also observed soiled and cracked ceiling tiles on the low side near the elevator. On 7/22/25 at 10:40 AM, during an interview with the surveyor, the Director of Maintenance acknowledged that the floor, paint, and ceiling tiles were all in disrepair. [...]

Inspectors wroteNJ 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. [...]

Inspectors wroteComplaint #: 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteNumber 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). [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteComplaint #s: NJ00182470, NJ00182480 Based on interview, record review, and review of pertinent facility documents on 03/26/2025 and 04/01/2025, it was determined that the facility failed to (a) provide a safe environment for a wandering, ambulatory, and cognitively impaired resident (Resident #1) and (b) follow facility policy on thorough investigation of accident/incident. On 10/15/2024 Resident #1 was found stuck to the floor in an opened room where the floor was being redone. Resident #1 was found by a Certified Nursing Assistant (CNA) when she/he fell backwards and hit her/his head hard and started vomiting which resulted in Resident #1 being sent out to an acute care hospital #1[name] ER [emergency room] and later was transferred to acute hospital #2 [name] where she/he was found to have three (3) brain bleeds. Resident #1 was not in the facility during the survey. [...]

Inspectors wroteComplaint 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; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteREPEAT 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteREPEAT 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. [...]

Inspectors wroteAn 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]