The New Homestead Care Center

Inspectors wroteBased on clinical record review, observations, staff interviews, and policy review the facility failed to provide professional standards of care by not providing treatments per physician orders for 2 of 2 (Residents #30, #3). The facility reported a census of 47 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 3 of 4 residents reviewed (Residents #10, #3, and #30). The facility failed to perform hand hygiene and change gloves when completing resident cares, failed to ensure use of enhanced barrier precautions (EBP) when required, and failed to maintain a catheter bag off the floor. The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, resident, family, and staff interview, and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 3 of 3 residents (Resident #1, #2 and #4) reviewed for call lights. The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, facility document review, resident interviews, observation and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 5 of 5 residents reviewed (Resident #1, #2, #40, #22 and #42). The facility reported a census of 50 residents.

Inspectors wroteBased on observations, resident interviews, staff interviews, and policy review the facility failed to provide food at an appetizing temperature to 2 of 5 residents ( Residents #1, and #40) reviewed. The facility reported a census of 50 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to properly label stored food and failed to maintain sanitary practices by failing to prevent cross-contamination during meal service. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical document review, staff interview, and policy review the facility failed to notify a resident 48 hours in advance when the end of a Medicare Part A stay or when all of Part B therapies were ending to 2 of 3 residents (Resident #204, and #205) reviewed. The facility reported a census of 50 residents.

Inspectors wroteBased on record review, policy review, and staff interview the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for 1 of 3 residents (Resident #26) reviewed. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, family interview, staff interview and policy review the facility failed to offer residents a bath or shower on a regular basis for 1 of 3 residents reviewed (Resident #103.) The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, observation, staff interviews and facility document review, the facility failed to implement timely interventions to prevent pressure ulcers for 1 of 2 residents reviewed. In an observation on 4/22/25 at 8:35 AM, Resident #16 was found to have a small open sore on her buttocks. On 4/23/25 at 7:00 AM nursing staff had not yet followed up with a skin assessment or intervention. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to offer Range of Motion (ROM) exercises for 1 of 2 residents reviewed (Resident #16). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to have a system in place to ensure residents who received warfarin (blood thinner) along with an antibiotic also received more frequent therapeutic monitoring for 1 of 1 resident (#41) reviewed. The facility reported a census of 50.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure that staff used adequate hand hygiene techniques to prevent the spread of pathogens for 2 of 3 residents (Resident #16, and #30). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, facility document review, personnel file review, resident interview, family interview, staff interviews, and facility policy review, the facility failed to protect 1 of 3 residents (Resident #1) reviewed from abuse. The facility reported a census of 46 residents.

Inspectors wroteBased on clinical record review, observations, resident interviews and staff interviews, the facility failed to answer the residents' call light in less than 15 minutes for 3 resident call lights seen during observation. Additionally, two residents (Resident #1 and Resident #50) reported extended call light response time during resident interviews. The facility reported a census of 48 residents.

Inspectors wroteBased on clinical record review, staff interviews, facility policy review, and guidance from the RAI manual, the facility failed to ensure the Minimum Data Set (MDS) assessment of each resident accurately reflected the resident's status at the time of the assessment for 2 of 15 residents reviewed (Resident #3 and Resident #10) . The facility reported a census of 48 residents.

Inspectors wroteBased on clinical record review, and staff interview, the facility failed to complete the residents restorative program 3-5 times a week for 1 of 2 residents reviewed for restorative program (Resident #15). The facility reported a census of 48 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review the facility failed to follow infection prevention standards during incontinence cares for 1 of 4 residents review for incontinence cares (Resident #16). The facility reported a census of 48 residents.

Inspectors wroteBased on clinical record review, observation, staff interviews and facility policy, the facility failed to administer tube feeding per physician orders for 1 of 1 resident reviewed for tube feeding (Res #51). The facility reported a census of 48 residents.

Inspectors wroteBased on observation, policy review, and staff interview the facility failed to implement appropriate infection prevention and control practices during medication administration by staff not completing hand hygiene between residents and touching pills with a bare hand. The facility reported a census of 48 residents.

Inspectors wroteBased on resident record review, facility record review, Resident [NAME] of Rights, resident and staff interview, the facility failed to treat each resident with dignity and honor the choices of care for 1 of 4 residents reviewed (Resident #1). Findings Include: The Minimum Data Set (MDS) Assessment of Resident #1 dated 7/6/23 identified a Brief Interview of Mental Status (BIMS) score of 14, which indicated cognition intact. The MDS revealed the resident required extensive assistance of 1 staff member for bathing. The Care Plan, review date 7/10/23, identified a Focus Area of the resident requiring assistance for Activities of Daily living. The Care Plan directed staff the resident was to have a whirlpool/shower two times per week. On 9/19/23 at 10:23 am, Resident #1 recalled a recent incident with Staff A, Certified Nurse Aide (CNA). [...]