Inspection Reports for
Homestead Rehabilitation & Health Care Center
129 Morris Turnpike, Newton, NJ, 07860
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
19.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
269% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
42% occupied
Based on a July 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 24, 2025
Visit Reason
The inspection was conducted based on complaints alleging staff-to-resident abuse by a Certified Nursing Assistant (CNA#1) and intoxication of a Licensed Practical Nurse (LPN#1) while reporting to work, as well as concerns about care plan implementation and staff training.
Complaint Details
The complaint investigation was triggered by an anonymous complaint alleging staff-to-resident abuse by CNA#1 on 2/2/25 and intoxication of LPN#1 on 7/2/25. The abuse allegation against CNA#1 was not substantiated after investigation, but the facility failed to report the allegation timely. LPN#1 admitted to alcohol use prior to work and was disciplined and reported to authorities.
Findings
The facility failed to timely report suspected abuse allegations to the New Jersey Department of Health, failed to implement care plan interventions for a resident's skin integrity, did not evaluate CNA performance annually, and did not provide mandatory in-service training for CNAs. The intoxicated nurse was sent home and reported to the Board of Nursing and Department of Health.
Deficiencies (4)
Failed to timely report suspected abuse and results of investigation to proper authorities.
Failed to ensure care plan interventions were implemented for a resident's skin integrity.
Failed to evaluate the performance of all Certified Nursing Assistants on an annual basis.
Failed to ensure Certified Nurse Assistants received at least 12 hours of mandatory in-service training.
Report Facts
Residents reviewed for abuse: 2
CNAs reviewed for performance evaluation: 5
CNAs reviewed for mandatory training: 5
Inspection Report
Routine
Deficiencies: 16
Date: Jul 24, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with state and federal regulations related to resident care, safety, infection control, staffing, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and safe environment, incomplete physician progress notes, inadequate nursing staffing, failure to timely report abuse allegations, improper medication administration, lack of proper infection control practices, failure to provide scheduled showers and snacks, unsanitary kitchen and garbage areas, unsecured handrails, and incomplete staff education and competency evaluations.
Deficiencies (16)
Facility failed to maintain residents' living environment in a clean, sanitary, and homelike manner on 1 of 3 nursing units with cracked floor tiles, chipped paint, and soiled ceiling tiles.
Facility failed to timely report allegations of staff-to-resident abuse and intoxicated staff to proper authorities.
Facility failed to implement care plan interventions for skin integrity and bathing for Resident #67.
Facility failed to maintain infection control standards during wound care treatment for Resident #2.
Physician progress notes were incomplete and unsigned for multiple residents, with notes held in draft for months.
Facility failed to ensure a Registered Nurse worked 8 consecutive hours daily on multiple days.
Facility failed to evaluate CNA job performance annually for 5 CNAs reviewed.
Medication errors observed including confusing labeling of potassium tablets and late administration of seizure medications; facility policy allowed borrowing medication from residents which is not acceptable.
Facility failed to provide and document evening snacks for residents when there was a 14-hour gap between meals.
Facility failed to maintain proper kitchen sanitation including expired foods, unlabeled opened items, and dirty freezer fans.
Facility failed to keep dumpster and surrounding area free of garbage and debris.
Medical director failed to ensure policies were reviewed and updated as needed and failed to document physician visits timely.
Facility failed to maintain accurate and accessible medical records including missing shower documentation and incomplete grievance investigation statements.
Facility failed to develop and maintain an infection prevention and control program with all required elements and failed to follow infection control procedures for oxygen therapy tubing placement for 2 residents.
Handrails on 3rd floor nursing unit were missing return parts exposing sharp metal components, creating a hazard.
Facility failed to ensure CNAs received at least 12 hours of mandatory in-service training.
Report Facts
Physician progress notes held in draft: 9
Residents affected by deficient practices: 58
Days without RN coverage for 8 consecutive hours: 5
CNA personnel files reviewed: 5
Medications administered incorrectly: 2
Residents reviewed for infection control: 3
Residents reviewed for bathing and skin care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error and infection control findings |
| LPN #2 | Licensed Practical Nurse | Named in medication administration timing findings |
| LPN #3 | Licensed Practical Nurse | Named in medication packaging and administration findings |
| DON | Director of Nursing | Named in multiple interviews related to findings and facility policies |
| LNHA | Licensed Nursing Home Administrator | Named in multiple interviews related to findings and facility policies |
| MD #1 | Medical Director | Named in findings related to incomplete physician progress notes and policy review |
| FSD | Food Service Director | Named in kitchen sanitation and snack distribution findings |
| IP | Infection Preventionist | Named in infection control findings |
| MD | Maintenance Director | Named in handrail safety findings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 1, 2025
Visit Reason
The inspection was conducted based on complaints NJ00182470 and NJ00182480 regarding the facility's failure to provide a safe environment for a wandering, ambulatory, and cognitively impaired resident and failure to follow facility policy on thorough investigation of accident/incident.
Complaint Details
Complaint investigations NJ00182470 and NJ00182480 substantiated the facility's failure to provide a safe environment and proper investigation of an accident involving Resident #1 who suffered brain bleeds after a fall on 10/15/2024.
Findings
The facility failed to ensure a safe environment for Resident #1 who was found stuck to the floor in a room under renovation, resulting in a fall with head injury and three brain bleeds. The facility also failed to provide a complete incident/accident report and thorough investigation as required by policy. New management was unable to provide the incident/accident report during the survey.
Deficiencies (2)
Failure to provide a safe environment for a wandering, ambulatory, and cognitively impaired resident resulting in a fall and serious injury.
Failure to follow facility policy on thorough investigation and documentation of accident/incident.
Report Facts
Residents reviewed for incidents/accidents: 6
Brain bleeds: 3
Incident date: Oct 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Found Resident #1 stuck to the floor and witnessed the fall | |
| Nurse #1 | Documented initial assessment and vital signs after Resident #1's fall | |
| Licensed Practical Nurse (LPN) | Assessed Resident #1 after fall | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed during survey; unable to provide incident/accident report | |
| Director of Nursing (DON) | Interviewed during survey; unable to provide incident/accident report |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Jul 29, 2024
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
The survey was complaint-based and the facility was found compliant; no deficiencies were cited.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 3
Date: Jun 26, 2024
Visit Reason
The inspection was conducted based on complaints NJ #00174902, NJ00174912, and NJ00174921 regarding facility compliance with safety, staffing, and environmental standards.
Complaint Details
The complaint investigation was substantiated, identifying multiple deficiencies related to environmental safety, staffing shortages, and failure to report critical HVAC system failures.
Findings
The facility was found not in substantial compliance due to failure to maintain safe and comfortable room temperatures across multiple nursing units, failure to meet required staffing ratios on numerous shifts, and failure to timely report HVAC system interruptions to the New Jersey Department of Health. Corrective actions and plans of correction were documented.
Deficiencies (3)
Failure to maintain safe and comfortable room temperature levels in 2 of 3 nursing units, with temperatures exceeding the required range of 71 to 81 degrees Fahrenheit.
Failure to meet required minimum staff-to-resident ratios for certified nursing assistants on 19 of 21 day shifts and deficient total staff on 1 of 21 overnight shifts.
Failure to notify the New Jersey Department of Health immediately of HVAC system interruption lasting more than three hours.
Report Facts
CNA staffing deficiency: 19
Overnight staffing deficiency: 1
Room temperature: 86.9
Room temperature: 83.5
Room temperature: 84.9
Room temperature: 83.3
Room temperature: 82.4
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 20, 2024
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain safe and comfortable room temperature levels for residents in two of three nursing units (Second and Third Floor).
Complaint Details
Complaint NJ #00174902; NJ00174912; NJ00174921. The complaint was substantiated by observations of elevated room temperatures and malfunctioning air conditioning units.
Findings
The surveyor observed multiple rooms with elevated temperatures ranging from 81.7 to 86.9 degrees Fahrenheit, with several air conditioning units not functioning properly and water leaking from units in hallways. The facility administrator confirmed intermittent AC failures and ongoing repair efforts.
Deficiencies (1)
Failure to maintain safe and comfortable room temperature levels for residents in 2 of 3 nursing units.
Report Facts
Room temperatures: 86.9
Room temperatures: 81.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Person | Present during temperature checks and observations of AC units | |
| Administrator | Interviewed regarding AC unit repairs and intermittent failures | |
| Director of Nursing | Present during interview with Administrator |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Mar 12, 2024
Visit Reason
The inspection was conducted to verify the facility's plan of correction related to deficiencies in fall incident investigations and care plan updates, as well as to assess compliance with physician progress note documentation requirements.
Findings
The facility failed to ensure accurate investigation and root cause analysis of resident falls, specifically for Resident #3, and did not update care plans appropriately after falls. Additionally, the facility failed to ensure that physicians completed and documented monthly progress notes for 15 of 16 residents reviewed, with many notes held in draft status or missing.
Deficiencies (2)
Failure to ensure residents who had a fall incident were accurately investigated for falls root cause analysis and care plans were not updated to include appropriate interventions after falls.
Failure to assure that the physician responsible for supervising the care of residents completed monthly progress notes and signed orders at each required visit.
Report Facts
Residents reviewed for falls: 3
Residents with deficient physician progress notes: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #1 | Physician | Named in relation to incomplete and draft medical progress notes |
| Licensed Nursing Home Administrator (LNHA) | Administrator | Acknowledged responsibility for oversight of fall investigations and physician progress notes |
| Director of Nursing (DON) | Director of Nursing | Responsible for conducting reviews of fall investigations and overseeing fall committee meetings |
Inspection Report
Routine
Deficiencies: 13
Date: Mar 12, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility standards including resident care, medication administration, infection control, dietary services, and safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding, inaccurate medication documentation, improper wound care, incomplete fall investigations, respiratory care deficiencies, missing physician progress notes, medication errors, improper medication storage, dietary inconsistencies with mechanical soft diets, poor kitchen sanitation, and inadequate infection prevention practices including unqualified infection preventionist and improper sharps disposal.
Deficiencies (13)
Failed to maintain dignity during mealtime by staff standing while feeding residents requiring assistance.
Failed to accurately document medication refusals and daily weights as ordered.
Failed to provide appropriate pressure ulcer care and documentation for wounds.
Failed to conduct accurate fall investigations and update care plans after falls.
Failed to ensure proper respiratory care including oxygen equipment storage and oxygen delivery as ordered.
Physician progress notes were missing or incomplete for multiple residents over several months.
Narcotic medication shift-to-shift sign-in/out sheets were not consistently signed.
Medication error rate exceeded 5% due to administration errors including incorrect medication given and failure to administer with food as ordered.
Failed to maintain medication refrigerator temperature within required range.
Failed to prepare mechanical soft diet foods to proper consistency; foods served required cutting with a knife rather than being fork mashable.
Failed to maintain proper kitchen sanitation including unlabeled opened foods, dirty ovens, dusty storage areas, and improper food labeling.
Failed to follow proper infection control practices during wound care and medication administration; improper hand hygiene and contaminated sharps disposal.
Designated Infection Preventionist lacked required certification, training, and experience.
Report Facts
Medication error rate: 11.54
Missing physician progress notes: 15
Hand hygiene lathering time: 8
Medication refrigerator temperature: 32
Missing narcotic sign-in signatures: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration errors and infection control breaches |
| LPN #2 | Licensed Practical Nurse and Infection Preventionist | Named as Infection Preventionist without required certification or experience |
| RN #1 | Registered Nurse | Interviewed regarding oxygen therapy and medication refrigerator inspection |
| CDM | Certified Dietary Manager | Interviewed regarding dietary inconsistencies and kitchen sanitation |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding multiple deficiencies including medication errors and infection control |
| DON | Director of Nursing | Interviewed regarding wound care, infection control, medication errors, and staffing |
Inspection Report
Re-Inspection
Census: 61
Capacity: 128
Deficiencies: 29
Date: Mar 12, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Complaint Details
Complaint #s: NJ00171520, NJ00170797, NJ00169688, NJ00169710. Complaint investigations were completed during the survey.
Findings
Deficiencies were cited related to resident rights, professional standards of care, pressure ulcer care, accident hazards, pharmacy services, medication error rates, medication storage, food consistency, kitchen sanitation, infection control, staffing ratios, physician documentation, and multiple life safety code violations including building construction, fire safety, sprinkler system, fire alarm, electrical safety, and HVAC systems.
Deficiencies (29)
Failure to maintain resident dignity during feeding assistance; staff were observed standing while feeding residents instead of sitting at eye level.
Failure to follow professional standards in medication documentation and administration for multiple residents.
Failure to provide care consistent with professional standards for pressure ulcer prevention and treatment.
Failure to investigate and prevent falls adequately; care plans not updated appropriately.
Failure to properly store and maintain oxygen equipment and tubing; oxygen flow rates not consistently checked.
Failure to maintain medication refrigeration temperature within required range.
Failure to prepare food in proper consistency for residents on modified diets.
Failure to maintain proper kitchen sanitation, including labeling, cleaning, and storage of food items.
Failure to follow infection control practices during medication administration and disposal of sharps containers.
Infection preventionist did not have required specialized training and qualifications.
Failure to maintain required minimum direct care staff-to-resident ratios.
Failure to ensure residents were evaluated by a physician within 48 hours of admission; physician progress notes incomplete or missing.
Building construction type was Type II unprotected construction with 4 stories, exceeding the maximum allowed 3 stories for this construction type.
Egress doors had locking devices that could restrict emergency exit; delayed egress doors lacked required signage.
Exit discharge had a wooden ramp with overgrown vegetation and slippery surface, not providing a firm level walking surface.
Emergency illumination in day rooms was controlled by wall switches and could be turned off, failing to provide continuous or automatic emergency lighting.
Fire-rated doors to hazardous areas were missing or not labeled and did not close or latch properly.
Kitchen exhaust hood grease baffles were improperly installed; fire suppression system inspection was overdue and incomplete.
Fire alarm system inspections were not performed semi-annually; smoke detector sensitivity testing was not completed as required.
Sprinkler system did not provide coverage in an interior vestibule; fire pump was not maintained or tested weekly as required.
Fire extinguishers were missing monthly inspection tags and some had outdated inspection tags.
Food consistency for residents on mechanical soft diets was not prepared properly; whole fish sticks and whole vegetables served instead of minced or chopped consistency.
Milk and condiment containers in kitchen refrigerator were not labeled with open or use by dates; ovens were dirty; spice containers were not properly dated; kitchen and dry storage areas were dirty and disorganized; dietary staff did not fully cover hair; walk-in refrigerator and freezer were dirty.
Hand hygiene breaches observed during medication administration; contaminated saline solution handled without hand hygiene; sharps containers overflowing and not sealed in soiled utility rooms.
Facility failed to maintain required minimum direct care staff-to-resident ratios for multiple shifts.
Physicians failed to complete required resident evaluations and progress notes within required timeframes; many notes left in draft status.
Electrical panels in resident accessible areas were unlocked and unguarded against accidental contact.
Oxygen cylinders were stored unsecured and unprotected against tipping and damage.
Plan of Correction for fall incident was incomplete; care plan not updated with appropriate interventions after fall.
Report Facts
Census: 61
Total Capacity: 128
Medication doses observed: 26
Medication errors observed: 3
Medication error rate: 11.54
Deficient CNA staffing shifts: 7
Deficient CNA staffing shifts: 5
Missing fire extinguisher inspections: 3
Fire extinguishers with outdated inspection tags: 1
Fire extinguishers with March inspection only: 12
Missing ceiling tiles: 14
Open electrical panels: 3
Portable oxygen cylinders unsecured: 1
Fire pump inspection overdue: 4
Fire alarm inspections overdue: 10
Fire alarm inspections documented: 2
Fire alarm smoke detector sensitivity testing: 0
Grease baffles improperly installed: 2
Missing or damaged fire doors: 3
Missing or damaged ceiling tiles: 9
Fire extinguishers missing monthly inspection: 3
Fire extinguishers with outdated inspection tags: 1
Fire extinguishers inspected only in March: 12
Milk and condiment containers unlabeled: 4
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 14
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Hand hygiene breaches: 2
Overflowing sharps containers: 2
Physician progress notes missing: 15
Open electrical panels: 3
Deficient CNA staffing shifts: 7
Deficient CNA staffing shifts: 5
Building stories: 4
Missing fire doors: 3
Grease baffles improperly installed: 2
Fire alarm inspections overdue: 10
Fire pump maintenance overdue: 4
Fire extinguishers missing monthly inspection: 3
Fire extinguishers with outdated inspection tags: 1
Food consistency errors: 2
Kitchen sanitation deficiencies: 14
Hand hygiene breaches: 2
Overflowing sharps containers: 2
Physician progress notes missing: 15
Open electrical panels: 3
Unsecured oxygen cylinders: 1
Missing fire doors: 3
Missing or damaged ceiling tiles: 14
Missing or damaged ceiling tiles: 9
Missing or damaged ceiling tiles: 7
Missing or damaged ceiling tiles: 5
Missing or damaged ceiling tiles: 2
Missing or damaged ceiling tiles: 2
Missing or damaged ceiling tiles: 1
Missing or damaged ceiling tiles: 1
Missing or damaged ceiling tiles: 1
Missing or damaged ceiling tiles: 1
Missing or damaged ceiling tiles: 1
Missing or damaged ceiling tiles: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and hand hygiene deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in wound care treatment and hand hygiene deficiencies |
| RN #1 | Registered Nurse | Named in medication documentation and oxygen equipment deficiencies |
| CNA #1 | Certified Nurse Aide | Named in feeding assistance and diet consistency deficiencies |
| CNA #3 | Certified Nurse Aide | Named in feeding assistance and diet consistency deficiencies |
| Maintenance Staff Member | Named in multiple life safety code deficiencies including fire pump, electrical panels, and building construction | |
| Physician #1 | Named in physician progress notes deficiencies | |
| Physician #2 | Named in physician progress notes deficiencies | |
| DON | Director of Nursing | Named in staffing and physician documentation deficiencies |
| Administrator | Licensed Nursing Home Administrator | Named in physician documentation and fall investigation deficiencies |
| Environmental Service Consultant | Named in multiple life safety code and kitchen sanitation deficiencies | |
| Housekeeping Director | Named in sharps container and kitchen sanitation deficiencies | |
| Dietitian | Named in diet consistency and kitchen sanitation deficiencies |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Date: Feb 27, 2024
Visit Reason
The inspection was conducted based on a complaint survey (Complaint # NJ00168765) to determine compliance with staffing ratio requirements mandated by the state of New Jersey.
Complaint Details
Complaint # NJ00168765 was substantiated, identifying deficient CNA staffing on all 28 day shifts reviewed during the survey period.
Findings
The facility was found not in compliance with New Jersey staffing ratio requirements, failing to maintain the required minimum certified nursing assistant (CNA) staffing ratios on 28 of 28 day shifts reviewed. The facility submitted a plan of correction addressing CNA staffing shortages and recruitment efforts.
Deficiencies (1)
Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 28 of 28 day shifts.
Report Facts
CNA staffing deficiency days: 28
Census: 63
Sample size: 4
Required CNAs: 8
Actual CNAs: 4
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Sep 22, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers from 09/20/2023 to 09/22/2023.
Complaint Details
Complaint numbers NJ00160554, NJ00166197, NJ00167409, NJ00160905, and NJ00160955 were investigated. The facility was found to be out of compliance with staffing requirements but was in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards due to failure to meet required minimum staffing ratios for Certified Nursing Assistants (CNAs) on multiple day shifts across several periods in 2023, potentially affecting all residents. The facility submitted a plan of correction including CNA training, recruitment efforts, and monitoring programs.
Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 60 of 63 day shifts.
Report Facts
Survey Census: 66
Sample Size: 8
Deficient CNA staffing day shifts: 60
Staffing periods reviewed: 9
Inspection Report
Life Safety
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
A Life Safety Code Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Health Department from 09/20/23 to 09/22/23.
Complaint Details
Complaint NJ00166904 was investigated and no deficiencies were found.
Findings
The facility was found to be in compliance with the requirements of 42 CFR 483.90. No deficiencies were issued related to complaint NJ00166904.
Inspection Report
Abbreviated Survey
Census: 75
Deficiencies: 1
Date: May 27, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CDC recommended practices related to COVID-19.
Findings
The facility was found not to be in compliance with infection control regulations and failed to meet minimum staffing ratios for certified nursing assistants on 14 of 14 day shifts and 2 of 14 evening shifts reviewed, potentially affecting all residents.
Deficiencies (1)
Failure to ensure staffing ratios were met for 14 of 14 day shifts and 2 of 14 evening shifts reviewed.
Report Facts
Census: 75
Deficiencies cited: 1
Staffing counts: 8
Staffing counts: 9
Staffing counts: 6
Staffing counts: 9
Staffing counts: 6
Staffing counts: 9
Staffing counts: 7
Staffing counts: 4
Staffing counts: 5
Staffing counts: 5
Staffing counts: 5
Staffing counts: 4
Staffing counts: 5
Staffing counts: 5
Staffing counts: 6
Staffing counts: 5
Staffing counts: 6
Inspection Report
Routine
Deficiencies: 6
Date: May 19, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, notification of hospital transfers, care planning, wound care, pharmaceutical services, and infection control practices at Homestead Rehabilitation & Health Care Center.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy during procedures, failure to notify families and Ombudsman in writing of hospital transfers, incomplete care plans for residents receiving oxygen therapy, inadequate wound care practices, incomplete documentation on DEA 222 forms for controlled substances, and failure to follow proper infection control procedures by a phlebotomist.
Deficiencies (6)
Failure to provide full visual privacy for residents during procedures, including blood draws.
Failure to notify resident families or representatives and Ombudsman in writing for facility-initiated hospital transfers.
Failure to develop a comprehensive care plan for a resident receiving oxygen therapy.
Failure to provide appropriate pressure ulcer care, including not cleansing wound prior to applying topical treatment.
Failure to ensure DEA 222 forms were completed with sufficient detail for controlled medication accountability.
Failure to follow appropriate infection prevention and control measures by a phlebotomist.
Report Facts
Residents reviewed for privacy: 18
Residents reviewed for hospitalization notification: 2
Residents reviewed for comprehensive care plans: 21
Residents reviewed for pressure ulcer care: 3
DEA FORM-222 reviewed: 3
Phlebotomist observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding privacy and care plan deficiencies |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding privacy and care plan deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding notification procedures and DEA form responsibilities |
| Administrator | Administrator | Interviewed regarding privacy, notification, wound care, infection control, and DEA form deficiencies |
| Social Worker | Social Worker | Interviewed regarding notification procedures |
| Phlebotomist | Observed and interviewed regarding infection control and privacy deficiencies | |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan updates |
Inspection Report
Annual Inspection
Census: 76
Capacity: 128
Deficiencies: 16
Date: May 19, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to privacy violations during blood draws, failure to notify families of hospital transfers, incomplete care plans, improper wound care, incomplete narcotic record keeping, infection control breaches by a phlebotomist, staffing shortages, and multiple life safety code violations including fire door inspections, stairwell markings, emergency lighting, exit signage, sprinkler system maintenance, electrical wiring, HVAC ventilation, elevator testing, fire drills, gas and vacuum system inspections, and generator remote stop station.
Deficiencies (16)
Failed to provide full visual privacy for 2 of 18 residents during blood draws.
Failed to notify resident families or representatives in writing for facility-initiated hospital transfers for 2 residents.
Failed to develop a comprehensive care plan for a resident receiving oxygen therapy.
Failed to provide care consistent with professional standards during wound treatment for a resident.
Failed to ensure DEA 222 forms were completed with sufficient detail for controlled medications.
Failed to follow appropriate infection control measures during blood draws by a phlebotomist.
Failed to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey.
Failed to inspect fire doors annually as required.
Failed to provide stair tread marking stripes on stairwells.
Failed to provide emergency lighting at fire pump house and emergency generator transfer switch room.
Failed to ensure exit directional signs were installed and illuminated at all times, especially on temporary plastic barriers in COVID-19 wing.
Failed to maintain sprinkler system; diesel fire pump had non-operational gauges and leaks.
Failed to maintain electrical wiring; missing outlet cover, frayed wires, and improperly installed cords observed.
Failed to ensure resident bathroom ventilation systems were functioning in multiple units.
Failed to perform monthly firefighter emergency operations inspection and test of elevators with documented Phase I recall and floor operation.
Failed to provide a remote manual stop station for the emergency generator.
Report Facts
CNA staffing: 8
CNA staffing: 6
CNA staffing: 6.5
CNA staffing: 6.75
CNA staffing: 8
CNA staffing: 8
CNA staffing: 8
CNA staffing: 5
CNA staffing: 5.75
CNA staffing: 6
CNA staffing: 8
CNA staffing: 7
CNA staffing: 7
CNA staffing: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phlebotomist | Named in infection control and privacy deficiency related to blood draws. | |
| Licensed Practical Nurse #1 | Interviewed regarding privacy during blood draws and care plan updates. | |
| Licensed Practical Nurse #2 | Interviewed regarding privacy concerns and care plan updates. | |
| Social Worker | Interviewed regarding hospital transfer notification process. | |
| Receptionist | Interviewed regarding hospital transfer notification process. | |
| Director of Nursing | Interviewed regarding hospital transfer notification process and narcotic record keeping. | |
| MDS Coordinator | Interviewed regarding care plan updates. | |
| Administrator | Interviewed regarding multiple deficiencies and corrective actions. | |
| Maintenance staff member | Interviewed regarding fire door inspections, emergency lighting, sprinkler system, electrical wiring, ventilation, elevator testing, fire drills, and generator remote stop station. | |
| Regional Plant Operations Director | Interviewed regarding fire door inspections, emergency lighting, sprinkler system, electrical wiring, ventilation, elevator testing, fire drills, and generator remote stop station. |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Date: Oct 21, 2021
Visit Reason
The inspection was conducted based on a complaint (#NJ 146772) alleging the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Complaint Details
Complaint # NJ 146772 regarding failure to maintain minimum CNA staffing ratios was substantiated based on observations, interviews, and staffing reports.
Findings
The facility was found deficient in maintaining the minimum CNA staffing ratios on 14 of 14 day shifts reviewed, with CNAs assigned to more residents than allowed by state law. Interviews with staff confirmed understaffing and the facility acknowledged awareness of the staffing requirements and efforts to meet them.
Deficiencies (1)
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey law.
Report Facts
Residents present: 75
CNA staffing deficiency days: 14
CNA staffing required: 10
CNA staffing actual: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) | Interviewed staff who reported being assigned 14 residents on the day shift | |
| Staffing Coordinator | Interviewed and stated facility awareness of staffing ratios and efforts to meet requirements | |
| Director of Nursing (DON) | Interviewed and stated facility awareness of staffing ratios |
Inspection Report
Abbreviated Survey
Census: 73
Deficiencies: 0
Date: Oct 19, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 73
Deficiencies: 0
Date: Jan 15, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 15
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