Homestead Health Services

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 19 residents residing in the facility. The facility did not cool food with an approved cooling method. The facility did not use sanitizing solution per manufacturer's instructions to ensure proper sanitization of kitchen prep surfaces.

Inspectors wroteBased on staff interview and record review, the facility did not implement their abuse policy for 3 (Certified Nursing Assistant (CNA)-J, Registered Nurse (RN)-I, and CNA-K) of 8 employees reviewed for caregiver background checks. This practice had the potential to affect more than 4 of the 19 residents residing in the facility. CNA-J was hired on 12/30/25. CNA-J's background check information did not contain Department of Justice (DOJ) or Government Findings (GF) (formerly known as Integrated Background Information System (IBIS)) reports completed prior to CNA-J working in the facility and caring for residents. RN-I was hired on 1/12/22. RN-I's background check information did not include an updated Background Information Disclosure (BID) form or DOJ and GF reports. CNA-K was scheduled to begin working on 3/9/26. CNA-K's BID form was dated 11/15/24. [...]

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure written notice or a choice of room/roommate was provided for 1 resident (R) (R8) of 1 sampled resident. R8's belongings were transferred to another room on 1/23/26 against the wishes of R8's Power of Attorney for Healthcare (POAHC). R8's belongings were moved back to R8's room after Ombudsman (OMB)-L contacted the facility. Neither R8 or R8's POAHC received prior written notice of the reason for the room change. In addition, R8 was not given a choice of rooms or potential roommates.

Inspectors wroteBased on staff interview and record review, the facility did not provide Pre-admission Screening and Resident Review (PASRR) services for 1 resident (R) (R1) of 8 sampled residents. The facility did not contact the state mental health authority to pursue futher PASRR Level I screening after R1's PASRR Level I 30-day exemption expired.

Inspectors wroteBased on staff interview and record review, the facility did not provide care and services to maintain the highest practicable physical well-being for 1 resident (R) (R1) of 2 sampled residents. R1 had a diagnosis of ascites (an abnormal accumulation of fluid within the abdominal (peritoneal) cavity). Staff did not reweigh R1 in accordance with a physician's order or notify the physician after R1 gained 9.7 pounds in less than a month.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program to prevent the transmission of communicable disease and infection for 1 resident (R) (R14) of 8 sampled residents. Certified Nursing Assistant (CNA)-M did not appropriately change gloves and cleanse hands during incontinence care for R14.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure an activated Power of Attorney for Healthcare (POAHC), physician, or Hospice services were notified of a change in condition for 1 resident (R) (R2) of 3 sampled residents. R2 had a change in condition on 9/25/25. R2's activated POAHC (POAHC-C), physician, and Hospice service were not notified of the change in condition.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R1) of 2 sampled residents or their legal representative was informed in advance of the risks and benefits of prescribed medication or consented to receive the medication. R1 was prescribed naltrexone (an opioid antagonist medication used to treat compulsive behaviors). The facility did not obtain consent prior to administering the medication to R1.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R1) of 3 sampled residents. R1 had an order for gabapentin (an anticonvulsant medication used to treat nerve pain and control seizures) four times daily. R1 did not receive the scheduled medication timely as ordered. The facility's Medication Administration policy, dated 1/2025, indicates: .14. Medications are administered within 60 minutes of the scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center .On 9/12/25, Surveyor reviewed R1's medical record. R1 had diagnoses including type 2 diabetes with neuropathy and mild neurocognitive disorder with behavioral disturbance. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure staff transferred 1 resident (R) (R1) of 1 sampled resident in accordance with their plan of care and the facility's policy. On 4/20/25, R1 fell during a mechanical lift transfer and incurred bilateral distal femur fractures when Certified Nursing Assistant (CNA)-D did not follow R1's care plan or the facility's transfer policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a potential allegation of neglect was investigated for 1 resident (R) (R1) of 1 sampled resident. On 4/20/25, R1 incurred bilateral femur fractures when staff did not transfer R1 in accordance with R1's plan of care. The facility did not thoroughly investigate the potential allegation of negelct.

Inspectors wroteBased on staff interview and record review, the facility did not ensure residents 2 residents (R) (R3 and R4) of 10 sampled residents were free from significant medication errors. R4 has a diagnosis of epilepsy and is prescribed six medications for seizures, including clobazam (a benzodiazepine used to help control seizures) and Fycompa (an anti-epileptic medication used to treat and prevent seizures). R4 did not receive clobazam between [DATE] and [DATE] because the pharmacy had not received an order for the medication. R4 did not receive Fycompa from [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], and [DATE] through [DATE] due to pharmacy issues. R4 fell from R4's wheelchair during a seizure on [DATE] and incurred a head laceration that required two staples. R3 has a diagnosis of epilepsy and is prescribed Depakote for seizures. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Infection Preventionist (IP) had current certification for specialized infection prevention and control training. This had the potential to affect all 31 residents residing in the facility. IP-J's certification in a specialized infection prevention and control program was expired and no longer valid.

Inspectors wroteBased on staff interview and record review, the facility did not ensure their abuse policy was implemented for 4 of 8 employees reviewed for caregiver background checks. The facility did not complete background checks within a 4-year time frame for Certified Nursing Assistant (CNA)-L, CNA-M, CNA-N, and CNA-P.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy in 2 of 2 medication storage rooms. This practice had the potential to affect more than 4 of the 31 residents residing in the facility. On 12/2/24, Surveyor observed expired syringes and medications in 2 of 2 medication storage rooms.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 4 residents (R) (R18, R2, R11, and R80) of 4 residents. R18 had suspected Clostridium difficile (C. diff) but was not on the facility's infection surveillance line list. R2 was treated for a urinary tract infection (UTI) with antibiotic medication but was not on the facility's infection surveillance line list. R11 had diagnoses including infection and inflammatory reaction due to indwelling urethral catheter and a stage 3 pressure ulcer of the sacral region. R11 was not on enhanced barrier precautions (EBP). R80 was treated for osteomyelitis (bone infection) with intravenous antibiotics administered through a peripherally inserted central catheter (PICC). [...]

Inspectors wroteBased on staff, resident, and resident representative interview and record review, the facility did not ensure 1 resident (R) (R17) of 1 resident reserved the right to make choices about an aspect of their life that was significant to them. R17 was removed from the dining room table where R17 usually sat and moved to a table where staff assisted residents with eating. The facility did not consult with R17 or R17's Power of Attorney (POA) prior to the change.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the medical record for 1 resident (R) (11) of 13 sampled residents contained a signed advance directive. R11 was admitted to the facility on [DATE]. R11's medical record contained a signed statement of incapacity (SOI). R11's medical record did not contain a signed advance directive.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not notify a Physician, Guardian and/or Power of Attorney for Healthcare (POAHC) of changes in condition for 2 residents (R) (R3 and R4) of 13 sampled residents. R3 did not received prescribed Depakote for seizures on 11/13/24, 11/17/24, 11/25/24 and 11/26/24. R3 had seizures on 8/30/24 and 11/26/24. R3's Physician and Guardian were not notified of R3's change in condition. R4's Physician and POAHC were not notified when the facility was not able to provide R4 with prescribed seizure medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 residents (R) (R231, R81, and R26) of 4 sampled residents received a timely copy of a Notice of Medicare Non-Coverage (NOMNC) form when their Medicare services ended. The facility did not provide a NOMNC form (used to inform Medicare beneficiaries when their covered services are ending and their appeal rights) to R231, R81, and R26 at least two calendar days before their Medicare services ended.

Inspectors wroteBased on staff interview and record review, the facility did not report injuries of unknown origin to the State Agency (SA) for 2 residents (R) (R3 and R4) of 2 residents. R3's medical record indicated R3 had multiple injuries of unknown origin that were were not reported to the SA. R4's medical record indicated R4 had an injury of unknown origin that was not reported to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure injuries of unknown origin were thoroughly investigated for 2 residents (R) (R3 and R4) of 2 sampled residents. The facility did not thoroughly investigate multiple injuries of unknown origin for R3. The facility did not thoroughly investigate an injury of unknown origin for R4.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R11) of 5 sampled residents met the Pre-admission Screening and Resident Review (PASRR) requirements. R11 had a negative PASRR Level I Screen upon admission. A Level II Screen was not completed when R11 received a qualifying diagnosis and was prescribed medication.

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 2 residents (R) (R17 and R11) of 5 sampled residents. Staff did not follow through on lab orders or complete an appropriate assessment when R17 had symptoms of generalized weakness, pain with urination and pericare, and low urine output. As a result, R17 did not receive the necessary care and services to diagnose and treat an infection of vulvovaginitis (vaginal inflammation). R11 was hospitalized for heart failure from 3/11/24 to 3/13/24 and had orders for daily weights. Staff did not consistently complete daily weights for R11.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure adequate assistive devices were in place to prevent falls for 1 resident (R4) of 2 sampled residents. R4 had a care plan intervention to add anti-rollback bars to R4's wheelchair after R4 had a fall that resulted in a head laceration. The facility did not install the anti-rollback bars in a timely manner.

Inspectors wroteBased on staff and resident interview and record review, the facility did not provide pharmaceutical services to ensure medications were received as ordered for 3 residents (R) (R3, R4, and R18) of 13 sampled residents. R3's Depakote (an anticonvulsant medication used to treat seizures) order was increased to two 500 milligram (mg) tablets to equal 1000 mg at bedtime (HS) on 5/28/24 following a hospital discharge. The Depakote order was not sent to the pharmacy which caused R3 to miss multiple doses of the medication until 11/26/24. The facility did not consistently have R4's prescribed medications available for administration. In addition, staff documented medications were given when the medications were not available. R18 refused R18's prescribed sertraline (an antidepressant medication and refused to sign consent for sertraline. The facility continued to provide R18 with sertraline.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R11 and R14) of 5 sampled residents were monitored for adverse reactions or the effectiveness of antipsychotic medication. R11 was prescribed Seroquel (an antipsychotic medication) for dementia with behaviors. Staff did not monitor R11 for side effects, adverse reactions, or the effectiveness of the medication. R14 was prescribed lorazepam as needed (PRN) with a start date of 7/19/24. R14's lorazeapm order did not contain a stop date and was not reviewed by R14's provider after 14 days.

Inspectors wroteBased on staff interview and record review, the facility did not ensure lab services were provided timely for 1 resident (R) (R18) of 5 sampled residents. The facility did not send a stool sample for testing in a timely manner for R18 who was diagnosed with Clostridium difficile (C. diff). A repeat test was ordered but not completed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure required nurse aid training was completed for 2 of 5 Certified Nursing Assistants (CNAs). CNA-Q was hired on 1/31/22. CNA-Q did not have 12 hours of in-service training during the most recent anniversary of hire year. CNA-R was hired on 7/26/23. CNA-R did not have 12 hours of in-service training during the most recent anniversary of hire year.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect all 37 residents residing in the facility. Food items were not covered and did not meet temperature safety requirements prior to lunch service on 8/14/23. Staff did not complete hand hygiene prior to donning gloves during lunch service on 8/14/23. Microwaves located in the dining room and kitchen contained dried food debris. Mixing bowls on a storage shelf were not stored upside down.

Inspectors wroteBased on staff interview and record review, the facility did not make a prompt and thorough effort to resolve a grievance for 1 Resident (R) (R17) of 14 residents. A grievance was filed on behalf of R17 on 8/7/23. The grievance was not thoroughly investigated, and the complainant did not receive a prompt response or resolution.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R29) of 2 sampled residents reviewed for hospitalization received the required information when transferred. R29 was transferred to the hospital on 6/25/23 and was not provided a written transfer notice.

Inspectors wroteBased on staff interview and record review, the facility did not ensure assessments were accurate for 3 Residents (R) (R17, R29, and R35) of 14 sampled residents and 1 closed record review. R17 had diagnoses of major depressive disorder and anxiety. R17's Annual Minimum Data Set (MDS) assessment, dated 1/17/23, indicated R17 did not have a serious mental health diagnosis. In addition, R17's Brief Interview for Mental Status (BIMS) was not assessed and the 9-question Patient Health Questionnaire (PHQ-9) (a diagnostic tool used to screen for the presence and severity of depression) was not completed. R29 had diagnoses of major depressive disorder and anxiety. R29's MDS assessment, dated 4/24/23, indicated R29 did not have a serious mental health diagnosis. In addition, R29's Return to Community Assessment (Section Q) was not completed. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 1 Resident (R) (R5) of 1 resident observed during the provision of cares. Certified Nursing Assistant (CNA)-C did not appropriately remove gloves and cleanse hands during the provision of cares for R5.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. This had the potential to affect all residents residing in the facility. The facility did not ensure DON (Director of Nursing)-B completed specialized training in infection prevention and control between designation as the IP on 5/2/23 and 8/14/23.