Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Homestead Health Services during CMS and state inspections, most recent first.
Improper Food Cooling and Sanitizing Practices: Surveyors observed multiple cooked foods stored in the cooler and freezer for future resident use, but the facility had no completed cooling log. The DM confirmed the foods were cooked, cooled, and saved for later use. Surveyors also found kitchen prep surfaces were sanitized with Cleanslate Knoxville Disinfectant-Sanitizer without the required 10-minute wet contact time and without rinsing food-contact surfaces with potable water afterward.
The facility failed to follow its abuse, neglect, and exploitation policy for 3 employees reviewed for background checks. A CNA began working before DOJ and GF reports were completed, an agency RN’s BID and background check renewal were not current until requested by the surveyor, and another CNA was scheduled to work without completed DOJ or GF reports. The DON and VPS-C confirmed the missing or delayed screening documentation and stated other individuals in the organization oversaw background checks.
A resident with dementia and impaired cognition was the subject of an attempted room change when staff tried to move the resident’s belongings to make room for other residents. The POAHC objected, denied giving consent, and reported no written notice was provided or choice of room or roommate offered. The Ombudsman intervened while the move was underway, and staff later acknowledged the facility was trying to increase census and had not documented proper permission.
PASRR screening for mental disorders or ID was not completed for a resident with depression who had intact cognition and was his or her own decision maker. The chart contained multiple PASRR Level I screens, including a 30-day hospital exemption and later screens noting antidepressant use and a mental health disorder, but no PASRR Level II screen was completed after the exemption expired. The SSD stated he or she lacked formal PASRR training and was unaware another Level I screen was required when the resident remained in the facility.
Failure to Reweigh Resident After Significant Weight Gain: A resident with ascites and cirrhosis gained 9.7 pounds in less than a month, but the record did not show a required re-weight or physician notification despite an order to reweigh after a 5-pound change. The facility policy required confirmation of significant weight changes and notification of the physician, and an LPN and the VPS both confirmed the missing re-weight and lack of documented physician notification.
Infection Control Lapse During Incontinence Care: A CNA provided incontinence care to a resident with dementia and diabetes while using the same soiled gloves to clean the perineal area, apply barrier cream, place a clean brief, and handle items in the bedside drawer. The CNA also removed and replaced the garbage bag without cleansing hands, and only sanitized hands afterward. The DON and IP stated staff should change gloves and complete hand hygiene after gloves are soiled during incontinence care.
A resident receiving Hospice services with multiple comorbidities, including heart failure, COVID-19, HTN, diabetes, and atrial fibrillation, experienced a significant change in condition characterized by moaning during care, increased RR, diaphoresis, lack of verbal response, low O2 saturation, and elevated blood sugar. Facility policy required immediate notification of the resident, physician, and the resident’s representative for such changes, but the activated POA, physician, and Hospice were not notified. The resident later died, and interviews with the POA, Hospice director, UM, and DON confirmed that the documented status change met criteria for a reportable change in condition that should have been communicated.
A resident with intact cognition and an activated POAHC was administered naltrexone for behavioral symptoms without prior informed consent from the resident or their representative. The DON confirmed that consent was only obtained after the medication had already been given, and the representative later revoked consent after reviewing potential side effects.
A resident with diabetes, neuropathy, and mild neurocognitive disorder did not receive gabapentin at the specific times ordered by the physician, despite clear instructions and facility policy requiring administration within a one-hour window. Multiple doses were given late, and this was confirmed by the DON and other staff during interviews.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
A resident with moderate cognitive impairment and multiple medical conditions sustained bilateral femur fractures during a transfer when staff did not follow the care plan requiring a two-person assist with a sit-to-stand lift. The facility failed to conduct a thorough investigation, as required by policy, by not interviewing the resident about the incident or other residents to rule out further neglect by the CNA involved.
Two residents with epilepsy in an LTC facility experienced significant medication errors due to pharmacy issues and staff inaction. One resident missed doses of clobazam and Fycompa, resulting in a seizure and head injury. Another resident missed increased doses of Depakote, leading to a seizure. The facility's Medication Reconciliation policy was not effectively implemented, contributing to immediate jeopardy.
The facility's designated Infection Preventionist (IP) did not have a current certification in specialized infection prevention and control training, as required. The IP, responsible for the infection prevention and control program, confirmed that their certificate had expired. The Director of Nursing, who was supposed to oversee the program, did not monitor it. This deficiency potentially affected all 31 residents.
The facility did not adhere to its abuse policy by failing to update caregiver background checks for four CNAs within the required four-year timeframe. The CNAs were hired in 2019, but their background checks were not updated until 2024, exceeding the compliance period. The Business Office Manager confirmed the oversight after a surveyor's review.
A surveyor found that a facility failed to store drugs and biologicals according to policy in two medication storage rooms. Expired syringes and medications, as well as unlabeled and undated packages, were observed. The ADON and DON confirmed the deficiencies, noting that medications should be properly labeled and disposed of when expired.
The facility failed to maintain an effective infection prevention and control program, as evidenced by the omission of residents with infections or conditions requiring Enhanced Barrier Precautions (EBP) from the infection surveillance line list. A resident with suspected C. diff and another with a UTI were not included in the surveillance, and EBP was not implemented for residents with chronic wounds and indwelling devices. The Infection Preventionist acknowledged these oversights, indicating a lapse in adherence to infection control policies.
A resident with severe cognitive impairment was moved to a different dining table without consulting them or their POA, violating their right to make significant life choices. The resident missed social interactions at their previous table, and the facility's policy on resident rights was not followed, leading to a deficiency.
A facility failed to ensure a resident's medical record contained a signed advance directive. The resident, admitted with dementia, diabetes, and congestive heart failure, had intact cognition but lacked a signed Power of Attorney for Healthcare (POAHC) document. The Director of Nursing was unaware of the unsigned paperwork, and the Social Services Director confirmed the oversight. The facility's admission agreement requires a complete and current copy of any advance directive, which was not obtained.
Two residents in an LTC facility did not receive prescribed seizure medications due to pharmacy issues, and their physicians and representatives were not notified as required. One resident experienced seizures, and the facility's Director of Nursing confirmed the lack of notification. Staff education was initiated to address the issue.
The facility did not provide a timely Notice of Medicare Non-Coverage (NOMNC) to three residents when their Medicare services ended. The NOMNC form, which should be delivered at least two days before the end of services, was not provided within the required timeframe. The Social Services Director confirmed the lapse in procedure.
The facility failed to report injuries of unknown origin for two residents to the State Agency. One resident had multiple injuries, including redness on the foot and bruises, which were not reported because the facility concluded no abuse occurred. Another resident had a large bruise with no known cause, and there was no documentation of a timely investigation to determine if it was reportable. The Director of Nursing did not provide documentation of an investigation, leading to a failure to report the injury.
The facility failed to thoroughly investigate injuries of unknown origin for two residents. One resident had multiple injuries attributed to a single incident without proper documentation or interviews, while another resident's large bruise was not thoroughly investigated, and a timely therapy evaluation was not conducted. The Nursing Home Administrator and Director of Nursing acknowledged the deficiencies in the investigation process.
A resident was admitted with a negative PASRR Level I Screen, but a Level II Screen was not completed after a new diagnosis and medication prescription. The resident had dementia, diabetes, and depression, and was prescribed bupropion. Interviews with the DON and SSD revealed uncertainty about PASRR requirements, leading to the deficiency.
The facility failed to provide necessary care for two residents. One resident with dementia and other health issues did not receive timely lab tests or appropriate follow-up for symptoms of weakness and painful urination. Another resident, hospitalized for heart failure, did not have daily weights recorded as ordered, impacting their care. The DON confirmed these deficiencies in care and monitoring.
A resident with dementia and epilepsy experienced a fall during a seizure, resulting in a head laceration. The facility failed to timely install anti-rollback bars on the resident's wheelchair as per the care plan, due to the bars not fitting the wheelchair. The Director of Nursing confirmed that interventions should be immediate, but the necessary equipment was unavailable, leading to a delay in addressing the fall risk.
The facility failed to provide adequate pharmaceutical services for three residents, leading to significant medication errors. A resident with severe cognitive impairment missed doses of Depakote due to a failure to send the order to the pharmacy. Another resident experienced missed doses of seizure medications due to unavailability and poor communication with the neurologist and pharmacy. A third resident refused sertraline, yet the facility continued to administer it, disregarding the resident's autonomy.
The facility failed to monitor two residents prescribed psychotropic medications. A resident on Seroquel for dementia was not monitored for side effects or effectiveness, lacking an AIMS assessment and care plan. Another resident was prescribed PRN lorazepam without a stop date, contrary to policy, and the order was not reviewed or discontinued as required. The DON confirmed these oversights.
A facility failed to provide timely lab services for a resident with C. diff. An OVA test was ordered but not completed due to a delay in sending the sample. A repeat test was ordered, but the results were not found in the medical record. The DON was unaware if the sample was sent.
The facility failed to ensure two CNAs completed the required 12 hours of in-service training, including dementia management and abuse prevention, as outlined in the Facility Assessment. Despite being responsible for monitoring training hours, the business office allowed the CNAs to continue working with residents without meeting the training requirements.
Improper Food Cooling and Sanitizing Practices
Penalty
Summary
Food was not stored and prepared in a sanitary manner. During a self-guided initial kitchen tour, surveyors observed multiple pre-cooked items stored in the walk-in cooler, including fried ham, ham, chicken, baked beans, beef gravy, and chili, as well as maple mustard pork chops in the walk-in freezer. These items were labeled with dates ranging from 2/26/26 to 3/7/26. A food cooling log was present near the walk-in cooler, but it contained no entries. During a later kitchen observation, the Dietary Manager verified that the items in the cooler and freezer were cooked, cooled, and saved for future resident consumption, and confirmed the facility did not have a cooling log for foods cooked and cooled for future use. The facility also did not use sanitizing solution according to the manufacturer's instructions for kitchen prep surfaces. Surveyors observed the facility using Cleanslate Knoxville Disinfectant-Sanitizer in the third compartment of the three-compartment sink, and the Dietary Manager stated staff prepared a bucket of sanitizing solution, wiped countertops with a cloth, and allowed the areas to dry. The manufacturer's directions required a pre-cleaning step for visibly soiled areas, fresh solution for each use, a 10-minute wet contact time, and rinsing with potable water for food-contact surfaces after sanitizing. The Dietary Manager verified the sanitizing solution was not left on surfaces for 10 minutes and kitchen prep areas were not rinsed with water after sanitization.
Failure to Complete Required Employee Background Checks
Penalty
Summary
The facility did not implement its abuse, neglect, and exploitation policy for 3 of 8 employees reviewed for caregiver background checks. CNA-J was hired and began working in the facility before DOJ and GF background reports were completed, and the BID form in the record was completed after the employee had already started caring for residents. RN-I’s background check file did not contain an updated BID form or DOJ and GF reports until the surveyor requested the information, and the renewal was not completed until that time. CNA-K was scheduled to begin work without completed DOJ or GF reports, and the BID form in the record was dated months earlier than the scheduled start date. The facility’s policy required screening of potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property and stated that background checks and re-checks would be completed consistently with applicable state law and regulations, with documentation maintained to prove the screening occurred. During the survey, the DON and VPS-C confirmed that CNA-J worked in the facility without completed DOJ and GF reports, RN-I’s background check renewal was not completed until requested by the surveyor, and CNA-K was scheduled to work without a completed background check. The DON and VPS-C also stated the facility did not have a Business Office Manager who completed background checks and that other individuals in the organization oversaw the process.
Failure to Provide Written Notice and Roommate Choice Before Room Change
Penalty
Summary
The facility did not ensure written notice or resident choice before attempting to change a resident’s room assignment. The resident, R8, had diagnoses including Alzheimer’s disease, vascular dementia, anxiety disorder, and major depressive disorder, and the most recent MDS indicated impaired cognition. R8’s room belongings were being moved on 1/23/26 when the resident’s activated POAHC objected, and the move was stopped after the Ombudsman contacted the facility. R8’s belongings were then returned to the room, and the resident later received a roommate. Staff interviews showed the facility was trying to move R8 to make room for other residents and to increase census. The Social Services Director and Nursing Home Administrator stated they spoke with the POAHC the day before the planned move and believed verbal permission had been given, but the POAHC denied giving consent and stated no written notice was received. The social services note did not document verbal permission for the room change. The facility also did not provide R8 with a choice of rooms or potential roommates before the attempted move. The resident’s family reported that the facility had previously moved R8 to a room with favorable sun exposure and quiet, and that the attempted January room change would have placed R8 with a roommate known to yell and scream, which the family said was not a good match for R8. The Ombudsman confirmed the family felt they had no say in the move and told staff the resident was not given choices. The facility’s own roommate policy stated residents’ preferences are to be considered and that written explanation is required when a resident is moved at the facility’s request.
PASRR Screening Not Completed After 30-Day Exemption Expired
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not provided for 1 resident with depression. The resident had a BIMS score of 15 out of 15, was his or her own decision maker, and the medical record contained three PASRR Level I screens but no PASRR Level II screen. The first PASRR Level I screen was a 30-day hospital exemption at admission, and later PASRR Level I screens noted a mental health disorder and prescriptions for fluoxetine and Wellbutrin, with one screen later reflecting that Wellbutrin had been removed. Despite these findings, a PASRR Level II screen was not completed. The Social Services Director stated he or she had worked in the role for a little over a year, had no formal PASRR training, and was self-learning the process. The SSD stated he or she was not aware of the requirement to complete another PASRR Level I screen if a resident remained in the facility after a 30-day exemption expired. The SSD also stated the resident had been admitted for rehabilitation and was supposed to transfer to another facility, and verified that the PASRR Level I screens were not submitted correctly and that a PASRR Level II screen was not completed for the resident who remained in the facility after admission.
Failure to Reweigh Resident After Significant Weight Gain
Penalty
Summary
The facility did not provide care and services to maintain the highest practicable physical well-being for a resident with ascites and cirrhosis of the liver when the resident gained 9.7 pounds in less than a month and was not reweighed in accordance with the physician’s order. The resident’s MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition. The physician had ordered monthly weights and a re-weight if there was a change of 5 pounds since the last weight, but the record did not show that the resident was reweighed after the weight increase was identified. The facility’s Weight Monitoring policy stated that any weight change of five pounds or more since the last weight assessment would be retaken for confirmation and that nursing staff would notify the physician of any unintended significant weight change. The resident weighed 285.8 pounds on 1/3/26 and 295.5 pounds on 2/1/26, but the medical record did not document a re-weight or physician notification. An LPN confirmed the 9.7-pound gain, stated a CNA had been asked to reweigh the resident, and verified that no re-weight or physician notification was documented. The VPS also confirmed the resident should have been reweighed and the physician should have been notified.
Infection Control Lapse During Incontinence Care
Penalty
Summary
The facility did not maintain an infection prevention and control program to prevent the transmission of communicable disease and infection for one resident, R14. The facility’s Hand Hygiene policy, revised 11/2/22, required staff to perform hand hygiene after handling contaminated objects, when moving from a contaminated body site to a clean body site during resident care, and after assistance with personal body functions. R14 was admitted with diagnoses including Alzheimer’s disease, dementia, and diabetes mellitus type 2, and the most recent MDS dated 2/3/26 showed a BIMS score of 9 out of 15, indicating moderately impaired cognition. On 3/8/26 at 12:59 PM, a surveyor observed CNA-M and CNA-O provide incontinence care for R14. CNA-M removed the wet brief and cleaned R14’s perineal area, then without changing gloves or cleansing hands retrieved barrier cream from the night stand drawer, applied it to R14’s groin, and returned the cream to the drawer. CNA-M continued using the same soiled gloves to place a clean brief under R14, assist R14 onto the left side, secure the brief, place the wipes package in the drawer, position a pillow under R14’s legs, and provide blankets. CNA-M then removed gloves, removed and replaced the garbage bag without cleansing hands, and only then sanitized hands. When interviewed immediately afterward, CNA-M stated gloves should be changed and hand hygiene completed after a resident’s brief is changed and a new brief is applied. The DON and Infection Preventionist later stated staff should change gloves and complete hand hygiene after gloves are soiled during incontinence care.
Failure to Notify POA, Physician, and Hospice of Resident’s Change in Condition
Penalty
Summary
The facility failed to notify an activated Power of Attorney for Healthcare (POAHC), the physician, and Hospice services of a significant change in condition for one resident. The facility’s policy on Change in Condition of a Resident, revised 9/20/22, required immediate notification of the resident, consultation with the physician, and notification of the resident’s representative when there is a significant change in the resident’s physical, mental, or psychosocial status. The resident involved was receiving Hospice services and had diagnoses including heart failure, COVID-19, hypertension, diabetes, and atrial fibrillation. An MDS assessment dated 9/21/25 showed a BIMS score of 14/15, indicating intact cognition, and the activated POAHC assisted the resident with medical decisions. On 9/25/25 at 5:22 AM, a progress note documented that the resident moaned during cares, had an increased respiratory rate, was diaphoretic, and was not talking. Vital signs at that time included a blood pressure of 130/51, respirations of 26, oxygen saturation of 85%, and blood sugar of 286. Despite these findings, the medical record contained no indication that the POAHC, physician, or Hospice services were notified of this change in condition. A Hospice note later documented that the resident died on 9/25/25 at 9:45 AM. During interviews, the POAHC stated they were not notified of the change in condition and were upset they were unable to be present when the resident died. The Director of Hospice Services, the Unit Manager, and the DON each confirmed that the 5:22 AM progress note reflected a change in condition that should have been reported to the POAHC, physician, and Hospice services at the time it was identified.
Failure to Obtain Informed Consent Prior to Administration of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident or their legal representative was informed in advance of the risks and benefits of a prescribed medication, naltrexone, and did not obtain consent prior to its administration. According to the facility's policy, residents or their representatives must be informed and provide consent before initiating or increasing psychotropic medications. In this case, the resident had an activated Power of Attorney for Healthcare (POAHC), and the medical record indicated that the resident was prescribed naltrexone for sexualized behaviors. The medication was administered without documented consent or prior notification to either the resident or the representative. Interviews and record reviews revealed that the resident had intact cognition and relied on their representative to consent to medications and treatments. The Director of Nursing (DON) confirmed that consent for naltrexone was only obtained after the medication had already been administered, and that the representative later revoked consent upon learning about potential side effects. The resident expressed being upset about not being informed or consulted before receiving the medication, which was against their rights as outlined in facility policy.
Failure to Administer Medication at Prescribed Times
Penalty
Summary
The facility failed to ensure the accurate and timely administration of medication for one resident who had an order for gabapentin to be given four times daily at specific scheduled times. The resident, who had diagnoses including type 2 diabetes with neuropathy and mild neurocognitive disorder but was cognitively intact and their own decision maker, had a physician order specifying gabapentin administration at 7:30 AM, 12:00 PM, 4:00 PM, and 8:30 PM, with instructions not to give the medication early. Review of the Medication Administration Record (MAR) revealed that on multiple occasions, the medication was administered outside the one-hour window allowed by facility policy, including doses given significantly late in both the morning and evening. Interviews with the resident's family representative, the Director of Nursing (DON), and the facility's President of Success confirmed concerns about the late administration of gabapentin and verified that the medication was not given at the prescribed times on several dates. The DON acknowledged that the specific administration times were requested by the family and ordered by the physician, and confirmed that the facility policy allows a one-hour window for administration unless otherwise specified. Despite this, the medication was not administered within the required timeframe, resulting in a failure to meet the resident's pharmaceutical needs as ordered.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Investigate Potential Neglect After Resident Injury During Transfer
Penalty
Summary
The facility failed to ensure a potential allegation of neglect was thoroughly investigated after a resident sustained bilateral femur fractures during a transfer. On the date of the incident, the resident, who had moderate cognitive impairment and multiple medical diagnoses including osteoporosis and a left artificial hip joint, was transferred from the edge of the bed using a sit-to-stand lift by a CNA. The resident's care plan at the time required a two-person assist for all transfers with a sit-to-stand lift. During the transfer, the resident's legs buckled, resulting in a fall and subsequent bilateral distal femur fractures that required surgical intervention. The incident report did not include an interview with the resident regarding the transfer or the equipment used, nor did it document the CNA's technique during the transfer. Further, the facility did not conduct interviews with other residents to determine if there were additional allegations of neglect or improper transfers involving the CNA. Both the Nursing Home Administrator and the Director of Nursing confirmed that resident interviews were not completed as part of the investigation, and the facility-reported incident documentation lacked a summary of an interview with the affected resident. This failure to follow the facility's abuse, neglect, and exploitation policy resulted in an incomplete investigation of the potential neglect.
Medication Errors Lead to Immediate Jeopardy for Residents with Epilepsy
Penalty
Summary
The facility failed to ensure that two residents with epilepsy were free from significant medication errors, leading to immediate jeopardy. One resident, diagnosed with epilepsy and dementia, was prescribed six medications for seizures, including clobazam and Fycompa. However, due to pharmacy issues, the resident did not receive clobazam for a period and missed multiple doses of Fycompa over several months. This resident experienced a seizure, fell from a wheelchair, and sustained a head laceration requiring staples. The resident reported having multiple seizures, some of which occurred when not on medication. Another resident with epilepsy, major depression, dementia, and anxiety was prescribed Depakote for seizures. The resident's bedtime dose of Depakote was increased, but the pharmacy did not receive the order, resulting in missed doses. The facility's contingency supply was exhausted, and the resident experienced a seizure. The Director of Nursing was not informed of the missed doses or the pharmacy's failure to fill the order until after the resident had a seizure. The facility's Medication Reconciliation policy was not effectively implemented, as evidenced by the failure to ensure prescribed medications were available and administered. Staff did not consistently notify the Director of Nursing or the residents' physicians and decision-makers about the unavailability of medications, leading to significant medication errors and immediate jeopardy for the residents involved.
Removal Plan
- Reviewed orders and medications on-hand to ensure medications were in-house and available to administer.
- Notified physicians, families, and residents of missing doses of medication.
- Educated staff on the facility's policy for when medication is unavailable.
- Initiated audits to ensure medications were administered as ordered.
Infection Preventionist Lacks Valid Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had a current certification in specialized infection prevention and control training, which is a requirement for long-term care facilities. The IP, identified as IP-J, was responsible for overseeing the infection prevention and control program but did not possess a valid certificate of completion for the necessary training. During the survey, the Nursing Home Administrator (NHA) was unable to provide the certificate upon request. IP-J later confirmed that the certificate had expired and was not valid. Additionally, IP-J indicated that the Director of Nursing (DON-B) was supposed to oversee the infection prevention and control program, but it was confirmed that DON-B did not monitor the program. This deficiency had the potential to affect all 31 residents residing in the facility.
Failure to Update Caregiver Background Checks
Penalty
Summary
The facility failed to implement its abuse policy by not ensuring timely completion of caregiver background checks for four Certified Nursing Assistants (CNAs). According to the facility's Abuse, Neglect, and Exploitation policy, background checks must be conducted on potential employees and re-checked in accordance with state laws and regulations. However, the facility did not complete background checks within the required four-year time frame for CNAs L, M, N, and P. These CNAs were hired on December 1, 2019, and their initial background checks were completed in November 2019, but were not updated until December 3, 2024, which is beyond the four-year requirement. During the survey, the Business Office Manager (BOM) indicated that the regional recruiter was responsible for completing background checks. Upon review, it was confirmed that the background checks for the CNAs were rerun on December 3, 2024, after the surveyor's request, confirming the original checks from November 2019 were out of compliance. This oversight in maintaining up-to-date background checks represents a failure to adhere to the facility's policy and state regulations, potentially compromising the safety and well-being of the residents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with their policy in two medication storage rooms. During an observation, a surveyor found expired syringes and medications, as well as unlabeled and undated packages of ipratropium bromide and sodium chloride saline vials. Specifically, the surveyor noted four unlabeled, undated open aluminum packages of ipratropium bromide, sixty-nine unlabeled and undated pink sodium chloride saline vials not in their original packaging, nine Once Care 1 ml insulin syringes that expired on January 31, 2024, thirty Assure 1 ml syringes that expired on January 25, 2023, one bottle of B-12 vitamin 1000 micrograms that expired in September 2024, and one bottle of oyster shell with calcium 250 milligrams and vitamin D that expired in May 2024. The Assistant Director of Nursing (ADON) confirmed that the medications and supplies were opened, unlabeled, and/or expired, acknowledging that they should be in their original packaging, labeled, and disposed of appropriately when expired. The Director of Nursing (DON) also confirmed that the expired medications should have been disposed of using the Drug Buster. This oversight in medication management had the potential to affect more than four of the thirty-one residents residing in the facility.
Inadequate Infection Control and Surveillance
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of inclusion of certain residents on the infection surveillance line list and the improper implementation of Enhanced Barrier Precautions (EBP). Resident 18, who was suspected of having Clostridium difficile (C. diff), was not included on the infection surveillance line list despite being tested for the infection. Similarly, Resident 2, who was being treated for a urinary tract infection (UTI) with antibiotics, was also omitted from the surveillance list. The Infection Preventionist (IP) acknowledged missing these entries and indicated that infections are only documented and surveilled upon receiving positive test results. Additionally, the facility failed to implement EBP for residents with conditions that warranted such precautions. Resident 11, who had an indwelling urethral catheter and a stage 3 pressure ulcer, was not placed under EBP despite having chronic wounds and a history of methicillin-resistant Staphylococcus aureus (MRSA) infection. The Assistant Director of Nursing (ADON) and the IP were unsure why EBP was discontinued for this resident, acknowledging that it should have been maintained due to the resident's condition. Resident 80, diagnosed with osteomyelitis and having a peripherally inserted central catheter (PICC) line, was also not placed under EBP upon admission. The IP confirmed that EBP should have been initiated for this resident due to the presence of wounds and the PICC line. The oversight was only corrected after the surveyor's observation, indicating a lapse in the facility's adherence to its own infection control policies.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to ensure a resident's right to make choices about significant aspects of their life was respected. A resident, who had severe cognitive impairment and an activated Power of Attorney (POA) for healthcare decisions, was moved from their usual dining room table to a table where staff assisted residents with eating. This change was made without consulting the resident or their POA. The resident expressed missing the social interaction with the other residents at their previous table and their POA confirmed they were not involved in the decision-making process regarding the table change. The facility's policy on resident rights emphasizes the importance of respecting and promoting resident choices, including being fully informed about changes in care or treatment. Despite this, the Nursing Home Administrator and Director of Nursing were unsure if the resident or their POA were consulted about the move. The Director of Nursing noted that the resident's food consumption had increased since the move, but acknowledged that residents should be consulted prior to such changes. The failure to involve the resident and their POA in the decision-making process led to a deficiency in honoring the resident's right to self-determination.
Failure to Ensure Signed Advance Directive for Resident
Penalty
Summary
The facility failed to ensure that the medical record for one resident contained a signed advance directive. The resident, who was admitted with diagnoses including dementia, diabetes, and congestive heart failure, had a Minimum Data Set (MDS) assessment indicating intact cognition. Despite this, the resident's medical record included an unsigned Power of Attorney for Healthcare (POAHC) document and a signed statement of incapacity (SOI). The facility's admission agreement requires residents to provide a complete and current copy of any advance directive or other written statements regarding treatment options or designation of a healthcare agent. During the survey, the Director of Nursing (DON) was unaware that the paperwork was unsigned and indicated that the Social Services Director (SSD) would address the issue. The SSD confirmed that the paperwork was not signed and was unsure of the reason. The facility should have obtained the signature of the resident's POAHC upon admission, as per the facility's procedures. This oversight resulted in a deficiency related to the resident's right to formulate an advance directive.
Failure to Notify Physician and Representatives of Medication Issues
Penalty
Summary
The facility failed to notify the physician, guardian, and/or Power of Attorney for Healthcare (POAHC) of changes in condition for two residents, R3 and R4, out of 13 sampled residents. R3, who had diagnoses including dementia with behaviors, seizures, and anxiety, did not receive prescribed Depakote for seizures on multiple occasions. Despite having seizures and missing medication doses, R3's physician and guardian were not notified of these changes in condition as required by the facility's policy. R3's medical record showed several instances where the facility was out of Depakote, and the pharmacy was unable to provide the medication. Progress notes indicated that the facility was aware of the medication shortages, yet there was no documentation of notification to R3's physician or guardian. The Director of Nursing (DON) confirmed the lack of notification and stated that staff are expected to notify the resident's physician and representative when medication is not available. Similarly, R4, who had diagnoses including dementia and epilepsy, did not receive prescribed seizure medications due to issues with obtaining prescriptions from the pharmacy. R4's physician was only notified after multiple missed doses, and the POAHC was not informed until much later. The DON verified that staff should have notified R4's physician and POAHC when medications were missed, but documentation of such notifications was not provided. The facility began staff education to address this issue, but the deficiency was noted during the survey period.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a timely Notice of Medicare Non-Coverage (NOMNC) form to three residents, R231, R81, and R26, when their Medicare services ended. According to CMS guidelines, the NOMNC form must be delivered at least two calendar days before the end of Medicare-covered services. However, R231's Power of Attorney for Health Care signed the form a day after the services ended, R81 signed the form one day before the services ended, and R26 signed the form one day before the services ended. This indicates that the facility did not adhere to the required timeline for notifying residents about the termination of their Medicare services. The Social Services Director confirmed that residents should be notified and the NOMNC forms should be signed two days prior to the end of their Medicare services, which was not the case for the residents mentioned. This deficiency was identified through staff interviews and record reviews conducted by the surveyor.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for two residents to the State Agency (SA) as required by their policy. Resident 3 (R3) had multiple injuries, including redness on the foot, a bump on the head, and bruises on the hand and thumb, which were not reported to the SA. The Nursing Home Administrator (NHA) indicated that these injuries were not reported because the facility concluded within the two-hour reporting window that R3 was not abused. However, the injuries developed over ten days, and R3 was on anticoagulant medication, which could cause bruises to form if R3 bumped something. Despite these findings, the facility did not report the injuries to the SA. Resident 4 (R4) had a large bruise on the chest and back, with no known cause, which was also not reported to the SA. R4 was not cognitively impaired and denied harm by staff or residents. The NHA expected staff to report such injuries if a timely investigation could not identify a cause. However, there was no documentation of an investigation being completed within two hours to determine if the injury was reportable. The Director of Nursing (DON) did not provide documentation of an investigation, leading to a failure to report the injury to the SA.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure thorough investigations of injuries of unknown origin for two residents, R3 and R4. For R3, the facility did not adequately document the steps taken to determine that multiple injuries, including a head bump, bruised left hand, and bruised left thumb, were not due to abuse or neglect. These injuries developed over a period of ten days, and the facility attributed them to an incident on 9/1/24 during care. However, there was no documentation of a root cause analysis, care plan updates, or staff education, and the investigation lacked staff and resident interviews. For R4, the facility did not conduct a thorough investigation into a large bruise that extended from the chest to the back, discovered on 8/5/24. The facility provided only an IDT note and a skin assessment as documentation. The IDT suggested the bruise might have occurred due to R4's arm rubbing against the wheelchair's metal arm, but there was no documentation of a timely therapy evaluation or a comprehensive investigation to rule out abuse. The Nursing Home Administrator acknowledged the deficiencies in the investigation process, including the lack of documentation and interviews. The Director of Nursing confirmed that R4 should have been evaluated by therapy promptly after the IDT's recommendation, but this did not occur until the week of 12/2/24, with no recommendations made. These oversights indicate a failure to adhere to the facility's policy on investigating injuries of unknown origin thoroughly.
Failure to Complete PASRR Level II Screen for Resident
Penalty
Summary
The facility failed to ensure that a resident met the Pre-Admission Screening and Resident Review (PASRR) requirements. The resident, identified as R11, was admitted with a negative PASRR Level I Screen. However, a Level II Screen was not completed when the resident received a qualifying diagnosis and was prescribed medication. The resident's medical record indicated diagnoses of dementia, diabetes, and depression, with a Minimum Data Set (MDS) assessment showing intact cognition. The resident was prescribed bupropion extended release for depression, but the necessary PASRR Level II Screen was not conducted following this change in condition. Interviews with facility staff revealed a lack of understanding and adherence to the PASRR process. The Director of Nursing (DON) and the Social Services Director (SSD) were both unsure of the requirements for completing a new PASRR when a new mental illness diagnosis or psychotropic medication was ordered. This lack of clarity and failure to follow the PASRR protocol resulted in the deficiency identified by the surveyor.
Failure to Provide Necessary Care and Monitoring for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for two residents, R17 and R11. For R17, the staff did not follow through on lab orders or complete an appropriate assessment when the resident exhibited symptoms of generalized weakness, pain with urination and pericare, and low urine output. Despite R17's symptoms and a request to see a doctor, there was a lack of follow-up after the resident was discharged from the hospital with a negative urine culture. The facility's Director of Nursing (DON) confirmed that there was incomplete follow-up on ordered tests and a failure to notify the required parties or involve the resident's physician to determine the cause of the symptoms. R17, who had diagnoses including dementia, type 2 diabetes mellitus with diabetic chronic kidney disease, and transient ischemic attack, experienced a significant change in condition. The resident's medical record indicated multiple instances of low urine output and painful urination, yet the necessary lab tests were not completed in a timely manner. The DON acknowledged that the Interdisciplinary Team did not meet to discuss R17's symptoms, and there was no action taken to address the resident's low urine output or pain during urination and pericare. For R11, who was hospitalized for heart failure, the facility failed to consistently complete daily weights as ordered by the physician. The resident's medical record was missing several weight entries, which were crucial for monitoring the resident's condition related to heart failure. The DON confirmed that the weights should have been recorded daily and that the nurses were responsible for ensuring this was done. This oversight in monitoring R11's weight trend could have impacted the resident's care and treatment plan.
Failure to Timely Install Anti-Rollback Bars on Resident's Wheelchair
Penalty
Summary
The facility failed to ensure adequate assistive devices were in place to prevent falls for a resident, identified as R4, who had a care plan intervention to add anti-rollback bars to their wheelchair. R4, who was not cognitively impaired and had diagnoses including dementia and epilepsy, experienced a fall in the dining room during a seizure, resulting in a head laceration that required staples. Despite the care plan being updated to include anti-rollback bars on the wheelchair, the facility did not install them in a timely manner. The Maintenance Director attempted to install the anti-rollback bars but found that the bars did not fit R4's wheelchair due to its width. The Director of Nursing confirmed that care plan interventions should be implemented immediately, but the necessary equipment was not available, leading to a delay in addressing the fall risk. This inaction contributed to the deficiency as the facility did not promptly provide the required assistive device to prevent further falls.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents, leading to significant medication errors. Resident 3, who had severe cognitive impairment and a court-appointed guardian, was discharged from the hospital with an increased order of Depakote for seizures. However, the facility did not send this order to the pharmacy, resulting in missed doses and a small seizure. The Director of Nursing (DON) was unaware of the depletion of the contingency supply and the failure to send the order, indicating a lack of oversight and communication within the facility. Resident 4, who was not cognitively impaired and had a Power of Attorney for Healthcare, experienced multiple instances where prescribed seizure medications were unavailable. Despite repeated attempts by staff to contact the neurologist and pharmacy, the medications were not provided timely, leading to missed doses and reported seizures. The facility's staff documented the administration of medications that were not available, further compounding the issue. Resident 18, who had moderately impaired cognition and was their own decision-maker, refused to take prescribed sertraline for depressive symptoms. Despite this refusal and the lack of consent, the facility continued to provide the medication, as indicated in the Medication Administration Record. This action was contrary to the resident's expressed wishes and highlights a failure to respect the resident's autonomy and decision-making rights.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring and documentation for two residents prescribed psychotropic medications. Resident 11, who had a diagnosis of dementia with behaviors, was prescribed Seroquel, an antipsychotic medication, but was not monitored for side effects, adverse reactions, or the effectiveness of the medication. The resident's medical record lacked an Abnormal Involuntary Movement Scale (AIMS) assessment and an antipsychotic monitoring care plan, which are required by the facility's policy. The Director of Nursing confirmed that the AIMS assessment was only completed after the surveyor's review. Resident 14, diagnosed with dementia, Alzheimer's disease, and anxiety, was prescribed lorazepam on an as-needed basis without a stop date, contrary to the facility's policy that requires PRN orders for psychotropic drugs to be limited to 14 days unless reviewed by a provider. The resident's PRN lorazepam was not administered for several months, and the order was not reviewed or discontinued as required. The Director of Nursing acknowledged the oversight in the PRN order management.
Failure to Provide Timely Lab Services for Resident
Penalty
Summary
The facility failed to provide timely laboratory services for a resident diagnosed with Clostridium difficile (C. diff). The resident, who had cognitive communication deficit, legal blindness, and vascular dementia with mild anxiety, had a moderately impaired cognition with a BIMS score of 12 out of 15. An order was placed on 11/1/24 for OVA and C. diff testing, but the OVA test was not completed because the sample was not sent within the required two-hour time frame. A repeat OVA test was ordered on 11/4/24, but the medical record did not contain results from this test. The Director of Nursing confirmed the order for the repeat test but was unaware if the sample was obtained and sent to the lab.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs), identified as CNA-Q and CNA-R, completed the required 12 hours of in-service training during their most recent anniversary of hire year. CNA-Q, hired on January 31, 2022, only completed 2.75 hours of the required training between January 31, 2023, and January 31, 2024, and had not worked additional hours since January 31, 2024. Similarly, CNA-R, hired on July 26, 2023, completed 6.83 hours of training between July 26, 2023, and July 26, 2024, with an additional 2.75 hours completed in 2024. Both CNAs last worked on August 15, 2024. The Nursing Home Administrator (NHA) confirmed that the facility's business office was responsible for monitoring CNA hours to ensure compliance with the 12-hour training requirement. Despite this, CNA-Q and CNA-R continued to work with residents without completing the necessary training. The facility's Facility Assessment, dated September 3, 2024, outlined the requirement for in-service training to include dementia management and resident abuse prevention, among other competencies. However, the facility did not adhere to these requirements, resulting in a deficiency noted by the surveyor.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Holstein
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowdale Health Services | 0.7 mi | ★★★★★ | 10 | 0 |
| Rocky Knoll Health Care | 11.8 mi | ★★★★★ | 6 | 0 |
| Plymouth Health Services | 15.4 mi | ★★★★★ | 1 | 0 |
| Sheboygan Senior Community Inc | 19.3 mi | ★★★★★ | 16 | 0 |
| Complete Care At Manitowoc Llc | 19.5 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.