Homestead Post Acute

Based on observation, interview, review of the Food and Drug Administration web site, and review of the facility's documents and policy, the facility failed to store and serve food in a sanitary manager. Observations on 07/15/2025 revealed 5 of 5 nourishment refrigerator/freezers did not have a thermometer, and the freezer temperatures were not recorded. Also, observations on 07/15/2025 during the breakfast tray line revealed not all modified texture foods were listed, and the temperatures were not recorded.The findings include:Review of the facility's policy titled, Food Preparation and Service, revised 11/2022, revealed it referenced the United States Food and Drug Administration (FDA) Food Code. Per the policy, the term danger zone meant temperatures in the range, between 41 degrees Fahrenheit (F) and below 135 degrees F, that allowed the rapid growth of pathogenic microorganisms that could cause foodborne illness. The policy stated potentially hazardous food (PHF), or Time/Temperature Control for Safety (TCS) foods held in the danger zone for more than four hours or six hours…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's policy, the facility failed to store all drugs and biologicals in locked compartments for 1 of 6 treatment carts. Observation on 07/14/2025 at 2:45 PM revealed the 500-A Unit treatment cart was left unlocked and unattended. The findings include: Review of the facility's policy titled, Storage of Medications, revised November 2020, revealed compartments containing drugs and biologicals were to be locked when not in use, and unlocked carts were not to be left unattended.Observation on 07/14/2025 at 2:45 PM revealed the 500-A Unit treatment cart was left unlocked and unattended. On 07/14/2025 at 3:13 PM, the State Survey Agency (SSA) Surveyor went through the cart with the Nurse Manger of the area, Licensed Practical Nurse (LPN) 1. Items in the unlocked cart were one double antibiotic ointment for Resident (R) 82; one triple antibiotic ointment for R83; two [NAME] and castor oil wound dressings, one for R26 and one for R124; one medi-honey for R84; one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's policy and protocol, it was determined the facility failed to protect residents from infection for 1 of 3 sampled residents who had an indwelling urinary catheter, Resident (R) 84.Observation on 07/14/2025 at 4:05 PM revealed R84's indwelling urinary catheter bag was dragging on the floor under the resident's wheelchair. The findings include:Review of the facility's policy titled, Infection Prevention and Control Program, policy revision not dated, revealed the infection prevention control program provided a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. Review of the facility's Catheter Care Protocol, not dated, revealed the catheter tubing and drainage bag were kept off the floor. Review of R84's admission Record revealed the facility originally admitted the resident on 01/13/2017 with diagnoses to include multiple sclerosis, diabetes with diabetic nephropathy, and transient cerebral ischemic attack. Review of R84's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, review of the facility's job descriptions for the Infection Preventionist and the Maintenance Director, and review of the facility's policy, the facility failed to establish written standards, policies, and procedures by having a documented water management program based on nationally accepted standards for all residents (census 122). The facility did not have a water management program that included a description of the building's water systems where Legionella and other opportunistic waterborne pathogens could grow and spread, flow diagrams, measures to prevent growth, testing protocols, acceptable ranges, and established ways to intervene when control limits were not met. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 12/2023, revealed the infection prevention and control program (IPCP) addressed the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment, and the program was reviewed annually and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive, resident-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 residents investigated for trauma-informed care, Resident (R) 85. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, revealed the facility was to develop and implement a person-centered care plan for each resident that included measurable objectives to meet the residents physical and psychosocial needs. Further review revealed the care plan was to include trauma-informed services, and interventions were chosen after data gathering and careful consideration of the relationship between the resident's problem areas and their causes. Review of R85's admission Record revealed the facility admitted R85 on 11/01/2021 with diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure that residents who were trauma survivors received trauma-informed care, including accounting for the resident's experiences in order to eliminate or mitigate triggers that may have caused re-traumatization of the resident for 1 of 3 residents sampled for trauma informed care, Resident (R) 85. The findings include: Review of the facility's policy titled, Behavioral Assessment, Intervention, and Monitoring, revised 03/2019, revealed the facility expected to provide residents with services to attain or maintain their highest level of mental and psychosocial function. Further review revealed the interdisciplinary team was to thoroughly assess each resident for a history of mental disorders, behavioral symptoms, including sleep disturbances, for underlying causes and to address any modifiable factors. Review of R85's admission Record revealed the facility admitted R85 on 11/01/2021 with diagnoses including sequelae of cerebral infarction (after-effects of a stroke),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure grievances presented by the Family Council involving resident care were addressed in writing. Review of the Family Council meeting minutes and responses provided by the facility revealed multiple instances of actions taken to address grievances that had not been presented to the Family Council. The findings include: Review of the facility's policy titled, Grievances/Complaints, Filing, not dated, revealed any resident, family member, or appointed resident representative could file a grievance concerning care or treatment or lack thereof, or any other concerns regarding his or her stay at the facility. The policy stated all grievances stemming from resident or family groups concerning issues of resident care would be considered, and actions on such issues would be responded to in writing, including a rationale for the response. Finally, the policy stated the person filing the grievance or complaint would be informed verbally and in writing of the findings and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, and interview, and review of facility Policy, it was determined the facility failed to provide each resident with food that is palatable, and at a safe and appetizing temperature. Staff interview and record review revealed food temperatures from the lunch meal tray line were not immediately documented on 12/10/19. [NAME] #1 stated she relied on memory to document food temperatures from tray line after meal service. Further, [NAME] #1 stated she obtained food temperatures for tray line from the stove and not from the steam table. In addition, observation of a test tray on 12/10/19, during the noon meal service for Unit B, revealed temperatures were not at acceptable temperatures for point of service. Furthermore, observation of a test tray on 12/12/19, during the breakfast meal service for Unit C, revealed temperatures were not at acceptable temperatures for point of service. The findings include: Review of the facility's Food Preparation and Service Policy, undated, revealed previously cooked food must be reheated to an internal temperature of 165 degrees for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure food was stored, prepared and distributed in accordance with professional standards for food safety service. Observation during initial tour of the kitchen on 12/10/19, revealed a shelving unit contained beverage pitchers which were randomly stored upside down or right side up, leaving the tops of some pitchers open. In addition, the shelves themselves were soiled with crusty dried debris. Also, during initial tour of the kitchen, the ice machine was observed to have a shield inside the ice compartment which was covered with gray-brown residue. The findings include: Review of the facility Sanitization Policy, undated, revealed the food service area shall be maintained in a clean and sanitary manner. Additionally, all equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Further review of the Policy, revealed ice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.