Homestead Health Center

In the surveyor’s words

From the most serious findings on record at Homestead Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF690Jan 4, 2024

  The facility reported a census of 42 residents with two reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) management. Based on observation, record review, and interview the facility failed to ensure appropriate indwelling urinary catheter care for Resident (R)1. On 12/24/23 at approximately 08:30 PM Licensed Nurse (LN) G flushed R1's indwelling urinary catheter, without a physician order, and used a non-sterile 60 milliliter (ml) syringe from R1's bathroom, which possibly contained some bleach and water mixture (used to clean R1's dependent drainage bag). R1 complained of burning pain immediately upon injecting the flush and LN G realized she performed the flush on the wrong patient. […]

• Immediate jeopardy, isolatedF726Jan 4, 2024

  The facility reported a census of 42 residents with two reviewed, Resident (R)1 and R2, for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) management. Based on observation, record review, and interview the facility failed to ensure nursing staff competency when LN G flushed R1's indwelling urinary catheter, without a physician order, and used a non-sterile 60 milliliter (ml) syringe from R1's bathroom, which possibly contained some bleach and water mixture (used to clean R1's dependent drainage bag) on 12/24/23 at approximately 08:30 PM. R1 complained of burning pain immediately upon injecting the flush and LN G realized she performed the flush on the wrong patient. […]

• Actual harm, isolatedF689Aug 28, 2024

  The facility reported a census of 43 residents with 12 included in the sample, and eight residents reviewed for accidents. Based on observations, interviews, and record reviews, the facility failed to ensure that four residents remained free of accident hazards related to falls, Resident (R) 21, R35 and R12, and included one resident, R37, who continued to fall and obtained additional injuries. Additionally, the facility failed to ensure that R20 remained free of accident hazards when staff pushed R20's wheelchair without foot pedals and his feet were suspended above the ground. These deficient practices had the potential to negatively affect the physical and psychosocial well-being of the residents. […]

• No harm, potential for more than minimal, widespreadF801May 14, 2026

  Based on observation, interview, and record review the facility failed to employ a full-time certified dietary manager for the residents who resided in the facility and received meals from the facility kitchen. Findings included:- Upon request the facility was unable to provide evidence of a Certified Dietary manager (CDM). On 05/12/26 at 07:40 AM, Dietary Manager BB revealed the facility does not have a CDM and said License Nurse (LN) G does act as the CDM when needed. On 05.13/26 at 11:30 AM, Administrative Staff A revealed the Registered Dietitian monitors the kitchen and dining and Dietary Manager BB oversees the ordering for the kitchen and attends the food meetings. Administrative Staff A stated three CDM have left and the facility was currently advertising for a CDM. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2026

  Based on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions to prevent potential food borne bacteria. Findings included:- On 05/12/26 at 07:40 AM, an initial tour of the main kitchen revealed refrigerator temperatures were missing for the following date: 05/04/26, 05/05/26, 05/06/26, 05/07/26, 05/09/26 and 05/10/26. During the tour three male dietary staff wearing beard guards without covering mustaches, including Dietary Manager BB. Additionally, the hand-washing station lacked a foot activated trash can, and the dishwasher chemical sanitization needed repaired. the staff did not use the three-sink sanitation until asked about their procedure, The three-sink sanitation was started. […]