Homestead Village, Inc

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 2, 2026

  Based on clinical record review, resident interview, and staff interviews, it was determined the facility failed to ensure equipment was used in a safe manner, resulting in actual harm to one of eight residents reviewed (Resident R1). Specifically, the facility failed to ensure a Broda chair was positioned and operated safely during resident care, resulting in Resident R1 sliding out of the chair and sustaining a fracture.Findings include:Review of Resident R1's clinical record revealed the following diagnoses: Hemiplegia and Hemiparesis following non-traumatic intracerebral hemorrhage (muscle weakness or partial paralysis on one side of the body), Cerebral Infarction (stroke), Osteoarthritis (degenerative joint disease, causing pain, stiffness, and reduced mobility when protective… […]

• Actual harm, isolatedF600Apr 23, 2021

  Based on observation, interview with staff and resident, review of the facility's policy and procedure, clinical records, and facility documentation, it was determined that the facility failed to ensure that one of 12 residents reviewed (Resident #17) was free from neglect when the temperature of the resident's tea was not checked before serving. The neglect resulted in actual harm when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A review of the facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Property, with a revision date of March 2017, revealed neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental… […]

• Actual harm, isolatedF689Apr 23, 2021

  Based on observation, interview with staff and resident, review of the facility's policy and procedure, clinical records, and facility documentation review, it was determined that the facility failed to implement interventions to prevent resident incident/accident for one of 12 residents reviewed (Resident #17). The incident resulted in actual harm when the resident sustained a redness (a burn) and required antibiotic treatment for an infection of the burn to the resident's left upper thigh. Findings include: A review of the facility's policy titled, Cooking: TCS (Temperature Control for Safety), which was undated, revealed that the team members must monitor the temperature of the food during preparation and cooking to ensure that the food reaches its required minimum internal temperature. […]

• No harm, potential for more than minimal, patternF880Mar 5, 2026

  Based on review of facility policy, resident records, and staff interview it was determined that the facility failed to follow transmission-based precautions and utilize enhanced barrier precautions (EBP) during wound care creating the potential for cross contamination for two out of three sampled residents (Residents R29 and R32).Findings include:Review of facility policy Transmission-Based Precautions & MDRO last revised June 2024, states Enhanced Barrier Precautions (EBP) are used for reducing transmission of multidrug-resistant organisms (MDROs) during high-contact resident care activities in residents with chronic wounds (e.g. pressure, diabetic, unhealed surgical, and venous stasis) and/or indwelling medical devices. […]

• No harm, potential for more than minimal, patternF689Mar 1, 2024

  Based upon observation and clinical record review, it was determined the facility failed to adequately investigate a missing extended-release opioid medication patch and failed to provide lock free doors to resident bathrooms for one of 18 residents reviewed (Resident 35) and three of three nursing units. Findings include: Review of Resident 35's physician orders revealed an order for Buprenorphine 5 mcg/hr [micrograms per hour] apply one patch transdermally every day shift every 7 days. […]