Homestead Health Services
Homestead Health Services in New Holstein, WI — inspection on September 12, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the form indicated R1's representative was informed and gave consent for the medication but called DON-B an hour later to revoke consent and discontinue the medication after reviewing the side effects.On 9/12/25 at 1:15 PM, Surveyor interviewed R1 who was not aware R1 was prescribed and administered naltrexone until R1's representative was informed and asked to give consent. R1 verified R1's representative consents to medications and treatments per R1's request. R1 indicated R1 was upset that the facility administered naltrexone without informing R1 or R1's representative which was against R1's rights. On 9/12/25 at 3:25 PM, DON-B approached Surveyor and indicated the facility did not obtain consent to administer naltrexone prior to 7/24/25 and confirmed naltrexone was administered to R1 without consent or knowledge of the medication, its intended use, and the risks and benefits.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Homestead Health Services
1712 Monroe St New Holstein, WI 53061
SUMMARY STATEMENT OF DEFICIENCIES
Based 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. R1's Minimum Data Set (MDS) assessment, dated 7/31/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker.Surveyor reviewed R1's Medication Administration Record (MAR) which contained the following order:~ Gabapentin oral capsule 300 milligrams (mg), give 2 capsules by mouth four times daily, please give at specific scheduled time, do not give early, related to hereditary and idiopathic neuropathy.
The scheduled times were: 7:30 AM, 12:00 PM, 4:00 PM, and 8:30 PM.
Surveyor reviewed R1's August and September 2025 MARs (audit time stamped record) and noted the following administration times:~ On 8/27/25, R1's 4:00 PM gabapentin dose was administered at 5:42 PM.~ On 9/1/25, R1's 7:30 AM gabapentin dose was administered at 9:03 AM.~ On 9/2/25, R1's 7:30 AM gabapentin dose was administered at 9:42 AM.~ On 9/4/25, R1's 8:30 PM gabapentin dose was administered at 11:03 PM.On 9/12/25 at 11:38 AM, Surveyor interviewed Family Representative (FR)-D who indicated there were concerns that R1's gabapentin was not administered timely. On 9/12/25 at 2:50 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility's medication administration times are as follow: 6:00 AM to 10:00 AM, 10:00 AM to 2:00 PM, 2:00 PM to 6:00 PM, and 6:00 PM to 10:00 PM. DON-B verified R1's gabapentin had specific administration times of 7:30 AM, 12:00 PM, 4:00 PM, and 8:30 PM. DON-B indicated the times were requested by FR-D and ordered by the physician. DON-B indicated if medications have specific times, nurses can administer them up to one hour before or after the specific times.On 9/12/25 at 4:20 PM, Surveyor interviewed [NAME] President of Success (VPS)-C who confirmed R1's gabapentin should be administered at the specific scheduled times and verified the medication was administered late on 8/27/25, 9/1/25, 9/2/25, and 9/4/25.
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