Homestead Health Services
Inspection Findings
F-Tag F0552
F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
the form indicated Resident 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 Resident R1 who was not aware Resident R1 was prescribed and administered naltrexone until Resident R1's representative was informed and asked to give consent. Resident R1 verified Resident R1's representative consents to medications and treatments per Resident R1's request. Resident R1 indicated Resident R1 was upset that the facility administered naltrexone without informing Resident R1 or Resident R1's representative which was against Resident 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 Resident R1 without consent or knowledge of the medication, its intended use, and the risks and benefits.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Homestead Health Services
1712 Monroe St New Holstein, WI 53061
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Based on staff and resident representative interview and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (Resident R1) of 3 sampled residents.Resident R1 had an order for gabapentin (an anticonvulsant medication used to treat nerve pain and control seizures) four times daily. Resident 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 Resident R1's medical record. Resident R1 had diagnoses including type 2 diabetes with neuropathy and mild neurocognitive disorder with behavioral disturbance. Resident 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 Resident R1 had intact cognition. Resident R1 was Resident R1's own decision maker.Surveyor reviewed Resident 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 Resident R1's August and September 2025 MARs (audit time stamped record) and noted the following administration times:~ On 8/27/25, Resident R1's 4:00 PM gabapentin dose was administered at 5:42 PM.~ On 9/1/25, Resident R1's 7:30 AM gabapentin dose was administered at 9:03 AM.~ On 9/2/25, Resident R1's 7:30 AM gabapentin dose was administered at 9:42 AM.~ On 9/4/25, Resident 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 Resident 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 Resident 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 Resident 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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HOMESTEAD HEALTH SERVICES in NEW HOLSTEIN, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NEW HOLSTEIN, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HOMESTEAD HEALTH SERVICES or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.