Inspection Reports for
The New Homestead Care Center

Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective January 7, 2026.

The complaint investigation was substantiated as the facility failed to provide timely nursing response to call lights for residents, confirmed by interviews with residents, family members, nursing staff, and review of call light logs and policies.

The facility failed to provide sufficient nursing staff to assure resident safety by not responding to call lights in a timely manner for 3 of 3 residents reviewed. Interviews and document reviews confirmed delays in call light responses exceeding 15 minutes.

The complaint investigation found substantiated delays in call light response times for residents #1, #2, and #4. Interviews and call light logs confirmed response times frequently exceeded 15 minutes, with one call light active for 47 minutes and 6 seconds.

The facility failed to provide adequate nursing staff to respond to call lights in a timely manner for 3 of 3 residents reviewed. Call light response times frequently exceeded the facility's 15-minute policy, with documented delays up to 47 minutes.

Complaint #127212-C was substantiated related to failure to notify residents timely about Medicare Part A and B service terminations.

The facility was found deficient in multiple areas including failure to notify residents timely about Medicare Part A and B service terminations, failure to notify the Long-Term Care Ombudsman of resident hospital transfers, inadequate provision of bathing and ADL care, failure to prevent pressure ulcers, insufficient range of motion exercises, inadequate nursing staff response to call lights, improper monitoring of warfarin therapy during antibiotic use, serving food at improper temperatures, improper food storage and labeling, and inadequate infection prevention and control practices including hand hygiene.

The facility failed to provide regular bathing for one resident, timely pressure ulcer interventions for another, consistent range of motion exercises, adequate nursing staff response to call lights, and proper maintenance of call light systems. The census was reported as 50 residents.

The visit was complaint-related, triggered by allegations of failure to notify residents and representatives about Medicare coverage and hospital transfers, inadequate care and monitoring, and infection control issues. The complaints were substantiated based on clinical record reviews, observations, staff interviews, and policy reviews.

The facility was found deficient in multiple areas including failure to notify residents timely about Medicare Part A coverage ending and hospital transfers, inadequate pressure ulcer prevention and care, failure to provide required range of motion exercises, insufficient nursing staff response to call lights, lack of monitoring for residents on warfarin and antibiotics, serving food at unsafe temperatures, improper food storage and handling, and inadequate hand hygiene and infection control practices.

Complaint #125029-A was substantiated. Facility reported incident #124515-I was substantiated. Additional findings for complaint #125029-A and facility reported incident #124515-M will be sent separately.

The facility failed to protect one resident (Resident #1) from abuse by a Certified Nurse Assistant (Staff A). Video evidence showed Staff A was rough, rushed, and uncommunicative during care, causing physical and emotional harm to the resident. Staff A was terminated following the incident. The resident and Power of Attorney reported distress and fear due to the abuse. The facility policy prohibits abuse and mandates resident dignity and respect.

Complaint #125029-A was substantiated. Facility reported incident #124515-I was substantiated. Additional findings for complaint #125029-A and facility reported incident #124515-M will be sent under separate cover.

The facility failed to protect one resident from abuse by a Certified Nurse Assistant (Staff A), who was observed on video being rough, uncommunicative, and neglectful during care. The resident was physically and verbally mistreated, resulting in the termination of Staff A. The complaint #125029-A and facility incident #124515-I were substantiated.

The complaint was substantiated. Video evidence showed Staff A being rough and unkind to Resident #1. Resident #1 and her Power of Attorney confirmed the abuse. Staff A was terminated. The police report found no criminality but recommended more compassion.

The facility failed to protect Resident #1 from abuse by Staff A, who was observed on video being rough and unkind during care, including using force to position the resident and denying requested bathroom use. Staff A was terminated following the investigation. Resident #1 reported pain and distress due to Staff A's actions.

The visit was triggered by complaints #116816-C and #118049-C, both of which were substantiated.

The facility was found deficient in multiple areas including accuracy of assessments, activities of daily living maintenance, incontinence care infection prevention, tube feeding administration, sufficient nursing staff to respond to call lights timely, and infection prevention and control practices during medication administration.

The facility failed to ensure accurate Minimum Data Set (MDS) assessments, complete restorative programs as scheduled, follow infection prevention standards during incontinence care and medication administration, administer tube feeding per physician orders, and respond timely to resident call lights. Several deficiencies were noted with minimal harm or potential for harm affecting a few to some residents.

The facility failed to follow infection prevention standards during incontinence care for one resident and failed to respond to resident call lights within 15 minutes for multiple residents. The facility reported a census of 48 residents.

The complaint was substantiated. Resident #1 reported being upset and disappointed by Staff A's refusal to provide a whirlpool bath and the manner in which the shower was given. Staff A received a disciplinary suspension.

The facility failed to honor a resident's request for a whirlpool bath, instead providing a shower while the resident was sitting on the toilet, causing the resident distress. Staff behavior did not respect the resident's dignity and preferences, and disciplinary action was taken against the involved employee.

The complaint was substantiated as the facility failed to honor the resident's care preferences and dignity. Staff A was disciplined and suspended for the incident.

The facility failed to honor a resident's request for a whirlpool bath, instead providing a shower while the resident was sitting on the toilet, causing the resident to feel upset and disrespected. Staff behavior did not align with the facility's expectations for treating residents with dignity and respect.

Complaint #114865-C was investigated and found not substantiated. Facility Report Incident #114980-I was substantiated.

The facility was found to be in substantial compliance with CMS and CDC recommended COVID-19 practices. Complaint #114865-C was not substantiated, while Facility Report Incident #114980-I was substantiated. A deficiency was identified related to resident rights and dignity for one of four residents reviewed.

The visit was complaint-related, triggered by allegations regarding failure to provide required written notices for transfers, discharges, and bed holds, inadequate care planning for mental health, inconsistent mental health services, and food safety concerns.

The facility was found not in substantial compliance with 42 CFR 483 subpart B, with deficiencies including failure to provide written transfer/discharge notices and bed hold notices to residents and their representatives, failure to develop comprehensive care plans for mental health diagnoses, failure to ensure consistent mental health services, and food safety violations including improper food storage and unclean kitchen equipment.

The facility failed to provide timely written transfer/discharge and bed hold notices to residents and their representatives, lacked complete care plans for residents with mental health diagnoses, did not consistently provide mental health services as required, and failed to maintain proper food storage and sanitation of kitchen equipment.

The facility failed to provide timely written transfer/discharge notices and bed hold notices to several residents and their representatives, potentially affecting their knowledge and rights. Additionally, the kitchen failed to properly label, date, and cover stored foods, discarded expired items, and maintain cleanliness of food preparation equipment, posing a risk to all residents consuming food from the facility.

The complaint investigation was substantiated. Staff A admitted to taking a fentanyl patch from Resident #1 and was arrested. Law enforcement confirmed Staff A's blood tested positive for fentanyl. The facility reported the incident to the Iowa Board of Nursing and local law enforcement.

The investigation found that Staff A, a registered nurse, tampered with and misappropriated a fentanyl patch from Resident #1 by removing, flipping, and reapplying the patch to the resident, thereby diverting medication for personal use. Staff A was terminated and criminal charges were pursued. The facility implemented new procedures for visual inspection of fentanyl patches at shift changes.

The facility was found deficient in updating comprehensive care plans, ensuring residents are free of significant medication errors, maintaining infection prevention and control practices, and complying with admission, transfer, and discharge policies related to veterans' benefits.

Complaint #95791-C was substantiated based on findings related to medication self-administration, access to medical records, and care deficiencies.

The facility was found to have multiple deficiencies including failure to ensure residents were properly assessed for self-administration of medications, failure to provide requested medical records timely, failure to follow physician orders for wound care and anticoagulant monitoring, insufficient nursing staff to respond timely to call lights, and failure to maintain safe food temperatures during meal service.

Complaint #91475-C and Complaint #92220-C were substantiated. The investigation focused on visitation restrictions during end of life and failure to notify family and physician of resident condition changes.

The facility failed to ensure resident rights by not allowing family visitation during end of life for one resident, failed to notify the physician and family of significant changes in a resident's condition, and failed to implement proper infection control practices including inadequate hand hygiene and incomplete COVID-19 visitor screening logs.

The facility was found deficient in multiple areas including failure to notify physicians of resident condition changes, failure to notify the Ombudsman of hospital transfers, failure to document bed hold decisions, failure to update care plans and restorative programs, failure to assess residents after condition changes, inadequate incontinence care, lack of communication with dialysis providers, failure to monitor high-risk medication labs, failure to annually review infection control policies, and failure to offer influenza vaccination to a resident.