Hunters Creek Nursing And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to accurately obtain and document fluid intake for a resident on a fluid restriction for 1 of 2 residents reviewed for hydration status, out of a total sample of 11 residents, (#2).Findings: Review of the medical record revealed resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including type 2 diabetes, chronic obstructive pulmonary disease, chronic kidney disease, stage 4, and heart failure. Review of resident #2's medical record revealed a care plan for nutrition and hydration initiated on 7/23/22 and revised on 4/21/26. The care plan showed resident #2 was at risk for decreased nutritional status and dehydration related to diabetes, chronic kidney disease, edema, hyponatremia (low sodium) and hypoosmolality ( low levels of electrolytes and other fluids in the blood). The goals included remaining free from signs and symptoms of dehydration. The interventions indicated resident #2 was on a fluid restriction of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food products were stored correctly in the walk-in cooler, and failed to ensure the temperature of hot foods being held was taken before service in accordance with professional food service safety. Findings: 1. On 12/15/24 at 11:50 AM, during a tour of the walk-in refrigerator with [NAME] D, a small plastic bag holding approximately 12 turkey slices, dated 12/11 (five days ago) was noted. [NAME] D stated the facility policy was to discard perishable food items three days after they were opened, and she removed it to be discarded. Another plastic bag with approximately 20 slices of sliced ham, dated 12/10 (six days ago) was noted and [NAME] D stated it also should have been discarded after three days and she removed it. An opened and resealed plastic bag of shredded mozzarella cheese dated 12/08 (eight days ago) and an opened bag of goat cheese, resealed in a plastic bag was dated 11/21 (25 days ago) was noted and [NAME] D reiterated these also should have been discarded after three days and she threw…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity for 4 of 15 dependent diners at the facility, out of a total sample of 32 residents, (#11 and #48). 1. Review of resident #11's medical record revealed she was readmitted to the facility on [DATE] with diagnoses including dementia, hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following a stroke affecting her right dominant side, dysphagia (difficulty swallowing), and aphasia (language disorder). Review of resident #11's Minimum Data Set quarterly assessment with Assessment Reference Date of 11/05/24 revealed a Brief Interview for Mental Status was not obtained because she was rarely or never understood. The assessment showed resident #11 was dependent on staff for eating and received a mechanically altered diet. On 12/17/24 at 12:18 PM, resident #11 was lying in bed with her lunch tray on her bedside table. Certified Nursing Assistant (CNA) E was assisting resident's #11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to address a pharmacy recommendation for 1 of 5 residents reviewed for unnecessary medications, out of a total sample of 32 residents, (#75). Findings: Review of resident #75's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease, congestive heart failure, type 2 diabetes, and abnormalities of gait and mobility. Review of resident #75's Minimum Data Set quarterly assessment with Assessment Reference Date of 11/05/24 revealed a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. The assessment showed resident #75 received a scheduled pain medication regimen. He experienced pain occasionally and the intensity was rated 8 on a scale of 0 to 10. Review of the physician orders included an order for Lidocaine External Patch 4% dated 4/28/23. The Lidocaine Patch was to be applied to the right leg topically two times a day for pain. Review of resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills sets to carry out the functions of food and nutrition service to prevent potential food borne illness for 1 of 3 residents reviewed for food, of a total sample of 32 residents, (#1). Findings: On 12/16/24 at 11:47 AM, resident #1 stated she had diabetes and liked a snack before bed for good blood sugar control. She continued, she often requested a sandwich snack from the nursing staff but had frequently been told there wasn't a sandwich available so now she received an egg or tuna salad sandwich on her dinner tray each night. Resident #1 explained although she received the sandwich on her dinner tray she did not eat it right away but instead usually ate it anywhere from 10:30 PM to 12:30 AM. She added, often the only snacks available were graham crackers which didn't have the necessary protein content for good blood sugar control. She stated her dinner meal usually arrived before 6:00 PM and she tried to wait at least four hours before she ate her nighttime snack.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected a skin condition related to an acquired pressure injury for 1 of 4 residents reviewed for pressure injuries, of a total sample of 9 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] for short-term rehabilitation. Her diagnoses included gastrointestinal hemorrhage, posthemorrhagic anemia, and generalized muscle weakness. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 6/27/24 indicated resident #1 was at risk for developing pressure injuries, and on discharge from the hospital, she had no pressure injuries, skin lesions, or wounds. Review of the admission Data Set, dated 6/27/24, revealed resident #1's skin color was normal and her skin integrity was clear, with no conditions present. The linked admission Note, dated 6/27/24, revealed a body assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop, implement, and update an appropriate baseline care plan to mitigate risk factors for skin impairment, and failed to incorporate person-centered interventions to promote healing for an acquired pressure injury for 1 of 4 residents reviewed for pressure injuries, of a total sample of 9 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] for short-term rehabilitation. Her diagnoses included gastrointestinal hemorrhage, posthemorrhagic anemia, and generalized muscle weakness. Resident #1 was transferred to the hospital for evaluation of a wound on 7/11/24. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 6/27/24 indicated resident #1 was hospitalized for a gastrointestinal bleed and anemia. The document revealed she was alert, oriented, and followed instructions, and was at risk for pressure ulcers. The form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for Dialysis received timely care and services to mitigate the risk for development of serious complications, from a total sample of 5 residents, (#3). Findings: Review of the medical record revealed resident #3, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included end stage renal (kidney) disease, dependence on renal dialysis, myocardial infarction, congestive heart failure, severe cardiomyopathy, atrial fibrillation, chronic pulmonary edema, and type 2 diabetes mellitus. On 12/08/23, four days after admission, the resident required re-hospitalization, and was readmitted back to the facility on [DATE] with additional diagnoses that included metabolic encephalopathy (biochemical brain dysfunction), and hyperkalemia (high Potassium). The Minimum Data Set (MDS) 5-day/Discharge Return Not Anticipated Assessment with Assessment Reference Date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement physician's orders for laboratory testing for 1 of 5 residents reviewed for medication regimen review from a total sample of 38 residents, (#87). Findings: Review of the medical record revealed resident #87 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of thrombocytopenia (low platelets), anemia, major depressive disorder, anxiety, and insomnia. The Minimum Data Set modified admission assessment with Assessment Reference Date 6/01/2023 noted the resident was rarely or never understood, assessed as severely cognitively impaired, and had not had any rejections of evaluation or care. The assessment showed the resident received insulin injections for 6 days, opioid medication for 5 days, antianxiety medication for 6 days, and antidepressant, anticoagulant, and diuretic medication for 7 out of 7 days during the look back period. The Comprehensive Care Plan noted focus items for high-risk medications that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent contamination during wound care for 1 of 3 residents observed for wound care out of a total sample of 38 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebrovascular disease, sepsis, urinary tract infection, bacterial disease, diabetes mellitus type 2, peripheral vascular disease, non-pressure wound left lower lateral back and pressure wounds sacrum and right lower lateral back. Review of resident #1's medical record revealed a care plan for actual skin breakdown revised on 6/19/23. The care plan indicated the resident had non pressure wound on left lateral lower back and pressure wounds right lower lateral back and sacrum. The care goal read, Resident will show signs of healing and remain free from complications .Wounds will be free from infection . Interventions included a wound care specialist for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services to ensure medications were administered according to physician orders for 1 of 6 sampled residents, of a total sample of 49 residents, (#70). Findings: Resident #70 was admitted to the facility on [DATE] with diagnoses including dementia, and depression. Review of the physician orders revealed an order dated 10/23/21 that read, Lorazepam tablet 0.5 mg [milligram], give one tablet by mouth every 4 hours as needed (PRN) for agitation related to anxiety for 14 days. Review of the Medication Administration Record (MAR) reflected the above order with a start date of 10/23/21 and a stop date of 11/03/21. The MAR had an X in all boxes for all dates after 11/03/21, to indicate that Lorazepam 0.5 mg should not be administered. Review of resident 70's Controlled Medication Utilization Record for Lorazepam 0.5 mg revealed nurses signed for removal of the medication on 5 occasions after the stop date of 11/03/21. Nurses documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.