Childserve Habilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview and policy review, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to implement Enhanced Barrier Precautions (EBP) to prevent cross contamination during routine cares for 3 of 4 residents reviewed for indwelling medical devices (Residents #2, #3 and #4). The facility reported a census of 70.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed that Resident #2 had diagnoses of Multidrug-Resistant Organism (MDRO), cerebral palsy and severe hypoxic ischemic encephalopathy (a critical neonatal brain injury caused by severe oxygen deprivation and restricted blood flow (asphyxia) around the time of birth). It also indicated he received tracheostomy care (a surgically created opening in the neck leading into the trachea (windpipe) to assist with breathing) and had a gastrostomy (a medical procedure to insert a feeding tube (G-tube) through the abdomen directly into the stomach, allowing 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.

Based on observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 70 residents. Findings included: Observations on 4/30/2025 revealed the following events; On 4/30/25 at 11:38 AM, Staff A, Licensed Practical Nurse (LPN) walked away from her medication cart in the patient care hallway and entered a storage room. A key was observed lying on top of the medication cart. At 11:40 AM, Staff A walked past the medication cart with water and entered a resident's room. There was one resident present but unable to manipulate the key or the medication cart. When Staff A returned to the medication cart, she confirmed the key was used to unlock the medication cart and stated she didn't realize she left it on the cart. At 11:41 AM, Staff A removed medications from her cart, locked the cart and entered a resident's room. The key was observed lying on top of the medication cart. At 11:43 AM, another staff member entered the hallway where Staff A's medication cart was…

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 observations, staff interviews, and policy review, the facility failed to implement the Infection Prevention and Control Program (IPCP) by staff not discarding Personal Protective Equipment (PPE) immediately after use nor appropriately performing hand hygiene. The facility reported a census of 70 residents. Findings include: On 4/30/25 at 7:45 AM, Staff C, Housekeeping (HSKG) entered a resident's room, that displayed a contact/droplet isolation sign, wearing gloves but no other Personal Protective Equipment (PPE). She grabbed the trash bag out of the trashcan closest to the entry, tied it in a knot, then grabbed the trash bag from the other trashcan against the furthest wall, tied it in a knot, and brought them out of the residents' room. She placed the bags of trash in a large container then entered another room with a standard precautions sign displayed, collected the trash bags, brought them out of the room, and placed them in the large container. She grabbed the roll of trash bags from the adjacent cart, separated two (2) trash bags from the roll, then handed the roll…

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 clinical record review and staff interviews, the facility failed to notify the long term care ombudsman for resident transfer to an acute care hospital for 6 of 6 (Res #22, #26, #46, #54, #56, #70) residents reviewed for hospitalization. Findings include: The Minimum Data Set (MDS) of Resident # 22 documented a discharge, return anticipated, to an acute care hospital on [DATE] and 5/2/24. The MDS of Resident #26 documented a discharge, return anticipated, to an acute care hospital on 2/5/24, 3/31/24, 4/10/24 and 4/13/24. The MDS of Resident #46 documented a discharge, return anticipated, to an acute care hospital on [DATE] and 3/23/24. The MDS of Resident #54 documented a discharge, return anticipated, to an acute care hospital on 3/1/24, 4/13/24, 4/18/24 and 5/19/24. The MDS of Resident #56 documented a discharge, return anticipated, to an acute care hospital on 5/19/24. The MDS of Resident #70 documented a discharge, return anticipated, to an acute care hospital on 3/9/24 and 4/11/24. The document…

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, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing enteral tube feedings, nasal and tracheostomy suctioning for 2 of 7 residents observed (Resident #57 & #60). The facility reported a census of 69 residents. Findings include: 1. Observation on 6/30/24 at 12:05 PM revealed Staff A, RN, was not wearing gloves, standing at Resident #57's bedside, setting up enteral tube feeding by pouring measured formula into feeding bag that runs into a pump, tubing from the pump connects to Resident #57's feeding tube (g-tube). Staff A rolled Resident #57 toward herself noticing mucus drainage from his nose. Staff A, not wearing gloves, used a nasal cannula attached to a suction machine and suctioned mucus from Resident #57's nose. Staff A, then used hand sanitizer, completed feeding set up and connected Resident #57's feeding tube port to the tubing from the pump and started the feeding. The Minimum Data Set (MDS) dated…

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, clinical record review, staff interviews, and policy review, the facility failed to provide timely notification to the physician or family when changes occurred in the resident's physical or mental condition for 2 of 3 residents reviewed (#1 & #3). The facility reported a census of 61 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was rarely or never understood and a Brief Interview for Mental Status (BIMS) score was not obtained. The MDS included diagnoses of Seizure disorder, Receptive-Expressive Language Disorder, dependence on supplemental oxygen, and Failure to Thrive. The MDS also indicated the resident was dependent in all areas of care. On 1/4/24 at 7:53 AM, Staff A, a Licensed Practical Nurse (LPN) documented a Nursing Assessment indicating the resident was on room air with a documented oxygen saturation (O2 sats) of 85%. The Care Plan dated 7/8/19 directed staff to communicate any changes in condition to the physician and to…

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 clinical record review, staff interview, and policy review the facility failed to ensure physician's orders were followed for 2 of 3 residents reviewed (#1 & #2). The facility identified a census of 61 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was rarely or never understood and a Brief Interview for Mental Status (BIMS) score was not obtained. The MDS included diagnoses of Seizure disorder, Receptive-Expressive Language Disorder, dependence on supplemental oxygen, and Failure to Thrive. The MDS also indicated the resident was dependent in all areas of care. The Care Plan dated 7/8/19 directed staff to communicate any changes in condition to the physician and to use oxygen to keep O2 sats greater than 90%. On 1/4/24 at 7:53 AM, Staff A, a Licensed Practical Nurse (LPN) documented a Nursing Assessment indicating the resident was on room air with a documented oxygen saturation (O2 sats) of 85%. The EHR contained a Physician Order entry directing…

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, clinical record review, staff interviews, and policy review, the facility failed to provide a complete, accurate, and detailed record for the resident's physical condition to maintain the resident's highest practical well-being for 2 of 3 residents reviewed (#1 & #2). The facility reported a census of 61 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was rarely or never understood and a Brief Interview for Mental Status (BIMS) score was not obtained. The MDS included diagnoses of Seizure disorder, Receptive-Expressive Language Disorder, dependence on supplemental oxygen, and Failure to Thrive. The MDS also indicated the resident was dependent in all areas of care. The Care Plan dated 7/8/19 directed staff to use oxygen to keep O2 sats greater than 90%. On 1/4/24 at 7:53 AM, Staff A, Licensed Practical Nurse (LPN) documented a Nursing Assessment indicating Resident #1 was on room air with a documented oxygen saturation (O2 sats) of 85%.…

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 record review, staff interview, and policy review the facility failed to immediately put effective measures in place to ensure further potential abuse or mistreatment does not occur for 1 of 1 dependent residents (Resident #52) when four (4) employees observed questionable physical and verbal abuse by Staff A, Respiratory Therapist (RT) to Resident #52. The facility reported a census of 61 residents. Findings include: On 9/13/23 at 9:58 AM Staff B, Certified Nurse Aid (CNA) described her observation she had of Resident #52 and Staff A's interaction on 4/23/23 as follows; Resident #52 was in sun room sitting on the floor and she pulled at her medical device on her neck, I was washing my hands at the sink, and Staff A pulled Resident #52 hand away, and she said something like, stop doing that, this is the fourth (4th) time I had to put a new one on you today, in a not nice tone. She then informed Resident #52 got up and walked off, and she looked sad, and she knew she had been yelled at. I felt it was inappropriate because Resident #52 is really grabby and she does that a…

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 record review, staff interviews, and policy review the facility failed to ensure 1 of 1 residents (Resident #52) reviewed was treated with respect and dignity by all staff, when Staff A, Respiratory Therapist, scolded Resident #52 for grabbing at her medical device. The facility reported a census of 61 residents. Findings include: The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #52 documented she has short-term and long-term memory problems, inability to recall current season, location of room, staff names and faces, and that she is in a nursing facility, and severely impaired cognitive skills for daily decision making. The MDS also documented she is totally dependent on 1 staff member for dressing, eating, toilet use, and personal hygiene. The MDS documented the diagnosis of seizure disorder or epilepsy, anxiety, dysphasia, hearing loss. Record review of an undated document titled, Care Investigation Summary informed the following Summary of Event(s): a. Child (Resident #52) from Long…

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 record review, staff interviews, and policy review the facility failed to report alleged physical and verbal abuse without bodily injury for 1 of 1 residents (Resident #52) within 24 hours of the incident to the state agency. The facility reported a census of 61 residents. Findings include: Record review of an undated document titled, Care Investigation Summary informed the following Summary of Event(s): a. Child (Resident #52) from Long Term Care (LTC) unit was receiving routine care on 4/23/2023 when she removed her heat and moisture exchanger from her tracheostomy. Staff A, a travel Respiratory Therapist (RT) allegedly slapped the child's hands and yelled at her. Event was witnessed by several staff. b. Resident #52 did not sustain any physical injury, but she appeared visibly upset following the event. She received a dose of Tylenol. c. The event was reported to DIAL on 4/26/23. Staff reported the event to their supervisor, but it was not immediate, per policy. Once the supervisor was notified of the event, she promptly share information with the Licensed Nursing Home…

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.