Huntersville Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications kept at bedside for 1 of 3 resident reviewed for self-administration (Resident #46). The findings included: Resident #46 was admitted to the facility on [DATE] with diagnosis of arthritis. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #46 cognitively intact. Review of Resident #46's medical records revealed no documentation Resident #46 was assessed to safely self-administer medications. A physician order dated 03/17/26 revealed an order for Tylenol 325 milligram (mg) give 2 tablets by mouth every 6 hours as needed for pain. Resident #46 did not have a physician's order for decongestant nasal spray. On 06/08/26 at 2:25 PM Resident #46 was observed to have a bottle of over the counter (OTC) Tylenol 325 milligrams (mg) and a bottle of decongestant nasal spray sitting on her bedside table. Resident #46 stated she had the Tylenol…

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 and staff interviews, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation request to North Carolina Medicaid Uniform Screening Tool (NC MUST-an internet-based application utilized to communicate and manage PASRR requests) for a resident diagnosed with a serious mental illness. This deficient practice affected 1 of 3 residents reviewed for coordination of PASRR assessments (Resident #10).The findings included:A review of Resident #10's medical record revealed that Resident #10 was deemed by the State to be Level I PASSR. The Level I PASSR was dated 8/21/2009 with no expiration date. Resident #10 was admitted to the facility on [DATE] with diagnoses which included dementia, depression and anxiety.A review of Resident #10's medical record revealed a hospital stay from 10/18/2025 to 10/22/2025. A review of an updated North Carolina Medicaid Long Term Care FL-2 form (FL-2) dated 10/22/2025 and completed by the hospital physician indicated…

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, Responsible Party, Medical Director, and staff interviews, the facility failed to ensure a safe and orderly discharge when the facility failed to remove a midline catheter (a long peripheral intravenous catheter, typically 6-15 centimeters in length, that is inserted into a large vein in the upper arm or forearm) before discharging a resident home for 1 of 3 residents reviewed for discharge (Resident #229). The findings included: Resident #229 was admitted to the facility 11/11/24 with diagnoses that included dysphagia and hyponatremia. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #229 had moderate cognitive impairment. A review of Resident #229's physician orders revealed an order dated 12/10/24 that read in part; midline [catheter] to be placed one time a day for hydration. Resident #229 had a physician's order dated 12/11/24 for an intravenous solution of one liter of normal saline at 75 milliliters (ml) per hour given one time on 12/11/24 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 record review and staff interviews the facility failed to complete a Preadmission Screening and Resident Review (PASRR) level II for a resident with a level II PASRR that expired prior to admission to the facility. This deficient practice occurred for 1 of 2 residents reviewed for PASRR (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder. Review of the PASRR level II dated [DATE] revealed it expired on [DATE] prior to Resident #43's admission to the facility [DATE] and a level II PASRR had not been obtained since admission. An interview conducted with the Assistant Discharge Planner [DATE] at 11:24 AM revealed she had been working at the facility for approximately four months. She indicated when a resident was admitted to the facility the PASRR was completed by the hospital prior to admission. The Assistant Discharge Planner stated she used the Medicaid Uniform Screening Tool (MUST) to access the completed PASSR and…

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, resident and staff interviews, the facility failed to provide a bagged meal or snack for 1 of 1 resident reviewed for dialysis (Resident #83). The findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included stage 5 chronic kidney disease. Resident #83's admission assessment dated [DATE] indicated she was cognitively intact and oriented to person, place, time and situation. The admission Minimum Data Set (MDS) was in progress and no information was available. A physician's order dated 5/01/25 revealed Resident #83's dialysis treatments were Mondays, Wednesdays, and Fridays at 12:25 PM. An interview conducted with Resident #83 on 5/06/25 at 12:30 PM revealed she was admitted to the facility from the hospital on 5/01/25 for short term rehabilitation. She stated during her hospital stay she started dialysis treatments and was continuing treatments at an outpatient dialysis center on Mondays, Wednesdays and Fridays. Resident #83 revealed the facility…

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, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy when the Treatment Nurse did not perform hand hygiene before each donning of clean gloves while providing wound care to Resident #53. This deficient practice occurred for 1 of 4 staff members observed for infection control practices (Treatment Nurse). The findings included: Review of the facility's policy and procedure entitled Hand Hygiene read in part: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: - When coming on duty. - Before and after assisting a patient with personal care (e.g., oral care, bathing). - Before and after changing a dressing. - After any contact with potentially contaminated materials (used wound/treatment dressings). A wound observation was made on 05/07/25 at 9:54 AM on Resident #53 with the Treatment Nurse. The Treatment Nurse was observed cleaning the bedside table with disinfectant wipe and placed her wound supplies on the table…

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, record reviews, and staff interviews, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) when the Wound Nurse failed to don a gown before entering residents' room to provide care for Resident #1 who was under transmission-based precautions. The deficient practice occurred for 1 of 2 staff members observed for infection control practices. The findings included: Review of the facility's policy for Enhanced Barrier Precautions (EBP) dated 03/26/2024 revealed the EBP will be implemented for the prevention of transmission of multidrug-resistant organisms. EBP employs gown and glove use during high resident care activities such as: Dressing Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device Care or use: central line, urinary catheter, feeding tube and tracheostomy, Wound Care: any skin opening requiring a dressing. On 10/02/24 at 11:28 AM an observation was made of Wound Nurse #1 entering Resident #1's room to provide wound care. Resident #1 was under EBP for 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.

Based on record reviews and staff interviews, the facility failed to remove expired food items, date open and perishable foods stored in 1 of 1 reach-in cooler and 1 of 1 walk-in freezer and ensure steamer pans were not stacked wet for 1 of 2 kitchen observations. These practices had the potential to affect food served to residents. The findings included: The facility's kitchen was toured on 1/22/2024 at 10:20 AM. An observation was conducted of the reach-in cooler and the following was observed: a. A container of vanilla pudding was noted with a creation date of 3/10 (no year). The expiration date was noted to be 3/14 (no year). b. A container of cantaloupe was noted with an expiration date of 1/21/2024. c. A container of tuna salad was noted with an expiration date of 1/21/2024. d. A container of pineapple pieces was noted without a creation date or expiration date. e. A second container of tuna salad was noted without a creation date or expiration date. f. A container of lettuce salad was noted without a creation date or expiration date. g. A container of shredded cheddar cheese…

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 record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented and effective procedures and monitor the interventions that the committee put into place following a recertification and complaint investigation dated 6/09/22 for one deficiency in the area of dietary services F 812. Also, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented and effective procedures and monitor the interventions that the committee put into place following the complaint survey date 4/10/23 for one deficiency in the area of accurate medical records F 842. These deficiencies were cited during a recertification and complaint survey dated 1/25/24. The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross referenced to: F 812 Based on record reviews and staff interviews, the facility failed to remove expired food…

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 observations, a resident interview, staff interviews and record review, the facility failed to honor food preferences for 1 of 3 sampled residents reviewed for food preferences (Resident #281). The findings included: Resident #281 was admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus, iron deficiency anemia, gastroesophageal reflux disease and lipoprotein deficiency, among others. An admission Minimum Data Set assessment dated [DATE] (in progress) indicated her cognition was intact, she had clear speech, able to understand and be understood, required set up/clean up assistance with meals and no weight loss/gain. A care plan revised 1/22/24 identified Resident #281 was at risk for nutritional decline related to a recent hospitalization, adjustment to a new environment, and diagnoses. Interventions included encouraging good food intake, recording the percentage of food eaten, and reviewing food preferences with the resident as needed. Food intake records from 1/17/24 -…

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.