Hurricane Health and Rehabilitation

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, a freezer in the outdoor storage room contained food items open to air, areas in the kitchen were not clean, food items in the reach in refrigerator were not labeled, and dead bugs were found in the outdoor dry storage room. Findings included:On 9/22/25 at 1:55 PM, an initial walk-through of the kitchen was conducted. In the outdoor storage room, a lift-top freezer contained a torn plastic bag with frozen pizza crusts that was open to air, and a large plastic bag containing what appeared to be frozen cookie dough was open to air, and appeared to have freezer burn. There was no thermometer in the freezer. In the kitchen the stove was not clean; there were crumbs, a dipping sauce packet and cheese wrapper under the stove. The ice machine was not clean with rust or water deposits above the ice. In the dry storage room, 2 bulk bins with what appeared to be flour and sugar inside, were not labeled or dated. In…

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 observation, for 1 of 25 sampled residents, the facility did not treat residents with respect and dignity and care for each resident in a manner that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, a Certified Nursing Assistant (CNA) was observed standing next to a resident in bed while providing feeding assistance . Resident identifier: 48. Findings included:Resident 48 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included multiple sclerosis, type 2 diabetes, dysphagia, congestive heart failure, and chronic pain.An admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident 48 had a Brief Interview for Mental Status (BIMS) score of 15 indicating she was cognitively intact. The assessment also revealed that resident 48 had upper extremity impairment on one side, and was dependent on staff for eating, oral hygiene, toileting, and bathing.On 9/24/25 at 10:50 AM,…

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, it was determined for 1 of 25 sampled residents, that the facility failed to ensure that a resident who was continent of bladder on admission received services and assistance to maintain continence unless his or her clinical condition was or became such that continence was not possible to maintain; and a resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible. Specifically, one resident who was assessed to be continent or a good candidate for bladder retraining was not provided services. Resident identifier: 59. Findings included:On 9/23/25 at 10:37 AM, an interview was conducted with resident 59. Resident 59 stated she wore a brief and was unsure why she needed to wear one because she can tell when she needed to use the bathroom. Resident 59 stated she needed assistance from staff to go to the bathroom. Resident 59 stated she did not need to wear briefs before coming to the facility and that staff just…

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, for 1 of 25 sampled residents, the facility did not ensure that residents who required dialysis received such services, consistent with professional standards of practice. Specifically, a resident receiving dialysis was not having his pre-dialysis vital signs information documented before leaving for dialysis as was required in the facilities' dialysis communication policy. Resident identifier: 30.Findings included: Resident 30 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, atrial fibrillation, and muscle wasting and atrophy.On 9/23/25 at 11:48 AM, an interview was conducted with resident 30 who stated he was taken to dialysis on Mondays, Wednesdays, and Fridays by the facility transportation van at 10:00 AM.Resident 30's medical records were reviewed between 9/23/25 and 9/25/25.A review of resident 30's care plan dated 11/2/21 revealed a Focus area, Needs hemodialysis r/t…

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, for 1 of 25 sample residents, the facility did not ensure that the monthly drug regimen recommendations by a licensed pharmacist were implemented in a timely manner. Specifically, a recommendation made by the pharmacist to separate administration of a medication and a supplement due to interaction was not acknowledged by the physician or implemented. Resident identifier: 3. Findings included:Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included ataxia, repeated falls, chronic kidney disease, encephalopathy, and memory deficit following nontraumatic subarachnoid hemorrhage. Resident 3's medical record was reviewed between 9/22/25 and 9/25/25.No documentation of the monthly pharmacy reviews were found in the progress notes. There was no documentation of the pharmacy reviews found in the resident's miscellaneous documents.The facility 2025 monthly pharmacy review binder was reviewed. In March 2025, a pharmacy recommendation 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 it was determined, for 1 of 6 sampled residents, that the facility did not ensure that residents were free from any significant medication errors. Specifically, a resident 's Clozapine medication was omitted due to unavailability from the pharmacy. Resident identifier 5. Findings included: Resident 5 was admitted to the facility on [DATE] with diagnoses which included hydrocephalus, repeated falls, schizophrenia, dysphagia, flaccid neuropathic bladder, need for assistance with personal care, and muscle weakness. Resident 5's medical records were reviewed on 3/19/2024. On 3/19/23 at 10:43 AM, an interview was conducted with resident 5. Resident 5 stated that he had missed his psychiatric medication for 3 days because it was hard to get. Resident 5 stated they had to check his blood before they could get the medication. Resident 5 stated he had not slept for the 3 days when he did not get his medication. Resident 5 stated this had happened a few times and he believed it was his…

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, it was determined for 1 of 26 sample residents, that the facility did not ensure that the resident's environment remained free of accident hazards. Specifically, the facility did not provide adequate locks to prevent residents access to harmful chemicals. Resident identifier: 11. Findings include: Resident 11 was initially admitted on [DATE] and readmit on 1/24/22 with diagnoses which included vascular dementia with agitation, bipolar disorder, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, altered mental status, and dysphagia. Resident 11's medical record was reviewed 10/16/23 through 10/26/23. An incident progress note dated 10/10/23 at 6:38 AM, Nurse was by the laundry room when she heard someone yelling for help. When she checked inside the laundry room she found the patient sitting on the floor next to her wheelchair with a pile of socks on h ER [sic] lap. Resident stated that she did not know…

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 observation, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, reusable ice packs were located in resident freezers, garbage cans in the kitchen were soiled, and kitchen cabinets were in disrepair. Findings include: 1. On 10/18/23 at 7:00 PM, an observation was made of the facility kitchen. The following was identified: a. There were 4 kitchen cabinets located next to the dishroom. The cabinets had been painted white, but were visibly soiled with a black grime on the outside, especially around the handles. Both the inside and outside surfaces of the cabinets were sticky to the touch. The shelves inside the cabinets were observed to be soiled with various substances. In addition, the cabinet doors were in a state of disrepair that did not allow the doors to completely cover the shelves when the doors were closed. b. There was a metal garbage can near the facility oven. The lid of the garbage can was connected to the garbage can and was open. The lid of the garbage can…

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 did not ensure that 2 of 26 sample residents had an accurate Minimum Data Set (MDS) Assessment. Resident identifiers: 29 and 34. Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis, severe protein-calorie malnutrition, diabetes mellitus, anemia, and dementia. Resident 29's medical record was reviewed on 10/16/23. Resident 29's quarterly MDS assessment completed on 6/14/23 did not include a Brief Interview for Mental Status (BIMS) score, even though the assessment indicated that the BIMS should be completed. Resident 29's annual MDS assessment completed on 9/14/23 did not include a BIMS score. 2. Resident 34 was admitted to the facility on [DATE] with diagnoses that included dementia, moderate protein calorie malnutrition, and altered mental status. Resident 34's medical record was reviewed on 10/16/23. Resident 34's initial MDS assessment completed on 5/17/23 did not include a BIMS score.…

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 it was determined, for 1 out of 26 sampled residents, that the facility did not ensure that a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections (UTI) and to restore continence to the extent possible. Specifically, a resident with a urinary catheter had a delay in treatment for a UTI. Resident Identifier: 39 Findings include: Resident 39 was admitted to the facility on [DATE] with diagnoses that included dementia, altered mental status, acute kidney failure, stage 3 chronic kidney disease, acute respiratory failure with hypoxia, adult failure to thrive, and anxiety disorder. Resident 39's medical record was reviewed on 10/17/23. On 10/9/23 at 12:47 PM, a nurse note documented, Resident has had an increase in confusion and restlessness. His urine is also cloudy with foul odor. Received orders to collect UA [urinalysis]. UA was collected and sent. A physician order with an start date of 10/9/23 and end…

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 it was determined that the facility did not provide each resident with a safe, clean, comfortable and homelike environment. Specifically, there were walls in resident room with scratched drywall, chipped paint, a wall with drywall missing and baseboard pulling away from the wall. Findings include: 1. On 9/19/22 at 2:26 PM, an observation was made of room [ROOM NUMBER]. There were large scrapes on the wall with missing paint behind the bed. The scraps were visible from the hallway. 2. On 9/19/22 at 3:00 PM, an observation was made of room [ROOM NUMBER]. room [ROOM NUMBER] had a chunk of drywall missing toward the floor outside the bathroom. The trim was pulling away from the wall. 3. On 9/21/22 at 8:30 AM, an observation was made of room [ROOM NUMBER]. room [ROOM NUMBER] had large scrapes in the drywall with missing paint behind the bed. The scrapes were visible from the hallway. 4. On 9/21/22 at 9:00 AM, an observation was made of the facility with the Administrator. The…

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 it was determined, for 5 of 5 contracted staff members, that the facility did not ensure that all staff including contracted staff members were fully vaccinated for COVID-19, except for those staff who had been granted exemptions to the vaccination. Specifically, contracted staff members vaccination status were unknown. Staff member identifiers: Contracted Staff Member (CSM) 1, CSM 2, CSM 3, CSM 4 and CMS 5. Findings include: On 9/19/22 at 1:30 PM, an initial observation of the facility was conducted. There were contractor staff members observed to be working with wires and construction. There were contractors outside the dining room, in resident hallways and at the nurses station. On 9/20/22 at 8:34 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility did not have contracted employees. On 9/20/22 at approximately 9:30 AM, an observation was made of (CSM) 1. CSM 1 was observed to be placing a gown and gloves on outside…

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 it was determined, for 2 of 19 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made during wound care of cross contamination during treatment application, lack of hand hygiene, and not changing soiled gloves. Additionally, observations were made of staff assisting a resident without the required Personal Protective Equipment (PPE) needed for the resident who was on contact/droplet precautions. Resident identifiers: 27 and 88. Findings included: 1. Resident 27 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included sepsis, quadriplegia, pyelonephritis, acute kidney failure, pressure ulcer stage 2 of right and left ankle, hypertension, atrial flutter, anoxic brain damage, idiopathic…

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.