Focused Care at Huntsville

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and 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 for 3 of 6 staff (CNA C, MA D, and RN A) reviewed for infection control.1. The facility failed to ensure CNA C followed infection control measures during dining service on 7/13/2026.2. The facility failed to ensure MA D followed infection control measures during medication administration on 7/14/2026.3. The facility failed to ensure RN A wore the appropriate PPE when wound care was provided to Resident #3 on 7/14/2026. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure an accurate MDS reflected the resident's status for 1 of 6 residents (Resident #6) reviewed for resident assessments. The facility incorrectly coded the MDS Assessments for Resident #6 to indicate the use of an anticoagulant (blood thinner); not an antiplatelet (prevents platelets from sticking together). This failure could place residents at risk of not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure the Dietary Manager maintained sanitary conditions while preparing trays during meal service on 07/13/2026. This failure could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 dining rooms (main Dining Room), 6 of 6 halls (100-600 halls) reviewed for the environment. The facility failed to ensure the exterior windows of the building were maintained and cleaned. The facility failed to ensure the kitchen floors, base boards, and shelving were free from dirt and debris. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents the right to be free from abuse and neglect for 1 of 7 (Resident #2) residents reviewed for abuse and neglect. The facility failed to protect Resident #2 from abuse from Resident #1 on 6/26/2025 when Resident #1 hit Resident #2 with his walker. This failure could place residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for 3 of 8 residents (Resident #3, #10, and #40) reviewed for accidents and supervision. 1. The facility failed to ensure CNA A and CNA B used a gait belt to transfer Resident #3 from the wheelchair to bed on 05/05/2025. 2. The facility failed to develop and implement a policy and procedure to properly handle the care of mechanical lift slings including interventions to inspect the mechanical lift sling for signs of damage before each use and remove damaged slings from service for Residents #10 and #40. These deficient practices could place residents at risk of falls and injuries during transfers.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to store and label foods in accordance with professional standards. 2. The facility failed to ensure staff wore hair coverings appropriately while preparing and serving food. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and/or transmission-based infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 15 residents (Resident # 3) reviewed for resident rights. The facility failed to ensure Resident # 3 was assisted with eating in a dignified manner on 05/05/2025. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide a safe, sanitary, comfortable and homelike environment for residents for 1 of 8 resident rooms (Resident #45's room) observed for resident environment. The facility failed to ensure the personal fan in Resident #45's room was clean. There was a black substance on the fan blades and outer covering on 5/05/2025 and 05/06/2025. This failure could place residents at risk for an unsafe and unsanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 6 residents (Resident #3) reviewed for pressure injuries. The facility failed to ensure Resident #3's wheelchair had a pressure reduction cushion on 5/05/2025. This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and 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 for 2 of 8 residents (Residents #3 and #21) and 2 of 8 staff (CNA A and CNA B) reviewed for infection control. 1. The facility failed to ensure CNA A followed infection control measures when providing incontinent care to Resident #3 on 05/05/2025. 2. The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions when providing care to Resident #21 on 5/05/2025. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents the right to be free from abuse and neglect for 1 of 10 residents (Resident #7) reviewed for abuse and neglect in that: The facility failed to ensure CNA D did not speak loudly and harshly to Resident #7 on 1/6/25 when he pushed the call light for assistance with incontinent care. The noncompliance was identified as PNC. The past noncompliance began on 1/6/25 and ended on 1/6/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse, neglect, and not having their needs met. Findings Include: Record review of a facility face sheet dated 4/9/25 for Resident #7 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of heart failure. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 10 residents (Resident #1) reviewed for misappropriation of resident property. The facility failed to ensure HSKP A did not use Resident #1's debit card for her personal use between the dates of [DATE] through [DATE]. The noncompliance was identified as PNC. The past noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for decreased quality of life, misappropriation, and dignity.

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 10 residents (Resident #7) reviewed for developing and implementing abuse policies. The facility failed to implement its own abuse policy when LVN E failed to report to abuse coordinator upon hearing CNA D yelling at Resident #7 on 1/6/25. The noncompliance was identified as PNC. The past noncompliance began on 1/6/25 and ended on 1/6/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of neglect, abuse, mental anguish, and emotional distress.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and 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 for 1 of 6 residents (Resident #15) and 2 of 5 staff (CNA E and CNA G) reviewed for infection control. CNA E did not change gloves, sanitize/wash hands between glove changes, and touched clean items with dirty gloves when providing incontinent care on 4/15/2024. CNA G failed to properly bag soiled linens and towels after giving Resident #15 a bed bath on 4/17/2024. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 1 of 7 residents (Resident #23) reviewed for notification of changes. The facility failed to notify and consult with the physician about the changes in Resident #23's high blood sugar readings. This failure could place residents at the risk of not receiving appropriate medical interventions, which could result in severe illness or hospitalization.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 1 of 6 residents (Residents #12) reviewed for MDS assessment accuracy. The facility failed to code Resident #12 as being on hospice services on her MDS assessments. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop a person-centered comprehensive care plan to address medical needs for 2 of 6 residents (Resident #15 and Resident #39) reviewed for comprehensive care plans. The facility failed to ensure Resident #15's and Resident #39's care plans were revised to reflect current transfer status of requiring mechanical lift transfer. This failure could place residents requiring mechanical lift transfer at increased risk of falls, injuries, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 16 resident reviewed for ADLs. (Resident #15) The facility failed to remove Resident #15's unwanted facial hair. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in feelings of poor self-esteem, lack of dignity, and health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 2 of 6 residents reviewed for accident hazards (Resident #15 and Resident #39). The facility failed to develop and implement a policy and procedure including interventions to inspect the Hoyer sling for signs of damage before each use. The facility failed to remove damaged mechanical lift slings from service. The facility failed to obtain physicians orders for Hoyer lift transfers. This deficient practice could result in a loss of quality of life due to injuries if the damaged lift sling broke during transfer for residents that use a Hoyer lift for transfers and inappropriate use of Hoyer (mechanical lift) for transfers if an order was not obtained by the physician.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 (Residents #3 and #39) residents reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Resident #3 and Resident #39. This failure could place residents who received pureed meat and vegetables at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes.