Hibbard Skilled Nursing & Rehabilitation Center

Inspectors wroteBased on review of the facility's abuse policy and procedure, review of the Adult Protective Services-APS reported incident, and interviews, the facility failed to notify the State agency (Division of Licensing and Certification-DLC) of an allegation of staff to resident abuse (Resident #1 [R1]) for 1 of 1 reviewed incident on 6/12/26.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a clinical record was complete and contained accurate information for 2 of 9 days for a treatment to check a pacemaker monitor and 1 of 1 treatment for a urinalysis dip for 1 of 1 resident reviewed (Resident #1 [R1]).

Inspectors wroteBased on record reviews and interviews, the facility failed to provide care in accordance with the resident's comprehensive care plan for 1 of 3 residents reviewed for falls during a complaint investigation (Resident #2).

Inspectors wroteBased on observation, record review, interviews, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection by failing to follow their own Enhanced Barrier Precautions (EBP) policy for 1 of 1 resident reviewed for wounds (Resident #1).

Inspectors wroteBased on record review and interview, the facility failed to ensure that a clinical record contained accurate and complete information regarding the location of a venous ulcer for Resident #1 (R1) for 7 of 7 months reviewed (May 2025 - December 2025).

Inspectors wroteBased on facility policy review, record reviews, and interview, the facility failed to ensure that the resident and/or resident representative received assistance/follow up assistance to complete the written information provided concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, for 5 of 7 residents reviewed for advanced directives. (Resident #21 [R21], R24, R42 R72, R75).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required, or incorporate the recommendations from a PASRR level II determination into a resident's assessment and care planning for 2 of 5 sampled residents reviewed for PASRR [Resident #30 (R30), R52].

Inspectors wroteBased on observation, record reviews, and interview, the facility failed to obtain physician orders for the treatment of a surgical wound and pressure ulcer for 1 of 1 Resident sampled for wound care (Resident #333).

Inspectors wrote2. On 6/3/25, review of R52's clinical notes indicated the following: On 12/2/24 at 7:23 p.m., a provider note stated During [R52's] hospital stay, [R52] made statements about wanting to kill [himself/herself] and [R52] was seen by behavioral health team with medication adjustment. There is no evidence that a referral was made for follow-up services at that time. On 12/4/24 at 3:22 a.m., a provider note indicated [complaint of (c/o)] hallucinations. [He/She] is seeing 'corpses in the room with [him/her] . Actively having visual hallucinations. [Differential diagnosis (Ddx)] includes hepatic encephalopathy, infection, medication. There was no evidence that R52's active diagnosis of PTSD was addressed. On 12/4/24 at 6:37 a.m., a nurse note stated [R52] stated There is a dead body's on the wall and decomposing body's with maggots coming out of their mouths. [...]

Inspectors wroteBased on record review, interview and facility policy the facility failed to ensure temperatures were monitored in the walk-in refrigerator and freezer in order to prevent food borne illness for 2 of 3 months reviewed (January and February 2025).

Inspectors wroteBased on observations, interviews and record review, the facility's interdisciplinary team (IDT) failed to determine if it was clinically appropriate for a resident to keep medications at bedside and self-administer medications for 2 of 29 Residents reviewed during a medication pass (Residents #1 [R1] and R9).

Inspectors wroteBased on interviews, record review and facility policy, the facility failed to thoroughly investigate an allegation injury of unknown origin for 2 of 3 facility incident reports reviewed [Resident #4 (R4) and R61].

Inspectors wroteBased on obervation, record review, and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 5 residents reviewed for baseline care plans (Resident #333).

Inspectors wroteBased on Smoking Policy review, record review and interviews, the facility failed to complete a Safe Smoking Evaluation for 1 of 1 sampled resident that actively smokes cigarettes (Resident #383 [R383]).

Inspectors wroteBased on record reviews and interview, the facility failed to notify the physician of a suspected Urinary Tract Infection (UTI) for 1 of 4 Residents (Resident #71) reviewed for indwelling urinary catheters. Resident #71 was admitted in December 2024 with diagnoses to include Benign Prostatic Hyperplasia (enlarged prostate), retention of urine, obstructive uropathy (a blockage in the urinary tract that causes difficulty urinating), and indwelling urinary catheter (Foley catheter). Review of Resident #71's clinical record revealed a nursing progress note dated 6/1/25 states, Flushed resident's foley with acetic acid solution, replaced bag and tubing as it was full of sediment and smelled badly. Resident may have a UTI, recommend a UA [urinalysis] to r/o [rule out]. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to implement, monitor and/or revise as necessary interventions to prevent or manage a resident's pain for 2 of 4 residents reviewed for pain (Resident #52 (R52) and R333)

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired medications were removed from the available for use supply, for 1of 3 Medication storage Carts reviewed (Treatment Cart).

Inspectors wroteBased on record reviews, interviews, and policy review, the facility failed to ensure that clinical records were complete and contained accurate information for 5 of 26 sampled residents reviewed. (Resident #46 [R46], R7, R52, R71, R333).

Inspectors wroteBased on observations and interviews, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to a dressing change and the processing of linens for 1 of 2 observations during the survey.

Inspectors wroteBased on facility policy review, record reviews, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to offer the updated Pneumococcal Conjugate Vaccination (PCV) 20 to 2 of 5 residents (Resident #47 [R47] and R72).

Inspectors wroteBased on record review and interview, the facility failed to update and revise a resident's care plan to reflect a new safety concern with the resident handling of hot fluids for 1 of 1 resident reviewed (Resident #1 [R1]).

Inspectors wroteBased on record review and interview, the facility failed to update a care plan for the area of constipation/fecal impaction for 1 of 3 residents reviewed for bowel management. (Resident #1 [R1]).

Inspectors wroteBased on record review, facility policies review, and interviews, the facility failed to ensure a clinical record contained complete and accurate information for 1 of 1 residents reviewed for a skin tear incident (Resident #1 [R1]).

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections in 3 of 16 residents diagnosed with Coronavirus (COVID-19).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 3 of 3 environmental tours. On 7/22/24 at 8:01 a.m. through to 8:35 a.m., environmental tours were completed with the Administrator and surveyors with the following findings at the time of the observations. 1. room [ROOM NUMBER]a - the veneer/stain on the bedside table and dresser drawer was chipped and missing creating an uncleanable surface. room [ROOM NUMBER]a - the Lansko fan was soiled with dust. room [ROOM NUMBER]a - the veneer/stain on the bedside table and dresser drawer was chipped and missing creating an uncleanable surface. room [ROOM NUMBER]a - the covers on the fall safety floor mats are soiled and cracked creating an uncleanable surface. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that physician orders for medications and treatments were followed for 6 of 8 Residents reviewed for unnecessary medications and/or treatments (Resident #39 [R39]), R22, R77, R55, R49, and R50).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded accurately on an admission and annual MDS assessment to indicate that a resident had a state Level II Preadmission Screening and Resident Review (PASRR) and Post Traumatic Stress Disorder (PTSD) for 1 of 1 sampled residents reviewed for PASRR (Resident #61 [R61]).

Inspectors wroteBased on record review and interview, the facility failed to ensure that a care plan was developed for a resident with the diagnosis of Post Traumatic Stress Disorder (PTSD) for 1 of 1 sampled residents reviewed for PASRR (Resident #61 [R61]).

Inspectors wroteBased on interviews and observations, the facility failed to follow physician orders for use a equipment (wedge pillow) to maintain and/or improve residents' highest level of bed mobility for 1 of 1 resident reviewed for positioning and mobility. (Resident #50 [R50])

Inspectors wroteBased on observations, manufacturer's manual review, and interview, the facility failed to ensure that an oxygen concentrator was operated and maintained per manufacturer's directions for 1 of 1 residents reviewed with oxygen (Resident #22 [R22]).

Inspectors wroteBased on record review and interview, the facility failed to ensure a Physician ordered lab was completed for a urine test for 1 of 2 urinalysis ordered for Resident #35 (R35).

Inspectors wroteBased on record reviews and interviews, the facility failed to accurately document resident weights for 2 of 3 resident reviewed for weight loss concerns (Resident #39 [R39] and R14).

Inspectors wroteBased on record review and interview, the facility failed to inform a resident representative that two new Stage II pressure ulcers were observed (Resident # 39 [R39]).

Inspectors wroteBased on facility's investigation, written statements, record review and interviews, the facility failed to complete a resident assessment and notify a physician regarding a resident's complaint of increased pain with signs and symptoms of a hip/leg injury including a bump and bruising to residents left leg/hip area, causing a delay in medical treatment for 1 of 1 residents (Resident #1[R1]) for 4 days (7/8/23, 7/9/23, 7/10/23, and 7/11/23).

Inspectors wroteBased on observations and interview, the facility failed to ensure resident furniture, baseboard for a radiator, privacy curtain, chairs, tables, carpeting, wheelchair, and bathroom were maintained in a clean and sanitary manner on 1 of 1 environmental tour. (4/12/23)

Inspectors wroteBased on record review, observation of a pressure ulcer wound dressing change, interview and facility wound care policy and procedure review, the facility failed to ensure that infection control procedures and the facility's wound management policy and procedures were followed for 1 of 3 residents that require pressure ulcer wound treatments (Resident #51).

Inspectors wroteBased on record reviews and interviews, the facility failed to provide services to maintain and/or improve residents highest level of Active Range of Motion (AROM) and dressing and grooming, the facility failed to provide Restorative services as outlined in the resident's restorative therapy program care planned for 2 of 2 sampled residents (Resident #51 and Resident #48).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of all 60 residents that reside on [NAME]-[NAME] and Main units. This has the potential to affect all residents that need assistance with Activities of Daily Living (ADL).

Inspectors wroteBased on interviews and record review, the facility failed to provide evidence that the menus were developed and based on the residents cultural needs based on the resident population, as well as being updated to reflect residents input for 4 of 4 days of survey. (4/10/23, 4/11/23, 4/12/23 and 4/13/23)

Inspectors wroteBased on observations and interviews, the facility failed to ensure that a call bell was accessible to 1 of 33 sampled residents, (#14)

Inspectors wroteBased on record reviews, facility policy, and interviews the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 2 of 2 residents reviewed for advanced directives (Resident #25 and #61).

Inspectors wroteBased on interview and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 1 of 2 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to follow Physician orders for 1 of 4 sampled Residents observed during medication administration (Resident #2).

Inspectors wroteBased on record reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely manner for 1 of 4 sampled residents reviewed for unnecessary medications (Resident #12).

Inspectors wroteBased on observations, clinical record review, and interviews, the facility failed to ensure that 'Contact Precautions were maintained for 1 of 1 resident (Resident #119) on contact precautions.