Hudson Bay Health and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (AD); and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 2 of 7 sampled residents (Resident 10 & 6) reviewed for ADs. This failure place residents at potential risk for losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 3 residents (Resident 10) reviewed for care conferences. This failure placed residents at risk of a diminished quality of life when not allowed to be involved and/or have a say in their long-term care needs.

Inspectors wroteBased on interview and record review, the facility failed to refer 2 of 7 residents (Resident 7 & 13) to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR, an in-depth, person-centered evaluation for individuals with serious mental disorders and individuals with intellectual disability). This failure placed residents at risk of not receiving specialized services and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 1 sampled resident (Resident 101) reviewed for death. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled with open date for 1 of 2 medication storage rooms (East Medication Storage Room) and 1 of 3 medication carts (Medication Cart 4) reviewed for medication storage and labeling. This failure placed residents at risk of receiving expired and/or less effective medications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff properly don (put on) personal protective equipment (PPE) for 2 of 3 sampled resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) reviewed for infection prevention and control. This failure placed residents at risk for the spread of infection transmission in the facility and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was served hot at a safe temperature. This failure to serve foods at proper temperatures placed resident at risk for decreased nutritional intake, food borne illness and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for 1 of 4 sampled residents (Resident 38) reviewed for mood and behavior. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings Included . Resident 38 was admitted to the facility on [DATE] with diagnosis to include Post Traumatic Stress Disorder (PTSD, a mental health condition that can develop after someone experiences or witnesses a traumatic event). The Quarterly Minimum Data Set assessment, an assessment tool, dated 03/22/2025, documented Resident 38 was alert and oriented, had a diagnosis of PTSD, and was taking antipsychotic medication. Review of Resident 38's Comprehensive Care Plan, on 04/24/2025, did not show a Focus, Goal, or Interventions/Tasks related to PTSD. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document/monitor targeted behaviors for 1 of 5 residents (Resident 48) reviewed for behavior-emotions. This failure to monitor targeted behaviors placed residents at risk for unmet psychosocial needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered by professional standards of practice for 1 of 4 sample residents (Resident 38) reviewed for medication administration. This failure placed residents at risk for medication errors, negative outcomes, and a diminished quality of life. Findings Included . Review of the facility's policy entitled, Oral Medication Administration, dated 01/01/2018, documented, .Administration .6.e. Observe the resident ingest the medication. Resident 38 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set assessment, an assessment tool, dated 03/22/2025, documented Resident 38 was alert and oriented. On 04/23/2025 at 11:03 AM, Resident 38 was observed lying in bed with no staff present in the room. A white oval pill was observed on Resident 38's overbed table lying on a napkin. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bed rails were securely fastened to the bed for 1 of 2 sampled residents (Resident 49) reviewed for accident hazards. This failure placed residents at risk for injury and/or entrapment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accurate medication administration for 1 of 5 sampled residents (Resident 1) reviewed for medication administration errors. This failure placed residents at risk for medical complications and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain the cleanliness of the vent covers in 1 of 1 facility kitchen. This failure placed residents at risk to consume food not prepared in a sanitary manner and a diminished quality of life. kitchen vent covers reviewed for kitchen. These failures had the potential to affect all residents who consumed food and may cause a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered care plan addressing limited mobility for 1 of 6 sampled residents (40) reviewed for comprehensive care plan related to mobility. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food preferences were honored for 1 of 3 sample residents (114) reviewed for food preferences. This failure placed residents at risk for not having their food preferences honored and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure the floor was inspected where medication was found in 1 of 3 resident hallways (East) reviewed for safe environment. This failure placed residents at risk for an unsafe living environment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nursing assistant for 3 of 3 agency nursing assistants (Staff C, D & E) reviewed for nursing aide registry. This failure placed residents at risk of unmet care needs and care being provided by unqualified nursing assistants.