Huebner Creek Health & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation was implemented for 2 of 3 residents (Resident #1 and Resident #2) reviewed for pharmacy services. The facility failed to ensure narcotic medications were accurately documented and reconciled on 5/29/26, 5/31/26, 6/1/26, and 6/2/26 for Resident #1 and 5/26/26, 5/28/26, 5/29/26, and 5/31/26 for Resident #2. These failures could result in the loss of residents' property, diversion of narcotics, and residents not receiving intended medication regimens.

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 for 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure the kitchen was free from insects in the dry storage area and standing water in the walk-in refrigerator and freezer areas on 6/03/2026. This failure could lead to food contamination and illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a sanitary and comfortable environment for 1 of 8 residents (Resident #3) reviewed for physical environment. The facility failed to ensure Resident #3's room was free from dead insects and had hot water available through the hand sink. These failures could lead to decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had a right to confidentiality of his or her personal and medical records for one (1) of six (6) residents (Resident #1) reviewed for privacy and confidentiality. The facility failed to ensure Resident #2's medical records did not contain Resident #1's Administration Report prior to the release of Resident #2's records, dated 04/28/2026, to Resident #2's family member. This deficient practice could place residents at risk of their medical information being accessed by unauthorized individuals.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure they provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) who were reviewed podiatry care. The facility failed to ensure Resident #1, Resident #2, and Resident #3 received podiatry care to maintain proper toenail length during the 3/4/2026 quarterly scheduled visit. The previous visit occurred on 10/28/2025. This failure could place residents at risk of experiencing pain when wearing footwear, difficulty walking, or poor hygiene.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 2 residents (Residents #1 and #2) reviewed for medical records. 1. The facility failed to ensure Resident #1's ADL-Bathing record recorded a bath or refusal for 2/28/2026, 3/5/2026, 3/7/2026, 3/10/2026, 3/12/2026, 3/14/2026, 3/17/2026, and 3/24/2026 as noted on the electronic medical record. 2. The facility failed to ensure Resident #2's ADL-Bathing record recorded a bath or refusal for 2/28/2026, 3/5/2026, 3/7/2026, 3/10/2026, 3/12/2026, 3/14/2026, 3/17/2026, and 3/24/2026 as noted on the electronic medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 3 residents (Resident #1), reviewed for a call light system. The facility failed to ensure Resident #1 could reach or trigger the call light installed near her bed when she fell on 3/11/26. This failure could place residents at risk of not receiving timely care and nursing interventions; and could result in falls, injuries, a diminished quality of life, and incontinent episodes.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. The facility failed to maintain the holding temperature for cream of corn at 135 F or above. The facility failed to maintain the cold temperature for the cold smore parfait at 41 F or below. The facility failed to sanitize the thermometer before taking food temperatures. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 disease and infection for 3 of 32 residents (Resident #6, Resident #8, and Resident #100) reviewed for infection control: 1. The facility failed to ensure LVN I cleaned the insulin pen for Resident #6 prior to administration and perform proper hand hygiene. 2. The facility failed to ensure LVN I cleaned the insulin pen for Resident #8 prior to administration and perform proper hand hygiene. 3. The facility failed to ensure Resident #100's indwelling urinary catheter bag was not touching the floor. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for 1 (Resident #99) of 16 residents. The facility failed to ensure RN A did not walk away from a computer without concealing Resident #99 private health information on the computer screen. This failure could place residents at risk of resident-identifiable information being accessed by the public, identity theft, or embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to within 14 days after a facility completes a resident's assessment to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 1 resident (Resident #89) reviewed for MDS transmission. Resident #89's discharge MDS assessment was not transmitted within 14 days of completion. This deficient practice placed residents at risk of not having assessments completed and submitted in a timely manner as required.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #6) reviewed for care plans: The facility failed to ensure Resident #6's comprehensive care plan included he received dialysis services outside the facility. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming, personal hygiene for residents who were unable to carry out activities of daily living for 2 of 8 Residents (Resident #45 and Resident #80) reviewed for quality of life. 1. The facility failed to ensure Resident #45 received scheduled showers on 3/3/26 and 3/7/26. 2. The facility failed to ensure Resident #80 received scheduled showers on 3/3/26, 3/5/26, and 3/10/26. This deficient practice could affect any resident and contribute to feelings of poor self-esteem and hopelessness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 1 residents (Resident #64) reviewed for quality of care. The facility failed to ensure Resident #64's sterile water was dated on the oxygen concentrator. This failure could place residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #6) reviewed for quality of care: The facility did not maintain communication, coordination, or collaboration with the dialysis facility for Resident #6. This failure could affect residents who received dialysis treatments and place them at risk of complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 5.88% based on 2 out of 34 opportunities, which involved 2 of 6 Residents (Resident #6 and Resident #8) reviewed for medication administration, in that: 1. The facility failed to ensure LVN I primed the insulin pen for Resident #6 prior to administration. 2. The facility failed to ensure LVN I primed the insulin pen for Resident #8 prior to administration. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 4 nurses' medication carts (600 hall nursing medication cart) reviewed for storage of drugs. The facility failed to ensure the 600-hall nursing medication cart was locked. This deficient practice could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observations, interviews and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 trash disposals areas that were reviewed for disposal of garbage. The facility failed to ensure trash was not left outside of the trash disposal container. This failure could place residents at risk for rodent infestation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 2 of 2 residents (Resident #1 and Resident #2) reviewed for infection control. The facility failed to ensure LPN A cleaned the blood pressure cuff between Resident #1 and Resident #2 on 02/13/2026. These deficient practices could place residents at-risk for infections.

Inspectors wroteBased on observation and interview, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 20 of 20 days (01/23/2026 - 02/12/2026) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information from 01/23/2026 to 02/12/2026. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. The facility failed to write a discard date on ham and cheese in the walk-in refrigerator. The facility failed to ensure foods were stored at least 18 inches from the ceiling. The facility failed to ensure that bacon was covered in the walk-in refrigerator. The facility failed to ensure [NAME] C wore a beard restraint while cooking for 01/13/26 dinner. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 5 residents (Resident #1 and #2) reviewed for assessments. 1. Resident #1's admission MDS, dated [DATE], was coded No regarding the resident had a pressure ulcer. Resident #1 had a pressure ulcer to her right buttock. 2. Resident #2's Medicare-5 days MDS, dated [DATE], was coded No regarding the resident had an indwelling urinary catheter. Resident #2 had an indwelling urinary catheter. These failures could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #3) of 3 residents reviewed for incontinence care. On 01/14/2026, CNA-B did not clean Resident #3's suprapubic area (region of the abdomen located below the umbilical region) and did not open the resident's labia area. This failure could place residents who require incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities based on the comprehensive assessment and care plan, designed to meet the interests of and support the physical, mental and psychosocial well-being of 3 (Resident #2, 3, 4) out of 12 who were reviewed for activities. The facility failed to consistently provide individualized activities and did not meet the needs of the Resident #2, #3, and #4, especially nights and weekends. These failures placed the residents at risk of becoming apathetic (marked indifference to the environment), isolated from others, having a depressed mood, boredom, loneliness, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 (Resident # 1) reviewed for call light. The facility failed to ensure Resident # 1's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident had the right to observe resident's religious beliefs in the facility that were significant to the resident for one (Resident #5) of twelve residents reviewed for self-determination. The facility failed to promote Resident #5's self-determination by not honoring his choice to practice his religion. This failure could place residents at risk for poor self-esteem and decreased self-worth due to their needs and preferences not being met.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 2 of 12 residents (Residents #2 and #5) reviewed for care plans, in that. 1. The facility failed to update Resident #5's care plan to reflect his religion. 2. The facility failed to update Resident #2's care plan to reflect his diagnosis of PTSD. This failure could place residents at risk of not receiving appropriate care.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 (Resident #1) of 3 residents reviewed for clinical records. The facility failed to ensure Resident #1's wound care treatments were accurately documented on his Wound Administration Record (WAR) for 3 (06/14/2025 ***Ev, 06/15/2025 Day, and 06/15/2025 ***Ev) of 39 treatments scheduled between the day shift of 06/01/2025 through the day shift of 06/20/2025 reviewed. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for 1 (CNA F) of 5 staff observed for infection control. CNA F failed to perform hand hygiene while serving and assisting residents with their meal on 06/26/2025. These deficient practices placed residents at risk for cross contamination and spread of infection.

Inspectors wroteBased on observation and interview the facility failed to post, in a form and manner accessible and understandable to residents, resident representatives list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, including the Office of the State Long-Term Care Ombudsman program for 3 of 3 days (05/21/2025, 05/22/2025, and 05/23/2025) reviewed for posting of required information. The facility failed to post the required Office of the State Long-Term Care Ombudsman program information from 05/21/2025 to 05/23/2025. This failure could place residents at risk of lack of knowledge of who to contact should they require advocacy, investigation, and not knowing their rights or how to exercise their rights.

Inspectors wroteBased on observation and interview, the facility failed to post daily information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 3 of 3 days (05/21/2025, 05/22/2025, and 05/23/2025) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information from 05/21/2025 to 05/23/2025. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 disease and infection for 1 of 4 residents (Residents #3) reviewed for infection control: The facility failed to ensure CNA A utilized hand hygiene between glove changes during peri-care on Resident #3. This failure could place residents at-risk for infection due to lack of hand hygiene and could result in infection or illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment for 2 (Residents #39 and #43's) of 20 resident rooms reviewed for environment, in that: 1. A strong urine odor was coming from from Resident #39's room, and there were urine and feces found on his sheets. 2. The toilet in Resident #43's restroom was loose and wobbled when Resident #43 used the toilet. These failures could result in resident injury and psychosocial harm due to diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan which included the minimum healthcare information necessary to properly care for the resident within 48 hours of the resident's admission, for 2 (Residents #12 and #29) of 8 residents reviewed:: 1) Resident #12's baseline care plan was not completed within 48 hours of admission. 2) Resident #29's baseline care plan was not completed within 48 hours of admission. This failure could place newly admitted residents at risks of not receiving the proper care and continuity of services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 8 residents (Resident #12) reviewed for care plans. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to review and revise resident care plans after each assessment for 1 of 8 residents (Resident #39) reviewed for care plan revision/timing. The facility failed to ensure Resident #39's care plan was revised to reflect 3 falls in a 4-hour time period. This deficient practice could affect residents' care and services and may cause a delay in treatment and/or decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practices, the comprehensive care plan, and the residents' choices and based on the comprehensive assessment of a resident for 1 of 2 residents (Resident #37) reviewed for wound care. The facility failed to ensure wound dressings and leg wrapping were applied daily for Resident #37. This failure could place residents at risk of pain and lead to systemic infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for the only medication room and one of seven nurse medication carts (Hall 500 nurse medication cart) observed for drug storage and usage, as evidenced by: 1. The facility failed to ensure the controlled medication compartment inside the refrigerator of the medication room was locked. 2. The facility failed to ensure three medications for Resident #54 were stored and locked inside the Hall 500 medication cart. These failures could place residents at risk of misappropriation of medication, ingesting medications not prescribed or drug diversion.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 (CNA G, LVN H, LVN I, LVN J and PT) of 25 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to CNA G, LVN H, LVN I, LVN J, and PT annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for medications at the bedside. The facility failed to monitor residents for medications at the bedside when on 02/24/2024 Resident #1 was assessed by RN A as lethargic and difficult to arouse with a Tylenol bottle at the bedside. RN A called 911 and EMS transported Resident #1 to the emergency room for evaluation and treatment. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 8 residents (Residents #1) reviewed for reporting allegations of abuse, neglect, and [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action were taken, for 1 of 8 residents (Residents #1) reviewed for allegations of abuse, neglect, and exploitation. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to record in residents' medical records sufficient information to identify the Resident and services provided, for 1 of 8 residents (Residents #2) reviewed for services provided with documentation of nursing services. LVN LL failed to document her skin assessment, report to the physician and Resident's Representative, and detailed physicians order when on 10/23/2024 LVN LL assessed Resident #2 with a rash, communicated with the physician, and the physician prescribed Resident #2 a steroid skin cream. This failure could place residents at risk for inaccurate medical records.

Inspectors wroteBased on observation, interview and record review the facility failed to provide personal privacy for 3 of 6 (Resident #2, Resident #4, and Resident #6) reviewed for dignity. 1. The facility failed to ensure Resident #2 was provided with privacy during wound care. 2. The facility failed to ensure Resident #4 was provided with privacy during wound care. 3. The facility failed to ensure Resident #6 was provided with privacy during ADLs. These failures could affect residents by contributing to poor self-esteem, decreased self-worth, and quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident medical records are kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 3 of 4 residents (Residents #1, Resident #3, and Resident#4) reviewed for accuracy of records. 1. The facility failed to ensure Resident #1's treatments were documented per facility policy. 2. The facility failed to ensure Resident #3's treatments were documented per facility policy. 3. The facility failed to ensure Resident #4's treatments were documented per facility policy. These deficient practices could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on observations, interviews, and record review the facility failed to 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 5 of 6 residents (Resident #1, Resident #2, Resident #4, Resident #5, and Resident #6) reviewed for infection control. 1. The facility failed to use proper infection control practices during wound care and perineal care for Resident #1. 2. The facility failed to use proper infection control practices during wound care for Resident #2. 3. The facility failed to use proper infection control practices during wound care for Resident #4. 4. The facility failed to use proper infection control practices during toileting for Resident #5. 5. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to protect and facilitate resident's right to communicate with individuals and entities within and external to the facility, including reasonable access to a telephone for 1 of 1 facility's phone system reviewed for operation. The facility did not provide a staff member to monitor the facility secured entrance to allow visitors and providers access to residents and only provided a signage with the facility's phone number; however, the phone at the nurse station was unable to ring and alert anyone of an incoming call. This failure could place residents at risk for denying access to the residents to include a physician and or family.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to be adequately equipped to allow Residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 2 of 6 residents (Residents #2 and #4) reviewed for a nurse call system. 1. Resident #4 was placed in his room on 10/12/2024, without a call light system in place for Resident #4 to alert staff for assistance and or emergencies. 2. Resident #2 used his call light on 10/12/2024 to alert staff however Resident #2's call light system was inoperable due to a malfunctioning illuminator outside of his room. Resident #2 did not receive assistance for 36 minutes until the surveyor intervened and alerted staff Resident #2 needed assistance. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible for 9 of 25 residents (Residents #4, #30, #48, #49, #18, #25, #256, #20, #29) reviewed for homelike environment, in that: 1. Residents #4, #30, #48, and #49 did not have a nightstand for their personal use in their rooms. 2. Residents #18, #25, and #256 did not have their personal televisions or televisions that worked in their rooms for use. 3. Resident #29 and #20 did not have a television in their rooms. These failures could place residents at-risk for not having a setting to store personal items, and use of their personal belongings in a homelike environment and could result in feelings of frustration, loss of independence, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide residents who were unable to carry out activities of daily living the necessary services to maintain good personal hygiene to dependent residents for 3 of 3 residents (Resident #20, #27, #29) reviewed for ADL care: 1. Resident #20 had long nails and were not trimmed. 2. Resident #27 had long nails and were not trimmed. 3. Resident #29 was not able to shave himself for 2-3 days due to shaver in his old room. This could affect all residents who require assistance personal hygiene and it could contribute to poor hygiene and dignity.

Inspectors wroteBased on observation. interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment that included hand hygiene procedures to be followed by staff involved in direct resident contact for 1 of 3 halls (700 hall) reviewed for hand hygiene, in that: The 700-hall had no hand sanitizer in the wall units and rooms [ROOM NUMBER] had no paper towels. This failure could place residents at risk of cross contamination, illness, and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 10 residents (Resident #6) reviewed for accommodation of needs, in that: Resident #6's toilet and air conditioner were not working properly. This deficient practice could impact residents ADL's, create feelings of frustration and worthlessness, and could result in a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services for 1 of 1 resident (Resident #20) reviewed for Indwelling urinary catheters in that: Resident #20's indwelling catheter bag was in a basin and the basin had liquid in it. This could affect all residents with an indwelling catheter and could place them at risk for cross contamination and urinary tract infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to, based on a resident's comprehensive assessment, ensure that a resident was offered sufficient fluid intake to maintain proper hydration and health for 1 of 6 residents (Resident #26) reviewed for hydration, in that: Resident #26 was not given water when requested for his dry mouth and throat. This failure could place residents at risk of not receiving proper hydration and could result in feelings of frustration, worthlessness, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 (Resident #31) resident with a tracheotomy in that: Resident #31 had a trach with no AMBU device and the trach collar and plastic over it were dirty with hair. This could affect all resident with tracheostomy and could result in loss of oxygen and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to post nurse staffing data on a daily basis over two 24 hour time periods for 1 of 1 facility in that, The nurse staffing data was not posted for the dates of 12/03/23 and 12/04/23. This deficient practice could place residents at risk by not providing adequate staffing information for the staff and the general public to ensure that resident care needs are met.