Hunter Creek Health and Rehabilitation, LLC

Inspectors wroteBased on observation, interview and review of a facility policy Cleaning of Miscellaneous Equipment and Utensils, the facility failed to ensure the drying rack did not have dust and rust on it. This deficient practice had the potential to affect 74 of the 77 residents receiving meals from the kitchen. Findings Include A review of a facility policy, titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of September 3, 2019 revealed . PURPOSE: to prevent the spread of bacteria that may cause food borne illness. STANDARD: Equipment and utensils should be cleaned . 36. Shelving - Metal and Wood: (monthly or as needed) * Remove contents from shelves * Wash and scrub * Rinse and sanitize * Air dry . On 4/11/22 at 5:29 PM during the initial tour of the kitchen the surveyor observed the drying rack with rust and had visible dust particles. [...]

Inspectors wroteBased on medical record review, interview and a facility policy titled, Nursing Assessments, the facility failed to ensure a Quarterly MDS (Minimum Data Set) assessment was completed timely for RI (Resident Identifier) #1. This deficient practice affected RI #1, one of 25 residents reviewed for MDS assessments. Findings Include: A review of a facility policy titled, Nursing Assessments with an effective date of August 15, 2018, revealed: .STANDARD: Comprehensive assessments should be completed on admission, quarterly and with a significant change in the resident .condition. PROCESS: .III. Quarterly .Nursing Assessments include: (once every 3 months) . RI #1 was admitted to the facility on [DATE]. RI#1's admission MDS assessment was done on 1/14/19. An interview was conducted with EI (Employee Identifier) #1, MDS Coordinator on 6/5/19 at 4:14 p.m. [...]

Inspectors wroteBased on medical record review, observations, interview, and a facility policy titled, Oxygen Administration, the facility failed to ensure staff dated oxygen tubing and stored the oxygen tubing in a plastic bag when not in use. This affected RI( Resident Identifier) #9 and RI #32, two of four residents sampled for receiving oxygen. Findings Include: A facility policy titled, Oxygen Administration with an effective date of December 8, 2005, revealed: .PURPOSE: To administer high purity oxygen for the treatment of certain diseases or conditions . PROCESS: . 11. Cannulas and masks should be changed weekly . 14. O2 (oxygen) cannuala (cannula)/mask should be stored in a plastic bag when not in use . 1) RI #9 was admitted to the facility on [DATE] and re-admitted on [DATE], with a diagnosis of Chronic Atrial Fibrillation. A review of RI #9's June 2019 Physician Orders revealed: [...]

Inspectors wroteBased on observation, interview, and a review of a facility policy titled, Garbage and Refuse, the facility failed to ensure the dumpster was not leaking and that liquid was not pooling on the ground around it. This affect one of three dumpsters and had the potential to affect 67 of 67 residents residing in the facility.

Inspectors wroteBased on observations, interviews, a review of facility policies titled, Hand-washing Guidelines, Food Cooking and Serving Temperatures, Cleaning of Miscellaneous Equipment and Utensils, and review of a document titled, Lunch Menu Log, the facility failed to ensure: 1. staff washed their hands when entering the kitchen; 2. food temperatures on the tray line were taken and recorded on the menu log and 3. plates were not stacked wet. This had the potential to affect 67 of 69 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Hand-washing Guidelines with an effective date of 2/1/2002, revealed: .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses PROCESS: 1. Frequency of Hand-washing: Hands should be washed in the following situations: Every time an employee enters the kitchen; . [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure Room Locators (RL) # 1 was free of a missing dresser drawer, RL #2, 3 and 4 was free of missing caps on the commode bolts and RL #5 was free of scrapped and peeling sheetrock on the wall behind bed A. This affected five of 42 rooms in the facility. Findings Include: On 6/6/18 and 6/7/18, RL #1 was observed with the top dresser drawer on the left missing. 6/7/18 at 4:00 PM an observation and interview was done with EI (Employee Indentifer) #4, Maintenance Director. In RL#1, EI #4 was asked what did he see. EI #4 replied the top dresser drawer was missing. EI #4 was asked if there should be a drawer. EI #4 replied, yes. EI #4 was asked why was there no drawer. EI #4 replied, he had not had time to build a new one. EI #4 was asked what was the harm in no dresser drawer. [...]

Inspectors wroteBased on record review and review of facility policy titled,Non-Controlled Medication Destruction, the facility failed to ensure medication destruction for non-controlled medication for November 2017 had two signatures. This affected one of 12 months of medication destruction sheets reviewed. Findings Include: A review of a facility policy titled, Non-Controlled Medication Destruction dated 3/11 revealed: .NON-CONTROLLED MEDICATION DESTRUCTION .Procedures .3. The registered nurse and/or pharmacist witnessing the destruction, .ensures that the following information is entered on the Record of Medication Destruction form . J. Signature of witnesses, two witnesses required for non-controlled substances, . in the designated areas on the destruction form On 6/6/18 at 9:00 AM, the surveyor reviewed the medication destruction sheets from May 2017 through May 2018. [...]

Inspectors wroteBased on observation, interview and review of facility policy titled, Wound Care Procedure for Major Wounds, the facility failed to ensure licensed staff: 1. did not place a container of 4x4's on Resident Identifier (RI) #49's bed during wound care, and 2. licensed staff did not touch a pen pulled from another staff member's pocket then touch the hydrogel treatment for RI #49. This was observed on 6/7/18 and affected one of one residents observed for wound care. Findings Include: A review of a facility policy titled, Wound Care Procedures for Major Wounds with an effective date of 12/1/09 revealed: PURPOSE: To provide guidelines for clean technique in doing wound care NOTE: . Care must be taken to prevent contamination of the supplies and surfaces used in wound care . RI #49 was admitted to the facility on [DATE], with a diagnosis of Pressure Ulcer of Sacral Region. [...]

Inspectors wroteBased on observation, interview and a review of a facility policy titled Garbage and Refuse with an effective date of February 1, 2002 the facility failed to ensure that the door of the dumpster was closed on 6/6/18. This had the potential to affect all 69 residents residing in the facility.