Hunters Pond Rehabilitation and Healthcare

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status for 1of 5 residents (Residents #1) reviewed for resident assessments. The facility failed to ensure Resident #1's BIPAP was reflected on the quarterly MDS assessment dated [DATE]. BIPAP and oxygen were not reflected on her discharge MDS assessment dated [DATE]. This deficient practice could place residents at risk of missed or inaccurate care.

Inspectors wroteBased on observation, interview, 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 13 of 13 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) reviewed for reporting requirements for infection control. The DON and Administrator failed to report to the state survey agency when Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 tested positive for the influenza virus from 01/26/2026 to 02/05/2026. This failure could put the residents at risk of neglect, illness, communicable diseases, respiratory distress, and harm.

Inspectors wroteBased on interview and record review, the facility failed to assess each resident using the quarterly review instrument specified by the State and approved by CMS in a timely manner for 5 of 9 residents (Resident #47, #60, #62, #131, and #153) reviewed for timely completion of MDS assessments. The facility failed to transmit an MDS assessment in a timely manner for Resident #47, #60, #62, #131, and #153This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information.

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, in that: 1. The facility failed to date and label drinks, close sandwich bags and date them, date and label salads, and label and date brown rice. 2. The facility failed to keep boxes of food off the freezer floor. 3. The facility failed to log temperatures for the PM shift of a reach in refrigerator on the 8/7/25, 8/8/25, and 8/9/25. 4. The facility failed to log the sanitizing sink temperature and chemical levels on 8/6/25, 8/7/2, 8/8/25, 8/9/25, and 8/10/25. 5. The facility failed to remove black and brown slimy growth from the ice machine. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 3 of 24 residents (Resident #135, #25, and #170) reviewed for documentation.1. Resident #135's MAR did not accurately reflect the nurse administered medications on 5/27/25 at 4:00 AM. 2. Resident #25's shower sheets and Task Bathing document did not accurately reflect the resident received a shower. 3. Resident #170's shower sheets and Task Bathing document did not accurately reflect the resident received a shower. These failures placed residents at risk for delayed or inaccurate medication administration and ADL assistance and could result in a decline in health, dignity, and well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 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 and safety of the resident or others for 1 of 8 residents (Resident #111) reviewed for call light placement. The facility failed to ensure the call light was within reach for Resident #111. This deficient practice could place residents at risk of not receiving help as needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #25) reviewed for personal hygiene. The facility failed to provide Resident #25 with scheduled showers between 7/31/25 to 8/4/25, and 8/6/2025 to 8/8/25, and 8/10/25 to 8/13/25. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters (Dumpster #1) reviewed for disposal of garbage. The facility failed to ensure Dumpster #1 was closed and trash was not on the ground outside the dumpster. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

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 8 residents (Resident #47) reviewed for infection control: The facility failed to ensure the treatment nurse did not touch her personal cell phone and then grab a handful of clean gloves while preparing supplies to clean Resident #47's pressure wound. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 8 residents reviewed for accidents and hazards. MA A failed to have another staff assist while providing care for Resident #1 in the bed on 1/4/25. Resident #1 rolled out of the bed, fell to the floor, landed on her knees, and fractured both knees. Resident #1 was hospitalized after. An IJ was identified on 1/9/25. The IJ template was provided to the facility on 1/9/25 at 5:09 p.m. [...]

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 abuse and neglect. [...]

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 objective 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 #1) reviewed for care plans: The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's need for 2 staff to assist with bed mobility. This failure could place residents at risk for not having their needs and preferences met.

Inspectors wroteBased on observations, interviews, and record reviews, 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 2 of 8 residents (Resident #14 and Resident #16) reviewed for infection control 1. The facility failed to ensure CNA D used appropriate hand hygiene between glove changes when providing incontinent care to Resident #14. 2. The facility failed to ensure Resident #16's catheter bag was not laying on the floor. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for dialysis. Resident #1's did not have vital signs checked prior to leaving for dialysis on 10/4/24. This deficient practice could affect residents who received dialysis treatments and could result in inadequate care of dialysis treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 6 Residents (Resident #95 and Resident #104) whose MDS records were reviewed for accuracy. 1. The facility failed to ensure Resident #95's Quarterly MDS assessment dated [DATE] documented that Resident #95 received hospice services. 2. The facility failed to ensure Resident #104 Discharge MDS assessment dated [DATE] documented Resident #104 was discharged home. This failure could place residents at risk of improper or incorrect care or services necessary for their physical, mental, and psychosocial well-being due to inaccurate assessments.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 8 residents reviewed for PASRR (Resident #24). The facility failed to ensure Resident #24 had an accurate PASRR Level 1 Screening indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for 1 (Resident #39) of 21 residents reviewed for comprehensive care plans, in that: Resident #39's care plan was missing diagnoses and treatment information. This deficient practice could place residents at risk of receiving inadequate care and could result in a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 8% based on 2 out of 25 opportunities, which involved 2 of 4 Residents (Residents #52 and Resident #69) reviewed for medication administration, in that: 1. The facility failed to ensure CMA A administered Resident #52's isosorbide mononitrate (medication use to prevent chest pain (angina) in patients with certain heart conditions). 2. The facility failed to ensure LVN B administered Resident #69's insulin aspart (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) correctly. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records on each resident that were-accurately documented for 1 of 8 residents (Resident #24) reviewed for accurate medical records in that: The facility failed to document Resident #24's medical diagnosis of Major Depressive Disorder (MDD) in his medical record. The deficient practices could affect residents who have medical records and could result in misinformation about professional care provided.

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 involving 2 of 6 staff (LVN) reviewed for infection control, in that: 1. The facility failed to ensure LVN B cleaned a rubber stopper on an insulin pen prior to insulin administration for Resident #69. 2. The facility failed to ensure LVN C changed gloves while providing nephrostomy care to Resident #39. These deficient practices could place residents at-risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and maintain the residents' right to be treated with respect and dignity for 2 of 8 residents (Residents #2 and #3) reviewed for dignity and respect, in that: 1. The facility failed to provide Resident #2 assistance with eating his 03/21/24 lunch service for at least 10 minutes while he was waiting with food that was in front of him and other residents were able to eat. 2. The facility failed to allow Resident #3 to receive her food preferences and Resident #3 felt upset because she was not being heard or accommodated by the facility. This deficient practice could place residents at risk of psychosocial harm due to diminished self-image and could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 residents (Resident #1 and #5) reviewed for care plans. The facility failed to care plan Residents #1 and #5 allergies to lactose. This failure could have placed residents at risk of not having their needs identified and met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 2 of 2 residents (Resident #1 and #4) reviewed for dietary services, in that: 1. The facility failed to ensure that Resident #1's breakfast meal on 03/21/24 did not include any products with lactose as was read on her meal tray ticket. 2. The facility failed to ensure that Resident #4's lunch meal on 03/21/24 did not include mixed vegetables as was reflected on his lunch meal tray ticket. This deficient practice could affect residents with preferences/dislikes, and place them at-risk by contributing to poor intake and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 3 meals observed in that: The lunch meal for 03/21/24 included mushrooms in a Chicken Enchilada Casserole that was not called for in this recipe. This failure could affect residents by contributing to dissatisfaction, poor intake, and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 57 Residents (Resident #1) reviewed for psychosocial concerns, in that: The facility failed to put interventions in place or promptly arrange for psychiatric services for Resident #1 after he displayed increased signs of depression on [DATE]. On the evening of [DATE], Resident #1 committed suicide by a firearm. This failure resulted in the identification of an Immediate Jeopardy (IJ) on [DATE] at 5:05 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 3 of 16 residents (Resident # 1, #2, and #3) reviewed for significant medication errors, in that; The facility failed to ensure Resident #1 insulin glargine (a long-acting insulin used to treat high blood sugar from diabetes) was held and not administered for a blood sugar level less than 100 per physician orders which resulted in the resident becoming unresponsive and requiring hospitalization in the ICU. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 1/12/2024 at 3:49 p.m. The IJ template was provided to the facility on 1/12/24 at 3:59 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents who have authorized the facility in writing to manage any personal funds have access to those funds for 2 of 2 residents (Resident #4 and Resident #5) reviewed for personal funds. The facility failed to ensure Resident #4 and Resident #5 had access to their personal funds when requested. This failure could place residents whose funds are managed by the facility at risk of not receiving their personal funds deposited with the facility and not having their rights and preferences honored.

Inspectors wroteBased on interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as described in the plan of care for 1 of 3 staff (RN A) reviewed for nursing competencies, in that: The facility failed to assess medication competencies for RN A prior to 1/06/2024 when RN A failed to follow physician orders for holding insulin glargine for a blood sugar less than 100. This failure could place residents at risk for not having medications accurately dispensed, not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident # 7) reviewed for accuracy of medical records in that: The facility failed to ensure RN A's signature matched her job title and nursing license. This deficient practice could affect residents whose records are maintained by the facility and could place improper identification of staff and role in the resident medical records.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 12 residents (Resident #2) reviewed for comprehensive care plans, in that: The facility failed to amend Resident #2's care plan obtained on [DATE] promptly to include the use of a weighted blanket when it was implemented in [DATE]. This deficient practice could affect residents and place them at risk for not receiving appropriate treatment and services or activities.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for 6 of 6 residents (Residents #2, #3, #4, #5, #6 and #7) reviewed for food meeting residents' needs, in that: Cook B did not ensure the pureed food placed on a plate was a pudding or mashed potato consistency as required for food served to residents who received a pureed diet. Cook B did not provide enough chicken for the 6 residents receiving pureed diets. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to dissatisfaction, poor intake, choking, and/or weight loss.

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, in that: The facility failed to ensure proper dating and labeling of dry foods and refrigerator items. The facility failed to ensure residents eating over easy eggs were given pasteurized eggs. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible, for 1 of 1 Residents (Resident #1) reviewed for perineal/incontinent care, in that: CNA A failed to clean between Resident #1's vaginal folds during incontinent/peri care. This deficient practice could place residents at risk of increased urinary tract infections and skin breakdown due to improper care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11% based on 4 errors out of 36 opportunities, which involved 2 of 6 residents (Resident #1 and Resident #2) reviewed for medication errors. - CMA A failed to administer medications as ordered to Resident #1 by administering Baclofen (a treatment for muscle spasms), Lithostat (a treatment for UTI), and Gabapentin (a treatment for nerve pain) 1 hour and 15 minutes after the scheduled time. - CMA A failed to administer a medication as ordered to Resident #2 by administering Protonix (a treatment for GERD) 1 hour and 23 minutes after the scheduled time. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled pain.

Inspectors wroteBased on observation, interviews 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 and 1 of 3 food carts reviewed for kitchen sanitation in that: 1. The kitchen was soiled, dietary staff did not properly wash their hands, and food was not appropriately stored. 2. The 100-hall food cart had two lunch trays with food that was uncovered. These deficient practices could place residents who received meals from the main kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #44) reviewed for catheter/perineal care, in that: CNA F used multiple passes with the same wipe while providing catheter/perineal care to Resident #44. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observation, 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 2 residents (Resident #33) reviewed for dialysis in that: The facility did not maintain communication, coordination and collaboration with the dialysis facility for Resident #33. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, 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 1 of 2 residents (Resident #44) reviewed for infection control practices, in that: CNA F and CNA G failed to utilize appropriate hand hygiene and infection control practices during catheter/perineal care to Resident #44. These failures could place residents who required catheter/perineal care at risk for infection and or a decline in health.