Huntsville Health Care Center

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 4 residents (Resident #1) and 2 of 4 staff (CNA A and CNA B) reviewed for infection control. 1. The facility failed to ensure CNA A and CNA B followed EBP for Resident #1 when providing care on 12/15/2025. 2. The facility failed to ensure CNA A and CNA B changed gloves and washed or sanitized their hands when providing care to Resident #1 on 12/15/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 5 residents reviewed for accidents and supervision. (Resident #1)The facility failed to provide adequate supervision for Resident #1 who was assessed for 2 staff members for care. CNA A did not have another staff member to provided care to Resident #1, left Resident #1 to obtain more supplies for care, and the resident rolled off of the bed. Resident #1 sustained a fracture of the left thigh bone near the knee. This failure could place residents at risk of not receiving the amount of supervision or assistance required to prevent serious injury and/or actual harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans. The facility failed to ensure that Resident #1's, #2's and #3's care plans were initiated and included appropriate interventions for ADL Care. This failure could place residents who required assistance with care at risk of serious harm and injury.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of neglect to HHSC for 1 of 5 residents reviewed for neglect. The facility did not report when CNA A did not have another staff member to provided care to Resident #1, left Resident #1 to obtain more supplies for care, and the resident rolled off of the bed. Resident #1 sustained a fracture of the left thigh bone near the knee. This failure could place residents at risk of harm due to delays in reporting neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 3 of 15 residents reviewed for quality of care, (Resident #14, Resident #36 and #209) in that: The facility failed to remove worn, damaged and bleached mechanical lift slings from service for Residents #14, Resident #36 and #209. This deficient practice could result in a loss of quality of life due to injuries.

Inspectors wroteBased on observations, interviews, and record reviews 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 6 residents (Resident #15) and 1 of 5 staff (Nurse Manager) reviewed for infection control. Nurse Manager performed direct care to Resident #15 and failed to remove Personal Protective Equipment (PPE, gown, and gloves) prior to exiting Resident #15's room on 06/16/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a staff member or a centralized staff work area from toilet and bathing facilities for 1 of 8 residents reviewed for call lights. (Resident #8). The facility failed to ensure Resident #8's emergency call light in the bathroom would reach the floor. The call light cord for Resident #8 was three feet above the floor level. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for one of four hallways (Hallway 200) reviewed for physical environment. The facility failed to maintain the walls, ceiling, and floor in the shared restroom for rooms [ROOM NUMBERS] located on the 200 hallway. The facility failed to remove a broken dresser from room [ROOM NUMBER] located on the 200 hallway. The potential outcome statement goes here

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 in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure the DA effectively wore a hair net to cover all his hair on 5/20/2024 and the Dietary Manager effectively wore a hair net to cover all her hair on 5/20/2024 and 5/21/2024. 2. The facility failed to ensure foods stored in the refrigerators, freezers and dry pantry were labeled, dated, and not kept past their expiration dates. 3. The facility failed to ensure containers of oil and sugar were sealed properly. 4. The facility failed to ensure frozen green bean and frozen egg and cheese omelets were sealed and stored properly in freezer. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 3 of 4 residents reviewed for quality of care, (Resident #5, #39, and #41) in that: The facility failed to remove worn and damaged mechanical lift slings from service. The facility failed to obtain physician orders for mechanical lift transfers. This deficient practice could result in a loss of quality of life due to injuries.

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 15 staff (the DON) reviewed for develop and implement abuse policies. The facility failed to ensure HR implemented the facility's abuse/neglect policy and procedure when she failed to complete a Criminal History check for the DON upon hire. This failure could place residents at risk for abuse, neglect and/or exploitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that residents who were fed by enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #12) reviewed for quality of care. The facility failed to ensure that Resident #12's feeding tube bags were labeled which included the initials of staff that hung the bag and the time it was hung to ensure residents maintain nutritional status within optimal parameters on [DATE]. This failure could place residents receiving enteral feedings at risk of not receiving feeding care in a timely manner and receiving old or expired feed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 2 of 9 residents (Resident #17 and #34) reviewed for quality of care. 1. The facility failed to ensure Resident #17's oxygen concentrator had an external filter that was free of dust buildup on 5/21/2024 and 5/22/2024. 2. The facility failed to ensure Resident #34's oxygen concentrator had an external filter that was free of dust buildup on 5/21/2024 and 5/22/2024. This failure could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress.

Inspectors wroteBased on observations, interviews, and record reviews, 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 5 residents (Resident #12) reviewed for infection control. The facility failed to ensure CNA C sanitized or washed her hands after changing gloves when providing incontinent care to Resident #12 on 5/20/2024. This failure could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteThe facility failed to ensure that all written grievance decisions included date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 1 of 8 residents (Resident # 10) reviewed for grievances. The facility failed to provide rationale or response to the residents on their concerns or requests. This failure could place residents who file grievances at risk of frustration, a decreased confidence in administration and a decrease in resident rights.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 7 residents (Resident #4) reviewed for respiratory care. The facility failed to ensure Resident #4's nasal cannula tubing, on their wheelchair, was changed every 7 days, labeled and bagged to prevent contaimination when not in use. The deficient practice could place residents at risk of developing respiratory infections and complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain and ensure safe and sanitary storage of resident's food items for 1 of 5 resident's personal refrigerators reviewed for food safety (Resident #9). The refrigerator for Resident #9 had: One small cup of strawberry applesauce with a best by date of March 9, 2023 One small cup of applesauce with a best by date of March 10, 2023 These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 2 smoking areas (outside of dining room). The facility failed to keep trash out of a red can designated for cigarette butts and ashes. This failure could place residents at risk for injury, burns, and an unsafe smoking environment.