Childserve Habilitation Center

In the surveyor’s words

From the most serious findings on record at Childserve Habilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761May 1, 2025

  Based on observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 70 residents. Findings included: Observations on 4/30/2025 revealed the following events; On 4/30/25 at 11:38 AM, Staff A, Licensed Practical Nurse (LPN) walked away from her medication cart in the patient care hallway and entered a storage room. A key was observed lying on top of the medication cart. At 11:40 AM, Staff A walked past the medication cart with water and entered a resident's room. There was one resident present but unable to manipulate the key or the medication cart. […]

• No harm, potential for more than minimal, patternF623Jul 3, 2024

  Based on clinical record review and staff interviews, the facility failed to notify the long term care ombudsman for resident transfer to an acute care hospital for 6 of 6 (Res #22, #26, #46, #54, #56, #70) residents reviewed for hospitalization . Findings include: The Minimum Data Set (MDS) of Resident # 22 documented a discharge, return anticipated, to an acute care hospital on 12/5/23 and 5/2/24. The MDS of Resident #26 documented a discharge, return anticipated, to an acute care hospital on 2/5/24, 3/31/24, 4/10/24 and 4/13/24. The MDS of Resident #46 documented a discharge, return anticipated, to an acute care hospital on 12/19/23 and 3/23/24. The MDS of Resident #54 documented a discharge, return anticipated, to an acute care hospital on 3/1/24, 4/13/24, 4/18/24 and 5/19/24. […]

• No harm, potential for more than minimal, patternF610Sep 14, 2023

  Based on record review, staff interview, and policy review the facility failed to immediately put effective measures in place to ensure further potential abuse or mistreatment does not occur for 1 of 1 dependent residents (Resident #52) when four (4) employees observed questionable physical and verbal abuse by Staff A, Respiratory Therapist (RT) to Resident #52. The facility reported a census of 61 residents. Findings include: On 9/13/23 at 9:58 AM Staff B, Certified Nurse Aid (CNA) described her observation she had of Resident #52 and Staff A's interaction on 4/23/23 as follows; Resident #52 was in sun room sitting on the floor and she pulled at her medical device on her neck, I was washing my hands at the sink, and Staff A pulled Resident #52 hand away, and she said something like,… […]

• No harm, potential for more than minimal, isolatedF689Jun 18, 2026

  Based on observation, clinical record review, staff interview, and policy review, the facility failed to lock the wheelchair during a transfer for 2 of 58 residents dependent on mechanical lift transfers (#4, #57). The facility reported a census of 69 residents.Findings include: 1 Resident #57's Minimum Data Set (MDS) dated [DATE] did not include a Brief Interview for Mental Status (BIMS). The MDS documented that Resident357 (R57) had difficulty with short-term and long-term memory recall. It included diagnoses of spinal cord nerve loss with progressive muscle weakness, chronic respiratory failure, osteoporosis, and scoliosis. It indicated she was dependent with all Activities of Daily Living (ADLs) and mobility. […]

• No harm, potential for more than minimal, isolatedF880Jun 18, 2026

  Based on observation, staff interview, and policy review, the facility failed to implement infection prevention strategies by failing to place the protective cap on the tube feeding tubing connector between feeding schedules for 1 of 2 residents (#26), failing to wear appropriate Personal Protective Equipment (PPE) when providing care for 1 adult resident with invasive devices (#57), and failing to perform hand hygiene during resident care for 1 resident (#57). The facility reported a census of 69 residents.Findings include: 1 Resident #26's Minimum Data Set (MDS) assessment dated indicated a Brief Interview for Mental Status (BIMS) should not be conducted because the resident was rarely or never understood. […]