Huebner Creek Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Huebner Creek Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 13, 2024

  Based 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. […]

• Actual harm, isolatedF726Feb 5, 2021

  Based on interviews and record reviews, the facility failed to ensure nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents needs safely for 1 (Resident #10) of 10 residents reviewed for nursing services in that: 1. Facility failed to obtain wound care orders for Resident #10 when he was admitted to facility on 1/14/2021, post- surgical removal of left toes. 2. Assessment of Resident #10's wound appearance was not documented from 1/14/21 to 1/16/21. 3. LVN F provided wound care to Resident #10 without provider orders. 4. LVN F did not communicate to the charge nurse taking care of Resident #10 wound care done. 5. […]

• No harm, potential for more than minimal, widespreadF563Oct 13, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF755Jun 4, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF687Mar 27, 2026

  Based 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. […]