Hunters Creek Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Hunters Creek Nursing and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 20, 2024

  Based on interview, and record review, the facility failed to protect the resident's right to be free from neglect by not ensuring staff implemented measures to mitigate the risk and prevent elopement for 1 of 3 residents reviewed for elopement, of a total sample of 13 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury, harm, and/or death. While resident #1 was out of the facility unsupervised, there was likelihood he could have died , been accosted by unknown persons, become lost, or hit by a vehicle. On [DATE], resident #1, a [AGE] year-old male was admitted to the facility from the hospital. […]

• Immediate jeopardy, isolatedF689Sep 20, 2024

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and a secure environment to prevent elopement for 1 of 3 residents reviewed for elopement, of a total sample of 13 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious life-threatening injury or even death. While resident #1 was out of the facility unsupervised, there was high likelihood he could have sustained serious life-threatening injuries, become lost, been accosted by a stranger, or hit by a motor vehicle and died . On [DATE] at 6:28 PM, resident #1 exited the facility's front entrance when the receptionist unlocked the door for him to leave the facility. […]

• Actual harm, isolatedF686Nov 14, 2024

  Based on interview, and record review, the facility failed to provide appropriate care and services, consistent with professional standards of practice, to adequately evaluate skin integrity and promptly intervene to prevent the development and worsening of a pressure injury for 1 of 4 residents reviewed for pressure injuries, of a total sample of 9 residents, (#1). The facility's failure to identify early stages of skin breakdown, promptly initiate wound care and treatment, and develop nursing interventions to promote wound healing resulted in actual physical and psychosocial harm for resident #1. The resident's skin was intact on admission to the facility and within 12 days, she was diagnosed with a stage 4, full-thickness skin loss pressure injury. […]

• No harm, potential for more than minimal, widespreadF812Dec 18, 2024

  Based on observation, interview, and record review, the facility failed to ensure food products were stored correctly in the walk-in cooler, and failed to ensure the temperature of hot foods being held was taken before service in accordance with professional food service safety. Findings: 1. On 12/15/24 at 11:50 AM, during a tour of the walk-in refrigerator with [NAME] D, a small plastic bag holding approximately 12 turkey slices, dated 12/11 (five days ago) was noted. [NAME] D stated the facility policy was to discard perishable food items three days after they were opened, and she removed it to be discarded. […]

• No harm, potential for more than minimal, patternF550Dec 18, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity for 4 of 15 dependent diners at the facility, out of a total sample of 32 residents, (#11 and #48). 1. Review of resident #11's medical record revealed she was readmitted to the facility on [DATE] with diagnoses including dementia, hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following a stroke affecting her right dominant side, dysphagia (difficulty swallowing), and aphasia (language disorder). Review of resident #11's Minimum Data Set quarterly assessment with Assessment Reference Date of 11/05/24 revealed a Brief Interview for Mental Status was not obtained because she was rarely or never understood. […]