Huntsville Health & Rehabilitation, LLC

In the surveyor’s words

From the most serious findings on record at Huntsville Health & Rehabilitation, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 21, 2026

  Based on interviews, record review, review of Facility Reported Incidents (FRIs), review of the facility's investigative file, review of facility's policies titled Elopement and Wandering Residents, Supervised Smoker & Other Tobacco Products, Supervised Smokers, and Incidents & Accidents the facility failed to ensure Resident Identifiers (RI) #106 and RI #121 received supervision in a manner to ensure their whereabouts were known to the facility and the residents were in an environment free of accident hazards.The facility further failed to ensure RI #33 and RI #109 complied with established smoking safety policies and procedures. The facility failed to monitor and enforce safe smoking practices, which resulted in unsafe smoking behaviors. […]

• Immediate jeopardy, patternF740May 21, 2026

  Based on interviews, resident record review, and review of a facility policy titled Behavioral Health Care Services, The facility failed to ensure a behavior management process was implemented to ensure staff identified, evaluated, and implemented interventions to manage and address known resident behaviors that affected residents' safety. The facility failed to manage unsafe behaviors related to noncompliance with the facility's Smoking Policy and failed to manage unsafe wandering behaviors related to noncompliance with the facility elopement and wandering policy. The facility failed to recognize the need for adequate supervision and monitoring of residents with unsafe behaviors creating the risk for harming themselves and others in the facility. […]

• Immediate jeopardy, isolatedF604May 21, 2026

  Based on interview, record review, the facility investigation, and a policy titled titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation the facility failed to ensure Resident Identifier (RI) #48 was free from physical restraint when staff forcibly restrained him/her after he/she refused care. The facility further failed to ensure staff utilized non-forceful, resident centered approaches during care interactions. Specifically On 08/04/2025 RI #48 refused care on multiple occasions. Despite the refusal Registered Nurse (RN) #63 and Certified Nursing Assistant (CNA) #64 proceeded to forcibly hold RI #48 down and provide incontinent care. […]

• Immediate jeopardy, isolatedF686May 21, 2026

  Based on interviews, review of residents' medical records, and review of the facility policy titled Pressure Injury , the facility failed to provide ongoing skin assessments to ensure pressure injuries or pressure ulcers were identified at an early stage which resulted in pressure injuries being identified at advanced stages of unstageable wounds. Specifically:1. On [DATE], Resident Identifier (RI) #108 was noted to have excoriation and redness to his/her buttocks/sacral area. The facility did not perform a detailed assessment of the area such as measurements, drainage, or odor. An order was obtained on [DATE] to clean and cover the area three times a week. […]

• No harm, potential for more than minimal, widespreadF803May 21, 2026

  Based on observations, interviews, the Resident Council Minutes, the Grievance Log, the facility's Beef Stroganoff recipe, the facility's Spring/Summer 2026 Week 3 Menu and Diet Guides, the facility's chart of Scoop Sizes, and the facility's policies for Cycle Menus, Food Preparation Guidelines, and Puree Foods; the facility failed to ensure the portion sizes specified on the facility's menu for Wednesday, 04/22/2026 were provided for Puree Beef Stroganoff and Sliced Strawberries. In addition, Puree Noodles (Bow Tie Pasta) were not part of the Puree Beef Stroganoff entree as included in the facility's Beef Stroganoff recipe. This affected residents receiving Puree Beef Stroganoff and those receiving Sliced Strawberries. […]