Resident #5 wanted staff to know his religion "because if they did not know how they would be able to care for me accordingly," he told inspectors on October 24. He revealed he was proud to be Muslim and had told everyone about his religion, including staff members.
But the facility's care planning system broke down completely around his religious needs.
The resident didn't receive food before his fasting during a religious event because he was afraid to ask. He told inspectors he "did not think they could accommodate him" since the facility served meals three times a day at set times.
When inspectors interviewed the Director of Nursing that same morning, she revealed she was completely unaware of the resident's religion. She acknowledged it would be beneficial for staff to know "because there were specific things to follow for religion like food preferences."
The Activities Director thought including religion in care plans was important "so that the staff can care for him appropriately." She believed the Social Worker was responsible for care planning a resident's religion.
The Social Worker knew the resident was Muslim but said it was up to the Activities Director to care plan his religious needs.
The MDS Coordinator revealed he oversaw making sure care plans were current and correct. But he said the Social Worker would have to care plan the resident's religion, noting "the only time it was care planned was under dietary preferences."
Nobody took responsibility. The resident's religious identity fell through the cracks of a confused bureaucracy.
This wasn't the only care planning failure inspectors found. Resident #2 had PTSD from a traumatic brain injury, but staff handling wasn't documented properly either. One staff member said if he saw Resident #2 triggered, he would notify the nurse "if he was not able to calm Resident #2 down." But the same staff member wasn't sure if Resident #2 actually had PTSD.
The MDS Coordinator didn't specifically document that Resident #2 had PTSD, though he said they documented the traumatic brain injury that caused it.
Another resident's religion wasn't care planned at all because "the resident did not want anyone to know," according to staff interviews.
The facility's own policy required exactly what didn't happen for Resident #5. The Comprehensive Care Planning policy states each resident will have a person-centered care plan "developed and implemented to meet his other preferences and goals, and address the resident's mental, physical, mental, and psychosocial needs."
Person-centered care, according to the policy, includes "making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the nursing home."
The policy explicitly states that "residents' goals set the expectations for the care and services he or she wishes to receive."
Resident #5 had communicated clearly what was important to him. He told everyone about his religion because he was proud of it. He wanted staff to know so they could care for him properly. He needed accommodations for religious fasting.
Instead, he got a system where the Activities Director thought the Social Worker should handle religious care planning, the Social Worker thought the Activities Director should handle it, and the Director of Nursing didn't even know he was Muslim.
The MDS Coordinator, who was supposed to ensure care plans were up to date and correct, let religious needs get documented only under "dietary preferences" rather than as the comprehensive spiritual and cultural needs the resident had expressed.
Federal inspectors found the facility failed to develop and implement person-centered care plans that addressed residents' preferences and goals. The violation affected few residents but represented minimal harm or potential for actual harm.
For Resident #5, the harm was clear. He couldn't practice his religion in what was supposed to be his home.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Huebner Creek Health & Rehabilitation Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
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