Arkansas Veterans Home at Fayetteville

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 2 meals observed.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure opened food items in the freezer and the storage areas were covered and sealed; expired food items were promptly removed from stock to maintain freshness; dietary staff practiced good hand hygiene before handling clean equipment or food items; and hot food items were maintained at or above 135 degrees Fahrenheit on the steam table for 2 of 2 meals observed.

Inspectors wroteBased on interviews, record review, and facility document review, it was determined the facility failed to monitor and notify the resident ' s representative of high trust balances prior to reaching the Social Security resource limit for 1 (Resident #12) for 3 residents reviewed for resident trust fund accounting. As a result, Resident #12 lost their Medicaid benefits and was required to private pay for room and board at a personal cost of $7,817.56.

Inspectors wroteBased on observations, interviews, facility document review, and policy review, it was determined that the facility did not ensure that Enhanced Barrier Precautions (EBP) were carried out for 1 (Resident #31) of 4 sampled residents reviewed for Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a sufficient number of competent staff were employed to safely and effectively carry out the functions of 1 of 1 kitchen in the facility which fed 45 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents, to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The failed practice had the potential to affect 45 residents who received meal trays in their rooms and in dining rooms on 500 and 600 Hall.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that hot food was maintained at or above 135 degrees before serving and failed to ensure that cold food maintained at or below 41 degrees before serving, to minimize the potential for food borne illnesses for residents who received meals from 1 of 1 kitchen, and facility failed to ensure food was covered during transport. These failed practices had the potential to affect 45 residents who received meals from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nail care was provided, to maintain good personal hygiene for 1 Resident(#27) of 1 sample mix residents who required assistance with nail care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents with injuries of unknown source, received care and treatment according to practical nursing standards, for 1 (Resident #27) of 1 sampled residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents environment was free of accidents and hazards as possible, as evidenced by failure to ensure medications were not left at bedside for 1 (Resident #26) of 1 sampled resident; and failed to ensure staff reported the potential injury for 1 (Resident #11) of 1 sampled residents, to prevent further possible injury and delaying possible treatment, for 1 (Resident #11) of 1 sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident individualized care plan was updated to ensure appropriate care was received for 1 (Resident #2) of 1 sampled resident who had a new service or level of care ordered or provided.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure Certified Nursing Assistants (CNA's) and Licensed Practical Nurses (LPN's) were able to demonstrate competency in identifying, reporting, and investigating injuries of unknown sources for 1 (Resident #27) of 1 sampled residents; and failure to report injury to residents during care for 1 (Resident #11) of 1 sampled residents, to prevent possible further injury or harm, and to rule out possible abuse. This failed practice had the potential to affect 49 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 (Resident #3) of 1 resident that was reviewed for unnecessary medication did not receive a PRN (as needed) medication pass 14 days without justification, and an evaluation revision by the doctor.

Inspectors wroteSurveyor: [NAME], [NAME] Based on Observation, Interview, and Record Review the facility failed to assure the two medication carts were free from expired medications and that the controlled substances were separately locked in a permanently affixed compartment.

Inspectors wroteSurveyor: [NAME], [NAME] Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with a. Infection control procedures, b. with distributing and serving food in a sanitary manner, c. with the resident's being free of accidents/supervision/devices, d. with meeting Pre-admission screening and Resident Review (PASRR) requirements, e. with respiratory care and f. with Quality Assurance and Assessment (QAA) and Quality Assessment and Performance Improvement (QAPI) requirements. These failed practices had the potential to affect all 49 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff had on appropriate Personal Protection Equipment (PPE) for 1 (Resident #18) of 4 (Residents #2, #6, #14, #18) sampled residents that were on isolation, and failed to ensure proper signage was posted outside residents rooms to advise or instruct staff and or visitors on appropriate PPE to be worn, and failed to maintain and transport linens properly by staff in the hallway, and failed to ensure clean linen and dirty linen were handled properly in the laundry room to prevent cross contamination.

Inspectors wroteBased on Observation, interview and record review, the facility failed to provide mandatory in-services for the year to all staff. This failed practice had the potential to affect all 49 residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed before a resident was admitted to the facility for 1 (Resident #3) of 1 (Resident #3) sampled residents who required a PASRR before admission to a skilled nursing facility. The failed practice had the potential to affect 49 residents.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that an order to administer oxygen was written for 1 Resident (R #2) of 1 sampled resident. Who are receiving oxygen to prevent desaturation.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items stored in the refrigerator, freezer, and storage area were covered and sealed; dietary staff washed their hands before handling clean equipment or food items; failed to ensure 1 of 3 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen and hot foods were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen and failed to ensure staff fully covered the mouth and nose with their mask while serving a meal. These failed practices had the potential to affect 70 residents who received meals from the kitchen (total census: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were served on regular dinnerware to maintain a homelike environment for all residents. The failed practice had the potential to affect 70 residents who received meal trays from 1 of 1 kitchen, as observed by the Surveyors during the noon meal observation in the Dining Rooms and on room trays on the 500 and 600 Halls on 10/17/2022.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the physician was notified of a weight gain of 40.4 pounds to prevent possible complications for 1 (Residents # 33) of 71 residents that the facility was responsible for monitoring their weight according to a list provided by the Administrator on 10/21/2022 and failed to ensure Physician Orders were followed for therapy for 1 (Resident #49) of 6 (Resident #11, R #44, R #49, R #53, R #69, and R #272) sample selected residents with Physician Orders for therapy.

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident's environment was free from accident hazards for 3 residents (Resident #9, R #13 and R #16), as evidenced by allowing Resident #13 and R #16 to have a large bottle of (mouth wash) on the countertop in their room, and R #9 had aerosol shaving cream, a bottle of hand sanitizer, and a bottle of lotion in her room, of 8 (Resident #6, R #8, R #9, R #13, R #16, R #31, R #33, and R #68) sampled residents on the Secure Unit 600 Hall who were ambulatory or propel themselves in a wheelchair according to a list provided by the Director of Nursing (DON) on 10/20/22.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter collection bag was stored in a manner to prevent possible contamination and infections for 1 (Residents #64) of 1 (#64) sampled residents who have indwelling catheters according to a list provided by the Director of Nursing on 10/20/22.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the licensed nurse checked for tube placement according to standard nursing practice prior to administering medications and scheduled feeding through a PEG (Percutaneous Endoscopic Gastrostomy) tube for 1 (Resident #55) of 1 sampled resident (Resident #55) who had a Peg Tube per a list provided by the Administrator on 10/19/22 at 11:47 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure respiratory care was consistent with professional standards of care to prevent potential complications for three (Resident #6, #53, and #270) of 10 (Resident #6, #8, #9, #23, #30, #53, #55, #69, #270, #272) sample residents as evidenced by oxygen tubing and humidity bottles not dated, oxygen tubing not being stored in a bag or other closed container when not in use to prevent potential contamination and not having a physician order for oxygen flow rate. This failed practice had the potential to affect 29 residents who had Physician Orders for oxygen, according to a list provided by the Director of Nursing (DON) on 10/20/22 at 1:24 PM.

Inspectors wroteBased on observation of the 8:00 AM medication pass on 10/19/22, record review and interview, the facility failed to ensure a medication error rate of less than 5% [percent] was maintained to prevent potential complications for 2 (Residents #8, and #28) of 4 residents (Resident #8, #28, #55, #60) observed during the medication pass, which resulted in medication errors. This failed practice had the potential to affect 38 residents who received medications from Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #1 according to a list provided by the Administrator on 10/20/22 at 2:04 PM. The error rate was 14.29 % based on observation of 35 medications administered, with a total of 5 errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Assurance Committee (QAA) put forth good faith attempts to correct and reassess its own quality deficiencies for a homelike environment by providing meals using Styrofoam plates, bowls and cups, and plastic silverware for 70 residents who received meals from the kitchen, for proper respiratory care for 27 residents who were on oxygen therapy according to the oxygen list provided on 10/20/22 from the Director of Nursing (DON), and for timely assessments for 44 residents who had a significant change due to hospice per a list provided by the DON on 10/20/22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a glucometer was cleaned between residents per manufacture's recommendations for 1 (Residents #8) of 2 (#8, #13) sampled residents that the nurse on the 600 hall used the multi-use glucometer to monitor their Capillary Blood Glucose (CBG) according to a list provided by the Administrator on 10/19/22, failed to ensure clean linens and personable were covered and always kept separate from potentially contaminated linen to prevent the potential for cross contamination, and failed to ensure staff handling dirty laundry disposed of Personal Protective Equipment (PPE) immediately after completing task to help prevent the potential of cross contamination and spread of infection for 71 residents who receive their linens laundered by the facility and 68 residents who receive their personable laundered by the [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all aspects of Antibiotic Stewardship were conducted which included periodic review of antibiotic use by prescribing physicians was for true infections. This failed practice had the potential to affect 5 residents currently prescribed antibiotics per list received from Director of Nursing (DON) on 10/21/22.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pneumococcal Immunizations were administered to eligible residents in a timely manner and immunization records documented accurately in electronic system for 2 (Resident #31 and R #64) of 5 (R #31, R #47, R #62, R #64 and R #66) sample selected residents. This failed practice had the potential to affect the 78 residents admitted since the facility's last survey per the admission list provided by the Administrator on 10/21/22.

Inspectors wroteBased on interview and record review, the facility failed to ensure COVID-19 vaccinations were provided to eligible residents and accurate immunization records were kept for consents and declinations for COVID-19 vaccinations for 3 (Resident #31, R #62, R #64) of 5 (Resident R #31, R #47, R #62, R #64, and R #66) sample selected residents. This failed practice had the potential to affect the 78 residents admitted since the facility's last survey per the admission List provided by the Administrator on [DATE].

Inspectors wroteBased on interview and record review, the facility failed to ensure proper documentation and tracking of COVID-19 vaccination status for all staff, failed to ensure the accuracy of data entered into the National Healthcare Safety Network (NHSN), and failed to ensure accuracy of COVID-19 vaccination status of staff was given to surveyors. This failed practice had the potential to affect 71 residents residing in the facility per the Census and Conditions received from the Administrator on 10/18/22.

Inspectors wroteBased on interview and record review, the facility failed to ensure Significant Change Minimum Data Set (MDS) Assessments were completed for residents on hospice in the required timeframe for 1 of 1 (Resident #44) sample selected residents receiving hospice services per the Resident Matrix provided by the Administrator on 10/18/22. This failed practice had the potential to affect 44 residents that received hospice services since the facility's last survey per the hospice list provided by the Director of Nursing (DON) on 12/20/22.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) II evaluation process was completed in accordance with the State PASRR process for 1 (Resident # 66) of 15 (Resident #6, R #8, R #9, R #11, R #13, R #16, R #23, R #30, R #31, R #49, R #53, R #62, R #64, R #66, and R #68) sample selected residents who had a diagnosis of a Serious Mental Health Disorder and/or Intellectual Disability (ID) to ensure the resident received appropriate care and services per a list provided by the Director of Nursing (DON) on 10/20/22.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a Baseline Smoking Assessment and Care Plan was completed for safety and appropriate care for 1 new admission resident (Resident #270) of 1 new admission sampled resident reviewed who smoked. This failed practice had the potential to affect eleven residents admitted since 06/26/21 who smoked according to a list provided by the Director of Nursing (DON) on 10/20/22 at 1:24 PM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 11 residents on mechanical soft diets and 25 residents on regular diets who received meals from the kitchenette on 500 Hall and 19 residents on regular diets and 8 residents on pureed diets who received meals from the kitchenette on 600 Hall, according to a list provided by the Dietary Supervisor on 10/18/22 at.

Inspectors wroteBased on interview and record review, the facility failed to ensure Care Plans for residents on hospice included a description of the care and services provided by hospice and the facility for 1 of 1 (Resident #44) sample selected residents receiving hospice services per the Resident Matrix provided by the Administrator on 10/18/22. This failed practice had the potential to affect 44 residents that received hospice services since the facility's last survey per the Hospice List provided by the Director of Nursing (DON) on 12/20/22.

Inspectors wroteBased on interview and record review, the facility failed to notify the Resident and/or Resident Representative in writing of the reason for transfer to the hospital in a language they understood for 1 (Resident #64) of 7 (Resident #8, #13, #21, #53, #64, #66 and #69) sample selected residents who transferred/discharged to the hospital in the last 120 days. This failed practice had the potential to affect 28 residents who transferred/discharged to the hospital in the last 120 days as documented on a list provided by the Administrator on 10/21/22.