Conway Healthcare and Rehabilitation Center

Inspectors wroteBased on record review and interview, the facility failed to adequately monitor one (Resident #1) of one resident after an unwitnessed fall, which had resulted in a periprosthetic fracture of the right hip and a ping-pong ball sized knot to the left lateral scalp. Specifically, the nursing staff did not perform the ninth (7:15 AM) neuro check following an unwitnessed fall and did not alert the resident's provider when the resident later reported the possibility of striking their head during the fall.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure resident centered care was provided to two of two (Resident #8 and Resident #69) sampled residents dependent on staff for care based on one of one observation to ensure residents physical and psychosocial needs were met. Specifically, staff did not respond to a feeding tube alarm in a timely manner, a call light was placed out of the reach of a resident, and pain was not addressed in a timely manner.

Inspectors wroteBased on observation, record review, and interview it was determined that the facility failed to ensure proper hand hygiene during perineal care to prevent cross contamination for two (Resident #69 and Resident #74) of two sampled residents observed for bowel and bladder care.

Inspectors wroteBased on record review, facility document review, interview, and facility policy review, it was determined that the facility failed to not discharge on e (Resident #81) of one sampled resident after an appeal was filed.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to ensure the medication error rate was less than 5%, to prevent potential complications for two (Residents #35 and #76) of two sampled residents observed during the medication pass. The medication error rate was 6.67%, based on observations of 30 medications administered.

Inspectors wroteBased on interview, record review, and facility document review the facility failed to ensure one (Resident #52) of one sampled resident was free of a significant medication error, which caused Resident #52 to be hospitalized for acute toxic encephalopathy.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure one of four medication carts were always locked to prevent accidents.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a safe and homelike environment, ensuring safety from floor clutter, detached wall vinyl, and detached wall rails posing potential hazards for falls.

Inspectors wroteAccording to observation, record review, and interview the facility failed to ensure residents were free from abuse with continuous altercations of verbal abuse and physical abuse between two residents (Resident #47 and Resident #54). This failed practice had the potential to affect all 66 residents currently in the facility to psychosocial harm from repeated resident to resident abuse altercations. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 03/12/2024 at 12:30 PM, when Resident #47 and Resident #54 had an altercation in the dining room. [...]

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure interventions were utilized to prevent worsening of contractures for 2 (Residents #40 and #66) of 2 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dishes/utensils were stored under sanitary conditions and food preparation equipment was cleaned properly in the kitchen.

Inspectors wroteBased on observations, interviews, record reviews, facility document review, and facility policy review, it was determined that the facility failed to ensure hand hygiene was performed between resident rooms while delivering clean laundry. This failed practice had the potential to affect 14 residents residing on the secure unit, and the facility failed to keep a trash barrel covered to prevent residents from digging through trash on the secure unit for 1 (Resident #32) of 1 sampled resident observed. This failed practice had the ability to affect 14 residents residing on the secure unit.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide a pneumonia vaccine for 2 (Residents #63 and #69) of 2 residents reviewed for immunizations.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined the facility failed to ensure residents call devices were in reach in the resident's room for 1 (Resident #29) of 1 sampled resident with call devices not in reach.

Inspectors wroteBased on record review and interview, the facility failed to update a care plan regarding a resident's placement on the unit for 1 (Resident #54) of 1 sampled resident.

Inspectors wroteBased on interviews, record review, and medication prescribing information, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medication for 1 (Resident #51) of 2 residents reviewed for unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were showered/bathed as scheduled, fingernails were kept clean, and male residents were shaved to promote good personal hygiene for 02 (Resident #02 and #03) sample mix residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received notification that their Medicare Part A Services were being terminated for 1 (Resident #25) of 3 (Residents # 21, #25 and #124) sampled residents who were reviewed for beneficiary notification.

Inspectors wroteBased on interview, and record review, the facility failed to ensure showers were given as scheduled for 1 (Resident #47) of 6 (Residents #5, #17, #26, #47, #51 and #58) sampled residents who were dependent on staff for showers.

Inspectors wroteBased on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 11 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 03/16/23.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were provided with information on their right to formulate an advance directive and/or that their decisions to formulate or not formulate advance directives were documented in the medical record, to ensure residents and/or their responsible parties were able to make advance decisions regarding end-of-life care if they wished to do so for 1 (Resident #10) of 19 (Residents #10, #16, #17, #19, #26, #29, #45, #46, #47, #48, #51, #58, #60, #69, #120, #121, #122, #123 and #220) sampled residents whose advance directives were reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide referral to appropriate state-designated authorities for Level II Preadmission Screening and Resident Review (PASARR) evaluation concerning residents who had a negative Level I pre-screening, and were later identified with newly evident or possible serious Mental Disorder/Intellectual Disorder (MD/ID) or related conditions for 1 (Resident #48) of 6 (Residents #5, #8, #46, #121, #122 and #220) sampled residents with a new diagnosis requiring a Level II PASARR screening since admission to the facility.

Inspectors wroteBased on record review, and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) screening was conducted for 1 (Resident #5) of 6 (Residents #8, #46, #48, #121, #122 and #220) sampled residents who had a Mental Disorder/Intellectual Disability (MD/ID), or a related condition since the last annual survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received oxygen therapy as ordered by the Physician for 1 (Resident #26) of 7 (Residents #10, #17, #26, #45, #46, #58 and #122) sampled residents who received oxygen. This failed practice had the potential to affect 17 residents who received oxygen therapy in the facility as documented on a list provided by the Director of Nursing (DON) on 03/16/23 at 12:14 PM.