Hurst Plaza Nursing and Rehab

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for 1 of 1 kitchen (Kitchen 1) reviewed for dietary services. 1. The facility failed to ensure residents did not receive cold food.2. The facility failed to ensure residents who received puree texture were served food that looked and tasted good. These failures could place residents at risk of weight loss, altered nutritional status and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen (Kitchen 1) reviewed for food and nutrition services. The facility failed to ensure fans used in the kitchen were free of grease and dust. This failure could place residents at risk of food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 medication carts (Hall 2 East nurses' medication cart) reviewed for pharmacy services .The facility failed to ensure expired medications were removed from the Hall 2 East nurses' medication cart. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #2) reviewed for infection control. The facility failed to ensure Resident #2's catheter bag was not on the floor. These failures could place residents at risk of infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure semi-thawed meat was stored properly, which caused the liquid contents of the meat drip onto the freezer floor. 2. The facility failed to ensure dry storage food was stored properly and off the floor. The failures could place all residents at risk for food-borne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided care, consistent with professional standards of practices for 5 of 7 residents reviewed for respiratory care (Residents #3, #4, #5, #6 and #7). 1. The facility staff failed to ensure Resident #3, #4, #6, and #7's nasal annular oxygen tubing was changed per the facility's policy and Physician orders on Sunday during the 10:00 PM to 6:00 PM shift and the following shifts by the nurse on 09/15/24, 09/17/24, and 09/18/24. 2. The facility staff failed to ensure Resident #3, #4, #5, #6, and #7's nasal annular oxygen tubing was dated per facility policy on 09/17/24 and 09/18/24. 3. The facility staff failed to ensure Resident #3, and #5's Sleep Apnea mask was bagged and dated when not in use per facility policy on 09/17/24 and 09/18/24. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, reviewed for 1 (Resident #7) of 3 Residents reviewed for baseline care plan in that: The facility failed to update Resident #7's baseline care plan dated 09/15/24 which did not include his oxygen treatment, sleep apnea treatment, and need for assessments of O2 sats every shift. This deficient practice could result in newly admitted residents receiving improper care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 8 residents (Resident #7) reviewed for quality of care. The facility failed to document Resident #7 diagnosis of COPD and oxygen orders on the care program. This failure could place residents at a risk of being receiving incorrect treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area for 2 of 14 residents (Residents #41 and #62) reviewed for physical environment. The facility failed to ensure Residents #41's and #62's call lights were accessible. This failure could place residents at risk of not having their needs met.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails and enabler/grab bars (smaller bars used by the person in bed to reposition themselves), with the resident or resident representative and obtain informed consent prior to installation for one (Resident #40) of 3 resident rooms observed and reviewed for bed rails/enabler bars. The facility failed to have evidence of informed consent, assessment of the resident for risk of entrapment, or a physician's order for the quarter bed rails/enabler bars for Resident #40. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for storage of drugs and biologicals for 1of 2 medication rooms reviewed for storage and labeling. The facility failed to ensure Influenza (flu) and Tuberculosis (TB) vaccines were dated with an open date. This failure could cause resident to receive less effective and or less strength vaccines.

Inspectors wroteBased on observations, interviews and Record Reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure foods stored in the refrigerator and freezer were labeled with the use by date. These failures could place resident at risk for food-borne illness and food contamination.

Inspectors wroteBased on interviews and record review, the facility's interdisciplinary team (IDT) failed to ensure the resident's person-centered comprehensive care plan was reviewed and revised for 1 of 8 (Resident #15) residents reviewed for care plans. The facility failed to revise Resident #15's care plan to update and remove conflicting hospice status. This failure could place residents at risk for harm with conflicting care plans and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for one (Resident #14) of four residents reviewed for intravenous fluids. The facility failed to ensure LVN C used proper technique of flushing Resident #14's midline (a midline is a long flexible tube that is inserted into the large vein in the upper arm) with 0.9 % sodium chloride and avoiding pushing air into the midline intravenous (IV) catheter. This failure could cause a resident to get an air bubble into their blood stream and cause hospitalization.

Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (#1 and #43 ) reviewed for infection control practices, in that: The Nursing Scheduler failed to follow proper infection control practices when assisting Resident #1 with her meal. The LPN failed to maintain a safe, sanitary surface during wound care for Resident 43. The failure could place residents at risk for the spread of infection. Review of Resident #1's admission Record, reflected a [AGE] year-old female admitted to the facility on [DATE] whose diagnoses included: [...]