Pocahontas Healthcare and Rehabilitation Center

Inspectors wroteBased on record review, interview, and facility document review, the facility failed to ensure that nursing staff responded appropriately to an unwitnessed fall, specifically failing to notify the appropriate parties and initiate neurological checks for an unwitnessed fall for one (Resident #1) of three residents reviewed for falls. Following the incident and prior to the surveyors entry into the facility, the facility terminated LPN #1 and initiated and completed a corrective action plan, thus these findings indicate past non-compliance.

Inspectors wroteBased on observation, interviews, and facility policy review, it was determined that the facility failed to ensure a portable oxygen cylinder was secured to prevent an accident or injury.

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to promote the dignity of a resident who was observed with staff shaving in the dining room for 1 (Resident #6) 1 residents reviewed for dignity.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by failure to wear personal protective equipment (PPE) in a contact isolation room for 1 (Resident #7) of 1 resident reviewed for infection control.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure cross contamination during lunch service did not occur for one of one kitchen.

Inspectors wroteBased on record review and interview the facility failed to provide an environment that promoted the maintenance or enhancement of the resident's quality of life, denying self-determination, and adequate communication for 1 (Resident #29) of 1 resident reviewed for resident rights.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a safe, clean, homelike environment was provided for the 100-hall secured unit. On 08/19/2024 at 11:28 AM, the surveyor observed in room [ROOM NUMBER], on side B, the wall was scratched with paint removed exposing bare drywall. The baseboard by the bathroom was coming away from the wall and was warped, and right above the baseboard paint was peeling back. In the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER], to the right and behind the toilet the baseboard was coming away from the wall and warped. In the right-hand corner, the paint was peeling, and the drywall was crumbling. On the baseboard right behind the toilet is what appears to be a black substance, and the surveyor noted the bathroom had a musty, stagnant odor. [...]

Inspectors wroteBased on observations, record review, and interview, the facility failed to a smoking apron was utilized for 1 (Resident #20) of 1 sampled resident.

Inspectors wroteBased on observation, record review, and interview, it was determined the facility failed to ensure refrigerated narcotics were stored in a permanently affixed storage box to ensure no misappropriation of resident medications affecting all 51 residents in the facility.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure mechanical soft diets and puree diets were in the proper form for 2 of 2 observed meals provided by the facility kitchen.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure infection control measures, including hand hygiene, were implemented during incontinent care for 1 (Resident #5) of 1 sampled resident to prevent potential infection and or the spread of infections.

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 1 (Resident #29) of 1 resident reviewed for MDS accuracy.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to reflect the residents needs and preferences, and to properly assess a resident's fluency in English, to obtain all preferences to provide a diet consisting of resident's preferences, and to provide communication assistant devices, which affected the resident's physical, mental, and psychosocial well-being for 1 (Resident #29) of 1 resident reviewed for care plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items stored in the freezer were dated to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; dented cans were removed from stock, and the dishwashing machine temperature reached the necessary, recommended minimum temperature specified by the manufacturer's instructions to destroy food borne illnesses for the residents who received meals from 1 of 1 kitchen and detergent levels in the low temperature dishwasher were consistently monitored to ensure there was detergent going through. This failed practice had the potential to affect 38 residents who received meals from the kitchen according to a list provided by the Administrator on 09/14/23 at 9:04 AM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a Physician's Order was obtained prior to administering a Trilogy unit for 1 (Resident #5) of 1 sampled resident and Physician Orders were obtained prior to administering oxygen for 1 (Resident #21) of 1 sampled resident and Physician Orders were followed for 2 (Residents #1 and #5) of 4 (Resident #1, #5, #11 and #37) sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were refunded within 30 days after the resident was discharged /expired and had a remaining balance in the facilities resident trust fund account for 1 (Resident #140) of sampled resident per a list provided by the Administrator on [DATE] on 8:45 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the walls in 2 (rooms [ROOM NUMBERS]) resident rooms were not damaged and cracked floor tiles were replaced on the 300 Hall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Comprehensive Care Plan addressed the use of a Trilogy unit (a ventilator that provides respiratory support) for 1 (Resident #5) of 1 sampled resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nebulizer treatments were administered as ordered for 1 (Resident #15) of 2 (Resident #15 and #21) sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure thickened water was provided at the bedside for 1 (Resident #6) of 1 sampled resident and tray cards were followed for likes and dislikes, substitutions were offered, food tray was set up with all foods opened.

Inspectors wroteBased on observation, interview, and review of the Centers for Medicare and Medicaid Services Resident Assessment Instrument Manual 3.0, the facility failed to accurately record the assessment for 1 (Resident #12) of 1 sampled resident.