Russellville Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure Minimum Data Sets (MDS) were completed in a timely and accurate manner for two (Resident #106 and Resident #70) of two residents reviewed; specifically, that a quarterly MDS was accurately completed for (Resident #70) to indicate an appropriate smoking status, and that an admission MDS was completed within 15 days of admission for Resident #106.

Inspectors wroteBased on record review, interview, and facility document review, the facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the 90-day regulatory timeframe for 11 (Residents #25, #36, #38, #50, #60, #62, #67, #69, #73, #76, and #83) of 15 residents reviewed for quarterly assessments.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure hand hygiene and gloving were appropriately performed for one (Resident #57) of one sampled resident observed during perineal care, and the facility failed to ensure appropriate Personal Protective Equipment (PPE) was worn when administering medication and water flushes through a feeding tube for one (Resident #11) of one sampled resident, to prevent the risk for infection. Specifically, LPN #11 wore gloves and no gown when administering medication and flushes through a feeding tube, a high-contact care activity.

Inspectors wroteBased on record review and interview, the facility failed to ensure wounds were identified, documented, accurately reported to the physician, and treated for one (Resident #20) of four sampled residents reviewed. Specifically, an undated, unsigned, and undocumented dressing was discovered by staff on the lower right extremity of Resident #20, which had been applied without physician orders, and Resident #20 was found to have a small fist sized wound under the dressing, with myiasis [a parasitic infection of maggots in human tissue], which was not reported to the resident's physician.

Inspectors wroteBased on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure one (Resident #8) of one resident reviewed for respiratory care, had an order for oxygen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure expired medication was not stored in the medication cart for one (300-Hall) of two medication carts observed.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure food was discarded prior to the use by date, staff hands were washed between clean and dirty tasks and that meals were served in a manner as to not promote cross contamination for 80 residents who receive their meal from one of one kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment for 1 (Resident #44) of 1 resident regarding linen changes, 2 (Resident #15 and #44) of 2 residents regarding plaster cracking, and 43 out of 43 residents who use the 100 Hall bath. 1. On 08/19/2024 at 11:36 AM, the surveyor noted Resident #44's bed to be unmade, covers pulled back, and bottom linens appeared soiled with two large, orange-colored spots on fitted sheet. The surveyor noted an orange colored spot on the pillowcase on pillow at the head of the bed. the surveyor noted multiple flies around the resident's bed and a urine odor present. The surveyor made additional observation of unmade bed with soiled linens on 08/20/2024 at 11:58 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accepted power source was used for medical equipment to prevent the potential for fire hazards. The oxygen concentrator and pacemaker equipment were plugged into a small white 6 outlet power strip hanging on the wall behind the head of the bed of Resident #4. The facility failed to provide an environment that is free from accidents and hazards affecting 1 (Resident #12) resident.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for 1 (Resident #63) of 1 resident observed during supplemental feeding via percutaneous endoscopic gastrostomy (PEG) tube. Specifically, the facility failed to ensure placement of PEG tube before enteral feeding and flush.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to ensure staff followed isolation precautions including the appropriate use of personal protective equipment (PPE) prior to high contact resident care, to reduce transmission of resistance organisms for 1 (Resident #63) of 1 sampled resident observed during supplemental feeding via percutaneous endoscopic gastrostomy (PEG) tube. Specifically, the facility failed to ensure a gown was worn before a supplemental PEG tube feeding and flush and failed to ensure used personal protective equipment (PPE) was disposed of properly and the container was closed to prevent possible cross contamination to anyone passing the trash can sitting in the hallway. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a grievance policy signed by the facility and resident upon resident admission to include completing a grievance form and prompt resolution of grievance for 1 (Resident #16) of 1 sampled resident. On 08/19/2024 at 10:30 AM, Resident #16 reported a lost tablet. A family member at bedside reported the tablet purchased by family was lost or stolen while the resident was in the facility. The family member reported Administration was made aware, and an investigation was supposed to be initiated. On 08/20/2024 at 2:44 PM, the Assistant Director of Nursing (ADON) was interviewed regarding Resident #16's family member reporting the missing tablet to the Administrator. When asked if tablet was found, the ADON stated she was never notified. [...]

Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure a comprehensive Minimum Data Set (MDS) assessment was completed within 14 days after a significant change was identified to facilitate the ability to determine if any changes in care were necessary for 1 (Residents #58) sampled resident admitted to hospice care.

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 for preparation of pureed foods, alterative foods, and enhanced food items to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 3 residents who received pureed diets, 2 residents who received alterative foods, and enhanced food items 24 residents who received enhanced food items from 1 of 1 kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 3 residents who received pureed diets.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items stored in the refrigerator were covered or sealed; staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents dietary; hot food items 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. The failed practices had the potential to affect 64 residents who received meals from the kitchen

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were not left in a resident's room unattended for 1 Resident (Resident #39) of 2 case mix sample Residents (Resident #33 and #39). This failed practice had the potential to affect 17 residents receiving medications residing in the facility on hall 300.

Inspectors wroteBased on observation, interview and record review, the facility failed to store nebulizer mask and tubing, for 3 Residents (Resident #2, #13 and #22), and ensure humidifier bottles were filled for 1 (Resident #22) and failed to enter a physicians order prior to administering oxygen to 1 Resident (Resident #13) receiving supplemental oxygen and/or utilizing nebulizer treatments in order to prevent the potential for infection and respiratory complications for (Resident #2, #4, #8, #12, #13, #15, #22, #25, #30, #58 and #68) sampled residents who received respiratory therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to post a contact isolation precaution sign to notify staff of appropriate precautions to follow during resident care for 1(Resident #55) of 1 sampled resident.

Inspectors wroteBased on record review and interview, the facility failed to clearly determine and document the Advanced Directives for 1 of 1 (Resident #25) residents reviewed. Review of a document DNR (Do Not Resuscitate)/ Cardiopulmonary Resuscitation (CPR) Instructions, signed on [DATE] by Resident #25, which showed the resident did not want CPR. Review of a document Acknowledgment of Receipt of Advance Directive Information signed on [DATE] by Resident #25 Power of Attorney noted the resident is a full code . Review of the electronic medical record Miscellaneous tab showed on [DATE] Resident #25 was coded as DNR. During an interview on [DATE] at 9:15 AM, the Administrator said I would go by the most recent signature which was in [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fingernail care was provided to maintain good hygiene and prevent potential injury or infection for 1 Resident (Resident #42) of 3 case mix sampled residents (Resident #2, #33, & #42).