Crittenden County Health & Rehabilitation Center

Based on interview and record review, the facility failed to ensure the physician acknowledged the pharmacist's recommendation for a resident's monthly medication regime review for one of five sampled residents (Resident (R) 43) reviewed for unnecessary medications.The findings include: On 03/05/2026 at 10:12 AM, the Director of Nursing (DON) stated the facility did not have a policy that specified the timeframe in which a physician must respond to the consultant pharmacist's monthly medication regime review. Review of R43's Resident Face Sheet revealed the facility the resident on 08/27/2020 with diagnoses which included heart failure, hyperkalemia, and gastro-esophageal reflux disease without esophagitis. Review of R43's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/2026, revealed the resident had a Brief Interview for Mental Status score of 14 out of 15, which indicated the resident had intact cognition. Review of R43's Consultation Report for the timeframe 11/01/2025-11/30/2025, 12/01/2025-12/31/2025, and 01/01/2026-01/31/2026, revealed no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure staff wore a gown when they provided care to residents on enhanced barrier precautions (EBP) for one (Resident 42) of one sampled residents reviewed for tube feeding, one of (Resident 33) of one sampled residents reviewed for pressure ulcer/injury, and one (Resident 42) of five sampled residents reviewed for infection control.The findings include: A facility policy titled, Enhanced Barrier Precautions, reviewed 01/2025, specified, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high contact resident care activities. The policy specified, 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Food items in the walk-in freezer were not labeled or dated. Staff failed to completely cover their hair while in the kitchen. Staff failed to cover prepared food on the warming table. A cold food was not at the proper temperature for serving. These failures had the potential to affect all 61 of the facility's residents who consumed food from the kitchen. The findings include: 1. Review of the facility's policy titled, Storage Procedures, dated 08/2023, revealed, Food shall be properly stored to preserve flavor, nutritive value, and appearance. Per policy review, all foods in the freezer were to be wrapped in moisture proof wrapping or placed in suitable containers, to prevent freezer burn. In addition, they were to be labeled and dated with use by dates clearly marked. Observation of the walk-in freezer, at 12:11 PM on 02/04/2025, revealed five chicken patties, six hamburger steaks, five…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to implement multiple interventions on the comprehensive person-centered care plan for one (Resident (R) 37) of two sampled residents reviewed for wound care. Interventions regarding treatment orders, infection control measures, and odor control were not implemented in accordance with the resident's care plan. The findings include: Review of the facility policy, Resident Assessment Comprehensive Care Plans, updated 05/24/2022, revealed the facility must implement a comprehensive person-centered care plan for each resident. The intent stated, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Review of the facility policy, Comprehensive Care Plans, effective 11/28/2017, revealed, the services provided or arranged by the facility, as outlined by the comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide non-pressure wound care in accordance with the resident's care plan and physician orders for one (Resident (R) 37) of two sampled residents reviewed for wounds. The findings include: Review of R37's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses which included a fistula of intestine-enterocolic and colocutaneous, and a colostomy related to megacolon/abdominal surgery. Review of the Comprehensive Care Plan, dated 09/04/2024, revealed the resident had a problem of an open area to the left buttock which was verified by the medical doctor as a chronic fistula wound. Review of the Comprehensive Care Plan, dated 05/23/2024, also revealed the resident had an open area to the right buttock. The care plan goal for each wound was to heal skin and prevent infection. An approach to meet this goal was for staff to deliver prescribed treatment. Review of physician orders, dated 02/01/2025, revealed an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections for one (Resident (R) 37) of two residents reviewed for wound care. Facility staff failed to perform hand hygiene as indicated before, during, and after ostomy and wound care. Staff failed to use enhanced barrier precautions (EBP) designed to reduce transmission of multidrug-resistant organisms even though the resident had wounds that required EBP. Treatment supplies, including scissors and ointment, were handled in a manner that did not prevent the spread of infection. In addition, hand hygiene was not monitored by supervisory staff as planned as part of the facility's surveillance/monitoring activities. The findings included: Review of the facility policy, Infection Control Program, reviewed 01/2025 revealed the purposed of the infection control program in the nursing facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for two (2) of three (3) sampled residents (Resident #40 and Resident #41). Although it was not within the Scope of Practice for a Licensed Practical Nurse to declare death or sign the Provisional Report of Death or Death Certificate, review of Resident #40's Provisional Report of Death, dated [DATE], revealed Licensed Practical Nurse (LPN) #3 completed and signed the form. Additionally, review of Resident #41's Provisional Report of Death, dated [DATE], revealed LPN #3 completed and signed the form. The findings include: Review of a facility policy titled, Provisional Report of Death Form, undated, revealed the facility was responsible for completing and ensuring completion of Sections A, B, and C. Part B was to be completed by the local Registrar, Coroner, or Hospice nurse and it was acceptable for a facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident who is unable to carry out Activities of Daily Living (ADL) receives the necessary services to maintain good personal hygiene related to incontinence care for one (1) of forty (40) sampled residents (Resident #17). Observation on 02/20/2024 at 1:20 PM, revealed a strong odor of urine in Resident #17's room, and the resident was noted to be lying in bed with his/her pants and bed linens soiled with a yellow/brown substance. The findings include: Review of the facility policy titled, Activities of Daily Living (ADLs)/Maintain Abilities, dated 03/2023 and reviewed 01/2024, revealed the facility would specify the responsibility to create and sustain an environment that humanizes and individualized each resident's quality of life by ensuring all staff across all shifts and departments understood the principle of quality of life and honor and support those principles for each resident; and that the care and services provided were person-centered and honor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible. Observation on 02/22/2024 at 9:00 AM, revealed lancets (a small needle used to puncture the skin of the finger in order to obtain a small drop of blood to test blood sugar) were left unattended on top of a treatment cart on the 500 hallway. The findings include: Review of the facility policy titled, Incidents, dated 11/2019 and reviewed 01/2024, revealed all incidents or accidents occurring on the premises would be investigated and reported to the Administrator and/or the Director of Nursing. Observation on 02/22/2024 at 9:00 AM, 11:05 AM, and 2:25 PM, revealed lancets were sitting in a basket on top of the treatment cart and left unattended on the 500 hallway. During an interview with Licensed Practical Nurse (LPN) #1, on 02/22/2024 at 2:25 PM, he stated he would normally lock the lancets and glucometer supplies inside the cart, but he just had not had time to do so. Observation during this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of the facility policy, it was determined 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 one (1) of three (3) sampled residents (Resident #34). Observation on 02/22/2024 at 11:05 AM, revealed Licensed Practical Nurse (LPN) #1 performed a blood glucose finger stick on Resident #34, then doffed his gloves, and failed to perform hand hygiene prior to exiting the room. The findings include: Review of the facility policy titled, Infection Control Program, reviewed 03/2023, revealed the facility would minimize the effects of infections on residents and employees and educate the staff by having an effective Infection Control Program. Review of Resident #34's Face Sheet revealed the facility admitted the resident on 11/21/2023 with diagnoses to include: Depression, Neuromuscular dysfunction of Bladder, and Type two (2) Diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's Policies, it was determined the facility failed to provide means for resident(s) to directly contact caregivers through a communication system which relays the call directly to a staff member or to a centralized staff work area for three (3) of forty (40) sampled residents (Residents #17, #35, and #36). Observation of Resident room [ROOM NUMBER] on 02/20/2024, revealed the call lights for Residents #17 and #36 did not have a push button on the end resulting in the residents not being unable to call for help if needed. Additionally, Resident 17's call light was hanging on the wall and out of reach. The findings include: Review of the facility policy titled, Standards of Nursing Practices, dated 05/2018 and reviewed 01/2024, revealed staff would respond to resident's request for assistance by answering call lights within a reasonable amount of time, within ten (10) minutes. Review of the facility policy titled, Resident Rights, updated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective antibiotic stewardship program for one (1) of twenty-two (22) sampled residents (Resident #75). On 11/03/19, Resident #75 was ordered to receive an antibiotic for an infected wound. However, staff interview and review of a Skin McGeer Criteria form (utilized by the facility to determine the eligibility for a resident to receive an antibiotic) revealed the resident did not meet the criteria for antibiotic therapy. However, there was no evidence that Resident #75's physician had been notified that the resident did not meet the criteria for use of an antibiotic. The findings include: Review of the facility's policy titled, Infection Control Program, dated November 2016, revealed the facility would utilize McGeer criteria to assist in the recognition of infections and to ensure antibiotic usage was appropriate as part of their Antibiotic Stewardship Program. Observation of a skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.