Based on interview and record review, during a site visit conducted on 12/19/23, it was confirmed the facility failed to notify the Department's Central Office immediately of the occurrence of epidemic disease in the facility. Findings include, but are not limited to:

During an interview on 12/19/23, Staff 1 (ED) stated, "The facility did have a covid outbreak in April, however, I was on vacation at the time. I had informed the County."  

A review of an email correspondence from Staff 1 to Benton County on 04/14/23 indicated the facility had notified the local public health of the covid outbreak. An email correspondence with the facility's policy analyst and the CS indicated the facility had not notified the Department of the covid outbreak in April 2023.

It was confirmed the facility failed to notify the Department's Central Office immediately of the occurrence of epidemic disease in the facility.

On 12/19/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility will report covid outbreaks immediately.  

Based on observation, interview, and record review, during a site visit conducted on 12/19/23, it was confirmed the facility failed to ensure a system for disposal of all unused, outdated, or discontinued medications administered by the facility for 2 of 2 sampled residents' (#s 1 and 2). Findings include, but are not limited to:

On 12/19/23, CS observed deceased Resident 1 to have 15 doses of Lorazepam 1mg and 2ml of Morphine, as well as Resident 2's four packets of Lorazepam .5 mg and 21.5ml of Morphine having been stored in the medication cart.

During separate interviews on 12/19/23, Staff 2 (MT) stated, "There are two deceased resident's Lorazepam and Morphine in my medication cart. Med techs can destroy medications that are not narcotics. The narcotics are destroyed by a Nurse and the ED." Staff 2 indicated Resident 1 had passed away on 11/30/23 and Resident 2 had passed away on 12/09/23. Staff 1 (ED) stated, "The facility does not have a specific policy and procedure for the disposal and destruction of narcotics. The facility does not have a time frame of when narcotics are to be destroyed, we will typically do it within a month. The Nurses and I have not been at the facility at the same time to have destroyed those medication yet."  

A review of the facility's tracking-controlled substance record book indicated Resident 1 and Resident 2's Lorazepam and Morphine had yet to be destroyed.

It was confirmed the facility failed to ensure a system for disposal of all unused, outdated, or discontinued medications administered by the facility.

On 12/19/23, the findings were reviewed with and acknowledged by Staff 1 (ED).

Verbal plan of correction: not provided.

Based on observation and interview, during a site visit conducted on 12/19/23, it was confirmed the facility failed to ensure the interior of the facility was free from unpleasant odors. Findings include, but are not limited to:

On 12/19/23, CS observed the following:

·An unsampled guest enter the facility while having said, "pew " and having pinched his/her nose with his/her fingers.

·A strong odor of urine in the main common area space and throughout the hallways.

During an interview on 12/19/23, Staff 3 (MT) acknowledged the facility had a strong urine smell.

It was confirmed the facility failed to ensure the interior of the facility must be free from unpleasant odors.

On 12/19/23, the findings were reviewed with and acknowledged by Staff 1 (ED).

Verbal plan of correction: Staff 1 was already in the process of removing the carpet in the common areas and would be replacing it with tile, s/he was waiting on a bid before moving forward.