Pocahontas Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Pocahontas Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF726Jun 20, 2025

  Based 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. The findings include: A review of the admission Record indicated that Resident #1 was admitted [DATE] with diagnoses that included hypertensive encephalopathy (brain dysfunction) and hypertensive emergency. […]

• No harm, potential for more than minimal, widespreadF812Aug 22, 2024

  Based on observations, record review and interviews, the facility failed to ensure cross contamination during lunch service did not occur for one of one kitchen. The findings are: On 08/20/2024 at 12:05 PM, the surveyor observed Dietary Aide #6 take a stack of plates to put inside the lunch cart for 100 Hall. Dietary Aide #6 had their hand on top of the stack as they slid it on a tray inside the cart. On 08/20/2024 at 12:08 PM, the surveyor observed Dietary Aide #6 touch the inside of a divided plate intended to serve the puree diet for the 100 Hall. On 08/20/2024 at 12:09 PM, Surveyor observed Dietary Aide #6 picked up a bowl, put their finger inside of the bowl where food would rest and serve gravy for 100 Hall. […]

• No harm, potential for more than minimal, widespreadF812Sep 15, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jun 30, 2022

  Based on observation, record review and interview, the facility failed to ensure foods stored in the kitchen freezer, refrigerator, and dry storage area and in the snack refrigerator were labeled dated, covered and sealed; expired food items were promptly removed /discarded on or before the expiration or use by dates; food was covered and utensils stored in a drawer to prevent flies from landing on the food and utensils; food temperatures were taken on the serving line prior to being served; staff who were ill were not allowed to continue to work and food/drink items prepped by them were not served to the residents, and sanitizing solution was maintained at the level per manufacturer's instructions for residents who received meals from 1 of 1 kitchen to minimize the potential for food… […]

• No harm, potential for more than minimal, patternF689Dec 31, 2024

  Based 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. The findings include: A review of the facility's undated policy titled Accident Hazards prevention indicated The environment will be free from an accident hazards as is possible .An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents . […]