Inspection Reports for
Barnes Healthcare
1010 Barnes Street, Lonoke, AR 72086, AR, 72086
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jan 9, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain clean bed linens for residents, inaccurate Minimum Data Set (MDS) assessments for several residents, lack of smoking assessments for residents who smoke, failure to use hand rolls for residents with contractures, failure to use specialized medicated shampoo as ordered, inadequate treatment for a resident's foot condition, and failure to ensure adequate nutrition and hydration documentation and care for a dependent resident.
Deficiencies (6)
Failure to ensure bed linens were maintained in clean condition for two residents.
Failure to complete accurate Minimum Data Set (MDS) assessments for 7 residents.
Failure to ensure residents who smoke had smoking assessments and use of smoking aprons.
Failure to ensure hand rolls were used for residents with contractures and specialized shampoo used as ordered.
Failure to provide appropriate treatment for left foot toenail condition for one resident.
Failure to ensure adequate nutrition and hydration and proper documentation for one dependent resident.
Report Facts
Residents sampled for bed linens: 7
Residents with inaccurate MDS: 7
Residents reviewed for smoking: 2
Residents reviewed for contractures: 1
Residents reviewed for ADL care: 1
Resident weight loss: 45.6
Missed nutrition documentation: 18
Missed hydration documentation: 17
Missed supplement documentation: 15
Snack offers documented: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Interviewed regarding bed linens and nutrition documentation |
| Registered Nurse #6 | Registered Nurse | Interviewed regarding bed linens |
| Certified Nursing Aide #7 | Certified Nursing Aide | Interviewed regarding bed linens |
| Certified Nursing Aide #8 | Certified Nursing Aide | Interviewed regarding bed linens |
| Director of Nursing | Director of Nursing | Multiple interviews confirming deficiencies in linens, MDS accuracy, smoking assessments, medicated shampoo use, and nutrition documentation |
| Administrator | Administrator | Interviewed confirming dirty bed linens |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS inaccuracies and coding errors |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Interviewed regarding nutrition and hydration documentation |
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Interviewed regarding hand roll use and documentation |
| Treatment Nurse | Treatment Nurse | Interviewed regarding medicated shampoo use and documentation |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Jan 9, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care, safety, infection control, medication management, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain clean bed linens, inaccurate resident assessments, incomplete preadmission screening and resident review (PASRR), incomplete and inaccurate care plans, lack of smoking assessments, failure to use hand rolls for contractures, inadequate use of prescribed medicated shampoo, inadequate nutrition and hydration documentation, unnecessary medications without proper indications, improper meal preparation and serving, unsanitary food storage and kitchen conditions, and infection control lapses related to meal tray handling.
Deficiencies (11)
Failure to ensure bed linens were maintained in clean condition for residents.
Failure to complete accurate Minimum Data Set (MDS) assessments for multiple residents.
Failure to complete preadmission screening and resident review (PASRR) for residents with mental illness diagnoses.
Failure to develop and implement complete, person-centered care plans including black box warnings and fall interventions.
Failure to complete smoking assessments for residents who smoke and failure to ensure use of smoking aprons.
Failure to ensure use of hand rolls for residents with contractures and failure to use prescribed medicated shampoo during showers.
Failure to provide adequate nutrition and hydration documentation and assistance for dependent residents.
Failure to ensure medication regimen was free from unnecessary medications without adequate indications.
Failure to prepare and serve meals according to the planned menu including correct portion sizes and substitutions.
Failure to store food items properly covered, sealed, and dated; failure to maintain sanitary kitchen environment including clean ceiling tiles, floors, and proper hand hygiene by dietary staff.
Failure to prevent cross-contamination by placing dirty meal trays on meal transport carts with clean trays.
Report Facts
Residents sampled for MDS accuracy: 11
Residents reviewed for PASRR screening: 4
Residents with incomplete care plans: 6
Falls documented for Resident #14: 15
Weight loss for Resident #47: 45.6
Portion size discrepancy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nursing Aide | Interviewed regarding bed linen changing practices |
| CNA #7 | Certified Nursing Aide | Interviewed regarding bed linen changing practices |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding bed linen changing and nutrition documentation |
| RN #6 | Registered Nurse | Interviewed regarding bed linen changing |
| Director of Nursing | Director of Nursing (DON) | Multiple interviews confirming deficiencies and responsibilities |
| Administrator | Facility Administrator | Interviewed confirming bed linen deficiencies |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS accuracy, care planning, and PASRR |
| CNA #11 | Certified Nursing Assistant | Interviewed regarding hand roll use and documentation |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and ice machine cleaning |
| Dietary Aide #3 | Dietary Aide | Observed and interviewed regarding hand hygiene |
| Dietary #1 | Dietary Staff | Observed and interviewed regarding hand hygiene and food handling |
| Treatment Nurse | Treatment Nurse | Interviewed regarding medicated shampoo use |
Inspection Report
Deficiencies: 2
Date: Apr 30, 2024
Visit Reason
The inspection was conducted to investigate the facility's management of residents' personal trust accounts, including allegations of failure to provide quarterly statements and misappropriation of resident funds.
Findings
The facility failed to provide quarterly statements of trust accounts to 34 of 41 residents reviewed and failed to protect residents from misappropriation of funds, with documented fraudulent charges totaling $181,384.19 affecting 49 residents. The facility suspended involved staff and initiated an investigation with police involvement.
Deficiencies (2)
Failure to provide quarterly statements of residents' trust accounts to 34 of 41 residents reviewed.
Failure to protect residents from misappropriation of funds, with fraudulent charges totaling $181,384.19.
Report Facts
Residents affected: 34
Residents affected: 49
Fraudulent charges total: 181384.19
Fraudulent charges balance: 4452.72
Residents reviewed: 41
Timeframe for repayment: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of [NAME] Office Manager (DBOM) | Confirmed residents did not receive quarterly statements and acknowledged misappropriation of funds | |
| Business Office Manager (BOM) | Handled resident trust account transactions and was suspended during investigation | |
| Social Service Director (SSD) | Handled resident money distribution and was suspended during investigation | |
| Administrator | Provided information on investigation, process changes, and repayment plans |
Inspection Report
Deficiencies: 12
Date: Dec 6, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, safety, hygiene, infection control, medication management, food safety, equipment maintenance, and environmental conditions at Barnes Healthcare nursing facility.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and rights during care, unsafe and unsanitary environmental conditions, inaccurate resident assessments, inadequate personal hygiene care, improper medication storage and administration, unsafe oxygen therapy practices, unsafe food handling and kitchen sanitation practices, failure to maintain essential kitchen equipment, inadequate infection prevention practices, and unsecured handrails posing safety hazards.
Deficiencies (12)
Failure to ensure residents dependent on staff for activities of daily living were provided assistance to protect and promote their rights and dignity.
Failure to maintain a safe, functional, sanitary, and homelike environment to promote dignity and prevent injury or spread of disease.
Failure to ensure accurate Minimum Data Set (MDS) assessments for residents to facilitate care planning.
Failure to provide adequate personal hygiene care including trimming fingernails, toenails, and removing chin hairs.
Failure to maintain kitchen vent-a-hood free of grease buildup, resulting in Immediate Jeopardy.
Failure to secure potentially hazardous personal care items in resident rooms to prevent access by cognitively impaired residents.
Failure to ensure oxygen cylinders were stored securely and oxygen therapy was administered at ordered flow rates.
Failure to secure medications in residents' rooms and leaving medications unattended on medication carts.
Failure to maintain kitchen cleanliness, proper food storage, food safety, and hand hygiene resulting in Immediate Jeopardy.
Failure to implement infection prevention and control practices including glove use and hand hygiene during incontinent care.
Failure to maintain essential kitchen equipment in safe, operational order resulting in Immediate Jeopardy.
Failure to ensure handrails were securely attached to walls to prevent resident injury.
Report Facts
Residents affected: 2
Residents affected: 51
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Assistant | Named in multiple findings related to improper feeding techniques, failure to maintain resident privacy, improper glove use, and infection control breaches |
| LPN #3 | Licensed Practical Nurse | Named in findings related to infection control, feeding practices, and oxygen therapy |
| Maintenance #1 | Maintenance Supervisor | Named in findings related to facility maintenance issues including handrails, windows, drain covers, and kitchen equipment |
| Dietary Manager | Named in findings related to kitchen sanitation, food safety, and staff education | |
| Administrator | Named in findings related to notification and oversight of Immediate Jeopardy and facility deficiencies | |
| ICP | Infection Control Preventionist | Named in infection control interview regarding feeding and glove use |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 12, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure that a sampled resident (Resident #3) received the correct dose of medication as ordered.
Complaint Details
The complaint investigation focused on whether Resident #3 received the correct medication dose. The investigation found that the resident had been receiving Oxycodone 10 mg without Acetaminophen instead of the ordered Oxycodone-Acetaminophen 10-325 mg for over a year. Staff, including nurses and the Director of Nursing, were unable to explain why the incorrect medication was administered.
Findings
The facility failed to ensure Resident #3 received the correct dose of Oxycodone with Acetaminophen as ordered. Instead, the resident was given Oxycodone 10 mg without Acetaminophen for an extended period, with staff unable to explain the discrepancy.
Deficiencies (1)
Failure to provide Resident #3 with the correct dose of Oxycodone with Acetaminophen as ordered, resulting in administration of Oxycodone 10 mg without Acetaminophen.
Report Facts
Deficiencies cited: 1
Medication count: 2
Medication order start date: Aug 9, 2022
Assessment Reference Date: Mar 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in medication error finding regarding Oxycodone administration |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about duration of incorrect medication administration |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about duration and reason for medication administration |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about duration and reason for medication administration |
| Director of Nursing | Director of Nursing | Interviewed about duration and reason for medication administration |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Oct 6, 2022
Visit Reason
The inspection was conducted to assess compliance with care planning requirements, including the development and implementation of Comprehensive Care Plans, Baseline Care Plans, and the review and revision of care plans for residents.
Findings
The facility failed to develop and implement Comprehensive and Baseline Care Plans timely for resident #32 and failed to review and revise care plans to reflect changes in resident needs for residents receiving oxygen and anticoagulation therapy, potentially affecting multiple residents.
Deficiencies (3)
Failure to ensure a Comprehensive Care Plan was developed to address individualized care needs for resident #32.
Failure to develop and implement a Baseline Care Plan within 48 hours of admission for resident #32.
Failure to review and revise the Care Plan and reassess effectiveness of interventions for residents with oxygen therapy and anticoagulation therapy.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 10
Residents affected: 7
Assessment Reference Date: Sep 1, 2022
Assessment Reference Date: Sep 5, 2022
Assessment Reference Date: Sep 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding care plan responsibilities and timelines | |
| Minimum Data Set (MDS) Nurse / Medical Records Nurse | Interviewed regarding care plan completion responsibilities and timelines | |
| Minimum Data Set Nurse/Licensed Practical Nurse (MDS Nurse/LPN) | Interviewed regarding care plan revision requirements |
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