Inspection Reports for
Barnes Healthcare
1010 Barnes Street, Lonoke, AR 72086, AR, 72086
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
18.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
256% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
36
27
18
9
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: 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 provide appropriate treatment and care for contractures and skin conditions, and inadequate documentation and provision of nutrition and hydration 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 smoking assessments were completed for residents who smoke and failure to use smoking aprons.
Failure to ensure hand rolls were used for residents with contractures and failure to use specialized medicated shampoo as ordered.
Failure to provide appropriate foot care treatment for a resident's left foot toenail condition.
Failure to provide adequate nutrition and hydration and incomplete documentation for a dependent resident.
Report Facts
Residents sampled for bed linen deficiency: 7
Residents with inaccurate MDS: 7
Residents reviewed for smoking: 2
Residents reviewed for contractures: 1
Residents reviewed for ADL care: 1
ADL nutrition documentation missing: 18
ADL fluids documentation missing: 17
ADL supplements documentation missing: 15
Weight loss: 45.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Interviewed regarding bed linen changes and nutrition documentation |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Interviewed regarding bed linen changing practices |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Interviewed regarding bed linen changing practices |
| Registered Nurse #6 | Registered Nurse | Interviewed regarding bed linen changing practices |
| Director of Nursing | Director of Nursing | Interviewed multiple times confirming deficiencies and policy requirements |
| Administrator | Administrator | Interviewed confirming bed linen deficiencies |
| MDS Coordinator | MDS Coordinator | Interviewed regarding inaccurate MDS coding and assessments |
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Interviewed regarding refusal to use hand roll for contracture care |
| Treatment Nurse | Treatment Nurse | Interviewed regarding medicated shampoo use and documentation |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Interviewed regarding nutrition and hydration 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
Annual Inspection
Deficiencies: 12
Date: Jan 9, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to maintain clean bed linens, inaccurate Minimum Data Set (MDS) assessments, incomplete preadmission screening and resident review (PASRR), incomplete and inaccurate care plans, lack of smoking assessments, failure to use hand rolls for contractures, failure to use ordered 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 breaches related to meal tray handling.
Deficiencies (12)
Failed to ensure bed linens were maintained in clean condition for residents.
Failed to complete accurate Minimum Data Set (MDS) assessments for multiple residents.
Failed to complete required preadmission screening and resident review (PASRR) for residents with mental illness diagnoses.
Failed to develop and implement complete, accurate, and person-centered care plans including fall interventions and black box medication warnings.
Failed to include family/responsible party and resident in care plan meetings.
Failed to conduct smoking assessments and ensure use of smoking aprons for residents who smoke.
Failed to ensure use of hand rolls for residents with contractures and use of ordered medicated shampoo.
Failed to provide adequate nutrition and hydration documentation and assistance for dependent residents.
Medication regimen included unnecessary medications without adequate indications.
Failed to prepare and serve meals in accordance with the planned menu including incorrect portion sizes and missing pureed dinner rolls.
Failed to store food items properly in the freezer and refrigerator, maintain kitchen cleanliness, and ensure dietary staff hand hygiene.
Failed to prevent cross-contamination by placing dirty meal trays on meal transport carts with clean trays.
Report Facts
Falls recorded: 16
Weight loss: 45.6
Medication orders without indications: 3
Portion size discrepancy: 1
Missing meal documentation: 18
Missing hydration documentation: 17
Missing supplement documentation: 15
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 practices. |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding deficiencies in care planning, smoking assessments, medication management, and infection control. |
| Administrator | Administrator | Interviewed regarding bed linen deficiencies. |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS inaccuracies, care planning, and PASRR screening. |
| CNA #11 | Certified Nursing Assistant | Interviewed regarding hand roll use and refusals. |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage, kitchen cleanliness, and ice machine cleaning. |
| Dietary Aide #3 | Dietary Aide | Observed contaminating hands and handling food without washing hands. |
| Dietary #1 | Dietary Staff | Observed contaminating hands and handling clean equipment without washing hands. |
| CNA #9 | Certified Nursing Assistant | Observed placing dirty meal trays on clean meal trays. |
| Treatment Nurse | Treatment Nurse | Interviewed regarding medicated shampoo use and documentation. |
| CNA #10 | Certified Nursing Assistant | Interviewed regarding nutrition and hydration documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 30, 2024
Visit Reason
The inspection was conducted due to allegations of misappropriation of resident trust funds and failure to provide quarterly trust account statements to residents or their representatives.
Complaint Details
The investigation was complaint-driven due to allegations of misappropriation of resident funds and failure to provide trust account statements. The allegations were substantiated with evidence of fraudulent charges totaling $181,384.19. The facility suspended implicated staff and involved law enforcement.
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 responsible staff and initiated an investigation with police involvement.
Deficiencies (2)
Failure to provide quarterly statements of resident trust accounts to 34 of 41 residents reviewed.
Failure to protect residents from misappropriation of resident funds affecting 34 of 41 residents reviewed.
Report Facts
Residents reviewed for trust account statements: 41
Residents affected by failure to receive quarterly statements: 34
Residents reviewed for misappropriation of funds: 41
Residents affected by misappropriation: 34
Total misappropriated funds: 181384.19
Fraudulent charges documented in 2024: 4452.72
Timeframe for repayment plan: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of [NAME] Office Manager (DBOM) | Confirmed residents did not receive quarterly statements and confirmed misappropriation of funds | |
| Business Office Manager (BOM) | Handled trust account transactions, reconciliations, and was suspended during investigation | |
| Social Service Director (SSD) | Handled resident money distribution and was suspended during investigation | |
| Administrator | Provided information on investigation, suspension of staff, and corrective actions |
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
Annual Inspection
Deficiencies: 15
Date: Dec 6, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations related to resident rights, safety, hygiene, infection control, medication management, food safety, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity during care, unsafe and unsanitary environmental conditions, inaccurate resident assessments, inadequate personal care and hygiene, improper medication storage and administration, unsafe oxygen storage and administration, food safety violations including expired and improperly stored food, poor infection control practices, and unsafe maintenance of equipment and handrails. Immediate Jeopardy was cited related to food safety and essential equipment maintenance.
Deficiencies (15)
Failure to ensure residents dependent on staff for activities of daily living were provided assistance to protect and promote dignity.
Failure to maintain a safe, functional, sanitary, and homelike environment, including torn window blinds, torn recliners, unsecured handrails, exposed electrical outlets, and unsafe bathroom conditions.
Failure to ensure accurate Minimum Data Set (MDS) assessments for residents.
Failure to provide adequate personal care including trimming fingernails and removing chin hairs for residents.
Failure to maintain kitchen vent-a-hood free of grease and grime, resulting in Immediate Jeopardy.
Failure to secure potentially hazardous personal care items from cognitively impaired residents.
Failure to ensure mattress fit bed frame to prevent potential harm.
Failure to secure cigarettes and vapes from residents without independent smoking privileges.
Failure to secure oxygen cylinders in storage room and maintain locked storage.
Failure to administer oxygen at physician ordered flow rate.
Failure to store medications securely and leaving medications unattended on medication cart.
Failure to maintain kitchen cleanliness, proper food storage, discard expired food, proper hand hygiene, and prevent contamination resulting in Immediate Jeopardy.
Failure to implement infection prevention and control practices including hand hygiene and glove use during incontinent care, and improper storage of dirty briefs and gloves.
Failure to maintain essential kitchen equipment in safe, operational order to ensure food safety, 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
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Assistant | Named in findings related to improper feeding technique, infection control failures during incontinent care |
| LPN #3 | Licensed Practical Nurse | Named in findings related to feeding assistance, infection control, and oxygen administration |
| Maintenance #1 | Maintenance Staff | Named in findings related to facility maintenance, handrail repairs, and equipment issues |
| Dietary Manager | Dietary Manager | Named in findings related to kitchen cleanliness, food safety, and staff education |
| RN #1 | Registered Nurse | Named in findings related to oxygen storage and safety |
| CNA #3 | Certified Nursing Assistant | Named in findings related to resident nail care |
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 Resident #3 received the correct dose of Oxycodone medication as ordered.
Complaint Details
The complaint investigation focused on Resident #3 who had an order for Oxycodone-Acetaminophen 10-325 mg but was administered Oxycodone 10 mg without Acetaminophen for over a year. Staff including RN, LPNs, ADON, and DON were unable to explain why the medication was not given as ordered.
Findings
The facility failed to ensure that 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 (RN) #1 | Pulled medications and acknowledged resident was out of Oxycodone with Acetaminophen | |
| Licensed Practical Nurse (LPN) #1 | Reported Resident #3 had been receiving Oxycodone 10 mg for over a year | |
| Licensed Practical Nurse (LPN) #2 | Reported Resident #3 had been on pain medication since she started working | |
| Assistant Director of Nursing (ADON) | Reported Resident #3 had been on Oxycodone for over 2 years but did not know why the medication was changed | |
| Director of Nursing (DON) | Uncertain about duration Resident #3 had been receiving Oxycodone |
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 |
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 revision of Comprehensive Care Plans, Baseline Care Plans, and the review of care plans for residents with specific therapies such as oxygen and anticoagulation.
Findings
The facility failed to ensure that Comprehensive Care Plans and Baseline Care Plans were developed and implemented timely for sampled residents, including Resident #32. Additionally, the facility failed to review and revise care plans to reflect changes in resident needs, such as oxygen therapy and anticoagulation therapy, potentially affecting multiple residents.
Deficiencies (3)
Failure to develop a Comprehensive Care Plan for Resident #32 within required timeframe.
Failure to develop and implement a Baseline Care Plan for Resident #32 within 48 hours of admission.
Failure to review and revise the Care Plan and reassess effectiveness of interventions for Resident #34 and Resident #49, including oxygen and anticoagulation therapy.
Report Facts
Residents sampled: 5
Residents affected by oxygen therapy care plan issue: 10
Residents affected by anticoagulation therapy care plan issue: 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 | Director of Nursing (DON) | Interviewed regarding care plan responsibilities and timelines |
| MDS/Medical Records Nurse | MDS/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 and knowledge |
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