Inspection Reports for
Van Buren Healthcare and Rehabilitation Center
1404 North 28th Street, Van Buren, AR, 72956
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
7% occupied
Based on a July 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 19, 2024
Visit Reason
The inspection was conducted due to a complaint regarding inadequate supervision of Resident #4, who was found with an open bottle of hand sanitizer in their room, posing a risk of ingestion.
Complaint Details
The complaint was substantiated based on evidence including family member concerns, staff interviews, incident reports, and progress notes indicating Resident #4 had access to an open bottle of hand sanitizer and may have ingested it. The resident has severe cognitive impairment and is a known wanderer, increasing risk.
Findings
The facility failed to ensure adequate supervision to prevent Resident #4, who has severe cognitive impairment and dementia, from accessing and potentially ingesting hand sanitizer. Interviews, record reviews, and observations confirmed the presence of an open sanitizer bottle next to a cup of water in Resident #4's room, despite known risks and care plans addressing wandering and hazardous items.
Deficiencies (1)
Failure to ensure adequate supervision to prevent Resident #4 from accessing and potentially ingesting hand sanitizer.
Report Facts
Assessment Reference Date: Jul 14, 2024
Incident Date: Sep 6, 2024
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Provided statement about open sanitizer bottle in Resident #4's room |
| Director of Nursing | Director of Nursing | Notified of family concern and stated education was done with staff to keep hazardous items out of reach |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with care plan implementation and communication interventions for residents.
Findings
The facility failed to ensure the care plan was followed for fall interventions for one resident with a history of falls, and failed to provide alternative communication methods for another resident who required them.
Deficiencies (2)
Failed to ensure the care plan was followed related to fall interventions for Resident #32, specifically the absence of a fall mat on one side of the bed.
Failed to provide alternative communication methods for Resident #15 who required alternative formats for communication, including lack of communication board or note pad.
Report Facts
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding fall mat placement for Resident #32 | |
| Housekeeper #1 | Reported no communication board or note pad present for Resident #15 | |
| Treatment Nurse | Interviewed about communication methods for Resident #15 | |
| Activity Director | Interviewed about communication with Resident #15 |
Inspection Report
Routine
Census: 10
Deficiencies: 1
Date: Jul 14, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with providing Activities of Daily Living (ADL) care, specifically focusing on personal hygiene and shaving assistance for residents requiring staff help.
Findings
The facility failed to ensure proper ADL care related to shaving for Resident #71, who had persistent facial hair despite scheduled bathing and shaving routines. Staff acknowledged refusals of care but did not adequately address the resident's hygiene needs, posing potential minimal harm to some residents.
Deficiencies (1)
Failure to provide adequate shaving assistance to Resident #71, resulting in persistent facial hair despite scheduled care.
Report Facts
Residents sampled: 10
Residents affected: 24
Scheduled bathing frequency: 3
Date of inspection: Jul 14, 2023
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jul 14, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Van Buren Healthcare and Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies including failure to maintain privacy of resident medical information, inaccurate resident assessments, incomplete care plans, inadequate assistance with activities of daily living, improper catheter care, failure to serve meals according to the planned menu and at appropriate temperatures, improper food handling and storage, inadequate dining environment on the Secure Unit, and pest control issues with flies and roaches observed in food preparation and resident areas.
Deficiencies (10)
Failed to ensure privacy and confidentiality of personal and medical information during medication administration by not locking computer screens when unattended.
Failed to accurately record resident assessments for 4 sampled residents.
Failed to develop and implement comprehensive person-centered care plans for 2 sampled residents.
Failed to ensure Activities of Daily Living care was provided to promote cleanliness and good personal hygiene for 1 resident.
Failed to ensure indwelling catheter bag was covered to maintain privacy for 1 resident.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs.
Failed to ensure meals were served at acceptable temperatures to improve palatability and encourage nutritional intake.
Failed to ensure food items stored were covered, sealed, dated, and expired items removed; dietary staff failed to wash hands before handling clean equipment or food.
Failed to ensure a comfortable, homelike, social dining experience on the Secure Unit due to inadequate seating and space.
Failed to ensure food preparation, service areas, and resident areas were free from visible signs of rodents and pests.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 71
Residents affected: 18
Residents affected: 6
Residents affected: 31
Residents affected: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Named in privacy and confidentiality deficiency related to unlocked medication cart computer screens |
| Director of Nursing | DON | Interviewed regarding privacy, care plans, ADL care, catheter care, dining environment, and policies |
| MDS Coordinator | Named in inaccurate resident assessment and care plan deficiencies | |
| Certified Nursing Assistant #3 | CNA | Named in ADL care and catheter care deficiencies |
| Dietary Employee #1 | DE | Named in food preparation and handling deficiencies |
| Dietary Employee #2 | DE | Named in meal service and portion size deficiencies |
| Dietary Employee #3 | DE | Named in food handling and glove use deficiencies |
| Dietary Employee #4 | DE | Named in food handling and glove use deficiencies |
| Dietary Employee #5 | DE | Named in food handling and glove use deficiencies |
| Certified Nursing Assistant #1 | CNA | Named in meal temperature observation |
| Certified Nursing Assistant #2 | CNA | Named in meal temperature observation |
| Certified Nursing Assistant #4 | CNA | Named in Secure Unit dining environment deficiency |
| Certified Nursing Assistant #5 | CNA | Named in Secure Unit dining environment deficiency |
| Certified Nursing Assistant #6 | CNA | Named in Secure Unit dining environment deficiency |
| Licensed Practical Nurse #2 | LPN | Named in pest control observation and Secure Unit dining environment deficiency |
| Licensed Practical Nurse #1 | LPN | Named in meal service observation |
| Registered Nurse #1 | RN | Named in meal service observation |
| Administrator | Named in Secure Unit dining environment and pest control deficiencies | |
| Dietary Supervisor | Named in multiple food handling, storage, pest control, and meal service deficiencies |
Inspection Report
Routine
Census: 93
Deficiencies: 7
Date: Apr 8, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, safety, and facility conditions at Van Buren Healthcare and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to ensure staff assisted residents with dignity during meals, failure to maintain a safe and sanitary environment due to unrepaired wall damage, failure to promptly identify and treat wounds, failure to provide ordered therapeutic diets, failure to administer oxygen at prescribed rates, medication administration errors, and failure to maintain kitchen equipment cleanliness.
Deficiencies (7)
Staff failed to sit at eye level while assisting Resident #82 with eating, compromising dignity.
Facility failed to repair holes, scratches, and gouges in walls on South Hall affecting 33 residents.
Failure to ensure prompt identification and treatment of a wound on Resident #49's hand.
Failure to provide ordered therapeutic and nutritional diet to Resident #82 at risk for weight loss.
Oxygen administered to Resident #30 was set above the physician ordered rate, risking respiratory complications.
Medication errors occurred during insulin administration for Residents #38 and #72, including failure to follow physician orders for timing.
Kitchen equipment including ice scoop holder, meat slicer, can opener, fan guard, and ice dispenser were not maintained in a clean condition.
Report Facts
Residents affected: 33
Residents affected: 12
Medication error rate: 5.88
Residents observed for fortified foods: 17
Residents affected by kitchen cleanliness: 92
Total census: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Named in medication error findings and oxygen administration issues |
| Certified Nursing Assistant #1 | CNA | Named in dignity and meal assistance deficiency |
| Certified Nursing Assistant #3 | CNA | Interviewed regarding dignity and wound reporting |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding wound reporting and meal tray responsibilities |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding wall damage reporting |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding wound reporting and change of condition |
| Dietary Aid #1 | Dietary Aid | Interviewed regarding meal tray responsibilities |
| Dietary Manager | Dietary Manager | Interviewed regarding meal tray responsibilities |
| Director of Nursing | DON | Interviewed regarding medication administration and meal tray responsibilities |
| Maintenance Employee | Maintenance Employee | Interviewed regarding wall damage and reporting |
| Activity Director | Activity Director | Interviewed regarding duration of wall damage |
| Dietary Employee #2 | Dietary Employee | Interviewed regarding kitchen equipment cleanliness |
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