Barnes Healthcare

Inspectors wroteBased on record review, interviews, and facility document review, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for 7 (Residents #5, # 25, #16, #27, #41, #14, #22) of 11 sample mix residents.

Inspectors wroteBased on record review, interview, and facility document review, it was determined that the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed prior to admission to ensure the resident received the needed care and services in the most appropriate setting for 3 (Residents #16, #22,#32) of 4 sampled residents whose records were reviewed for PASRR screening information.

Inspectors wroteBased on observations, interviews, and record review, it was determined the facility failed to document and complete a person-centered care plan to facilitate the ability to plan and provide necessary care and services for 6 (Residents #32, 22, 27, 3, 7, 14) of 19 sampled residents whose Care Plans were reviewed.

Inspectors wroteBased on observation, interview, record review, and facility document review, it was determined the facility failed to ensure that residents who smoke have a smoking assessment for 2 (Resident #14, #41) of 2 sample mix residents reviewed for smoking and to ensure hand rolls were used for residents with contractures for 1 (Resident #27) of 1 sample mix residents reviewed for contractures and to ensure specialized shampoo was used during showers as ordered by physician instead of regular body wash for 1 (Resident #47) of 1 resident reviewed for ADL (activities of daily living) care for dependent residents.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure adequate nutrition and hydration was provided for dependent residents for 1 (Resident #47) of 1 resident reviewed for nutrition and hydration status and weight loss.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure food items stored in the freezer were covered, sealed, dated; manufacturer specification was followed; kitchen ceiling tiles were replaced, cleaned to provide a sanitary environment for food preparation; floors, dish washer, kitchen walls, were free of chipped and stains and dietary staff washed their hands before they handled clean equipment or food for 1 of 1 meal observed.

Inspectors wroteBased on observation, interviews, record review, and policy the facility failed to ensure bed linens were maintained in clean condition for two (Resident #28 and #36) of seven residents sampled for safe, clean, and comfortable homelike environment.

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure preadmission screening and resident review (PASRR) was completed for 1 (Resident #32) of 1 resident reviewed for preadmission screening due to diagnosis.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure family/responsible party and resident were included in the care plan process for 1 (Resident #47) of 1 resident reviewed for care plan meetings.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure treatment was provided for the left foot for 1 (Resident #47) of 1 resident reviewed for skin and wound treatments and care.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, it was determined that the facility failed to ensure the medication regimen was free from unnecessary medications without adequate indications for its use for 1(Resident #7) of 1 resident reviewed for unnecessary medications. Findings Included: Review of a facility policy titled, Medication Therapy Policy, no date indicated Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 2 meals observed.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined that the facility failed to ensure staff did not place dirty meal trays on the meal transport cart while clean trays were still on the metal transport cart being served to residents to avoid cross-contamination.

Inspectors wroteBased on record review, resident and staff interview, facility document review, and facility policy review, it was determined that the facility failed to provide quarterly statements of their trust account managed by the facility to the resident or their representative for 34 (Residents #1, 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, and 36) of 41 residents reviewed for trust account statements.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure residents were free of misappropriation of resident funds for 34 (Residents #1, 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, and 36) of 41 residents reviewed for misappropriation of resident funds.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the vent-a-hood in the kitchen was kept free of a buildup of grease, grime and debris which could result in improper functioning and/or fire resulting in serious injury, serious harm, serious impairment, or death. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility. The Administrator was notified of the Immediate Jeopardy on 12/06/23 at 05:02 PM. The facility also failed to ensure potentially hazardous items were stored in a secure location to prevent potential access by cognitively impaired, independently mobile residents for 1 (Resident #19/31) of 1 sampled resident; the mattress fit the bed for 1 (Resident #23) of 1 resident to prevent the potential for harm; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a clean condition to minimize the risk of food borne illness; food products were used or removed prior to their expiration dates/viability; hands were washed between clean and dirty tasks and prior to applying gloves; dishes and utensils were cleaned prior to being used for residents during meal service; and food was stored in a manner that was free of exposure/contamination due to the presence of insects or rodents. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility. The Administrator was notified of the Immediate Jeopardy on 12/06/23 at 05:02 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure essential equipment in the kitchen was maintained in safe, operational order to ensure food was kept at a safe temperature to minimize the risk of food borne illness. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility due to the potential risk for food borne illness The Administrator was notified on 12/6/23 at 5:02 PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident's dependent on staff for activities of daily living (ADLs), were provided assistance to protect and promote the rights and dignity of 2 (Residents #38 and #26) of 2 sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain a safe, functional, sanitary, and homelike environment for the residents to promote dignity and prevent the potential injury or spread of disease.

Inspectors wroteBased on interview and record review, the facility failed to code the Minimum Data Sets (MDS) accurately for 2 (Residents #14, and #35) to facilitate, plan, and provide necessary care, and to complete a medication self-administration assessment for 1 (Resident #14).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fingernails and toenails were trimmed for 1 (Resident #35) and chin hairs were removed for (Resident #19) to promote good hygiene and dignity.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician, to minimize the potential for hypoxia or other respiratory complications for 1 (Resident #31) of 1 sampled resident who had orders for oxygen therapy.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were not in a residents room and were stored in in a secure location for 1 (Resident #31) of 1 sampled resident and medications were not left unattended on top of the medication cart.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff changed gloves/washed hands between providing incontinent care and handling of clean items to reduce the potential for infection and failed to ensure dirty gloves and incontinent briefs were stored off of the shower floor to prevent cross-contamination and the potential spread of infection to other residents for 1 (Resident #26) of 1 sampled resident.

Inspectors wroteBased on observation, the facility failed to ensure handrails were securely attached to the wall to provide support and prevent potential resident injury on 1 (Hall 300) of 3 halls.