Barron Center

Inspectors wroteBased on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included but is not limited to, the attending physician, a registered nurse, a Certified Nurses Aid (CNA) with responsibility for the resident, a member of nutrition services and to the extent possible participation of the resident and/or his/her representative after each assessment for 6 of 21 reviewed for care planning. (Resident #6, #3, #5, #91, #99 and #8).1. On 8/18/25 at 10:59 a.m., during an interview, with Resident #6 and his/her representative, Resident #6 stated he/she is not aware of the meetings and I've never been invited. The resident representative stated the IDT's have We do it on the phone and it's been without [Resident #6]. Review of Resident #6's medical record, the surveyor noted IDT meetings held on 2/21/25 and 12/19/24. [...]

Inspectors wroteBased on observations, interviews, record reviews and facility policy review, the facility failed to maintain a sanitary environment for 2 of 3 residents reviewed for respiratory care. (Resident #6 & #64) The facility's policy Oxygen Use and Storage, dated 10/20/21, indicates that: A sanitary environment must be maintained to prevent the transmission of disease and infection. Oxygen tubing must be discarded and changed every two weeks, labeled with the date and staff initials. Nasal cannulas must be discarded and changed weekly, labeled with the date and staff initials. Staff changing the tubing or cannula must document the change on the Treatment Administration Record (TAR). On 8/18/25 at 11:52 a.m. Resident #64 was observed receiving oxygen via nasal cannula through an oxygen concentrator. [...]

Inspectors wroteBased on observations and interviews, the facility failed to adequately date and properly dispose of open medications according to manufacturer specifications and failed to ensure expired medications were removed from the supply available for use on 3 of 4 units observed (2 South, 2 North and 3 South).1. On 8/18/25 at 12:09 p.m., during review of 2 South Medication room with the Registered Nurse (RN) #1, the following was observed: one unopened, available for use, bottle of Naproxen Sodium with exp date of 5/2025. The refrigerator contained 2 opened and undated vials of Lantus insulin with manufactures directions of, Throw away any medicine that remains 28 days after first use and one opened and undated Basaglar insulin KwikPen with manufactures directions of, throw away the Pen you are using after 28 days, even if it still has insulin in it. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a safe and sanitary environment for food preparation and storage. Specifically, the facility did not consistently maintain temperature logs for kitchen equipment and food storage areas, failed to monitor tray line temperatures, neglected to check for outdated supplies in unit kitchenettes, and did not ensure cleanliness of food preparation equipment. Main Kitchen Refrigerator/Freezer Logs:On 8/18/2025 at 9:15 a.m., during the initial visit to the Kitchen, with the Director of Dietary Services, a surveyor observed no ongoing documentation of refrigerator/freezer temperatures in the main kitchen. The only record provided was a single sheet with the last entry dated 5/5/2025. The Director of Food Services confirmed the absence of current documentation. Dish Machine Temperature Logs:On 8/18/2025 at 11:00 a. [...]

Inspectors wroteBased on facility policy, observations, interviews and record reviews, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the use of Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) (Resident #118 and #6) for 1 of the 4 days of survey. (8/19/25)The facilities Infection Control: Standard and Transmission-Based Precautions & Enhanced Barrier Precautions policy and procedure last updated on 10/2023 states under Enhanced Barrier Precautions that targeted gown and gloves use during high contact resident care activities: dressing, bathing, showering providing hygiene, changing linens, toileting or care r/t wound care. For both active and colonized MDRO. When a resident has an indwelling medical device, i.e. [...]

Inspectors wroteBased on the facility's policy, record review, and interviews, the facility failed to investigate an allegation of potential misappropriation of a resident's loss of personal property, and failed to ensure that the facility's investigation was sent to the State Agency within 5 business days of the incident for 1 of 6 intake investigations reviewed during an annual survey. A review of the facility's policy, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, Section G. Reporting and Response, stated All allegations of abuse or neglect will be reported to the Administrator or designee at the time the allegation is made. The facility will: Immediately report all alleged violations to the administrator. Take all necessary actions as a result of the investigation, which may include, but are not limited to the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 4 sampled residents reviewed for new admissions (Resident #5). Resident #5 was admitted on [DATE] with a diagnosis of cerebrovascular accident with right arm flaccid paralysis, type 2 diabetes mellitus, lung mass, fracture of right humerus with delayed healing, dysphagia and recurrent fall. Review of the clinical record lacked evidence of a baseline care plan was completed within 48 hours to include the instructions necessary to properly care for Resident #5's immediate health and safety needs for the above concerns. The care plan was initiated on 7/3/25, 3 days after admission. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that a comprehensive plan of care was developed in the area of Multidrug-Resistant Organism (MDRO) and Preadmission Screening and Resident Review (PASRR) for 2 of 23 residents reviewed for comprehensive care plans. (Resident #6 and #9)1. On 8/18/25 and 8/19/25 observations of Resident 6's bedroom door with an Enhanced Barrier Precautions (EBP) sign posted on the door. The clinical record indicated he/she was re-admitted to the facility in April 2025 with a diagnosis of neurogenic bladder requiring a suprapubic catheter and a history of Extended-Spectrum Beta-Lactamase (ESBL), an MDRO, in the urine. The current care plan, last updated on 6/3/25, lacked evidence of goals and interventions relating to the use of EBP precautions and history of ESBL in the urine. 2. [...]

Inspectors wroteBased on record review, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to develop a Coronavirus (COVID-19) policy and procedure for COVID-19 vaccination, and failed to offer an updated 2024-2025 COVID-19 vaccination for 1 of 5 residents reviewed for immunizations (Resident #80).1. A review of the facility's policies and procedures for infection control lacked evidence of a COVID-19 policy and procedure regarding immunizations. On 8/20/25 at 11:00 a.m., in an interview with a surveyor, the Director of Nursing, confirmed she was unable to find a current policy and procedure regarding COVID-19 vaccinations.2. Clinical record review indicated R80, was admitted in March, 2025, and is currently [AGE] years old. R80's last documented COVID-19 vaccination was on 11/3/22. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that the Minimum Data Sets (MDS) 3.0 were coded accurately in the area of Active Diagnosis and Preadmission Screening and Resident Review (PASRR) for 2 of 21 sampled (Resident #6 and #9).1. On 8/18/25 and 8/19/25, Resident 6's bedroom door was observed to have an Enhanced Barrier Precautions sign posted on the door. Review of the clinical record indicated the resident was re-admitted to the facility in April 2025 with a diagnosis of neurogenic bladder requiring a suprapubic catheter and a history of Extended-Spectrum Beta-Lactamase (ESBL), a Multidrug-Resistant Organism (MDRO), in the urine. [...]

Inspectors wroteBased on Interviews and Record Review the facility failed to provide care, based on the comprehensive assessment and the resident's comprehensive person-centered care plan as outlined in the facility policy Comprehensive Person-Centered Care Planning for resident (Resident #1) resulting in an avoidable accident (fall) as reported in the facility reported incident of 1/17/25.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure expired medications, vaccinations, and point of care testing supplies were removed from the supply available for use in 1 of 8 medication carts, and 1 of 5 medication refrigerators. In addition, the facility failed to ensure vaccines were stored in a refrigerator without a freezer compartment for 1 of 5 medication refrigerators, and failed to provide evidence of temperature monitoring for medication refrigerators in accordance with United States Center for Disease Control and Prevention recommendations, for 4 of 5 medication refrigerators.

Inspectors wroteBased on interviews and record review and facility policy, the facility failed to ensure an injury of unknown origin was thoroughly investigated for 1 of 5 facility reported incidents reviewed. (#6).

Inspectors wroteBased on record reviews and interviews, and Facility Reported Incident review, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 5 sampled residents reviewed for falls (#6), and for 1 of 3 sampled residents reviewed for respiratory care (#47).

Inspectors wroteBased on observations, interviews, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to wound care for and proper placement of Foley bag (urine drainage bag) for 1 of 1 resident (#25).

Inspectors wroteBased on record review and interviews, the facility failed to issue a written transfer/discharge notice, which included information regarding appeal rights, and the name and address of the Office of the State Long-Term Care Ombudsman, to the resident or resident's representative for 1 of 3 sampled residents transferred/discharged by the facility to an acute care hospital (#3).

Inspectors wroteBased on clinical record review and interview, the facility failed to ensure that the Minimum Data Sets, version 3.0 (MDS) were accurately coded for 2 of 2 resident reviewed for smoking (#97 and #99)

Inspectors wroteBased on observation and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, day of the month, a breakdown of the number of registered and licensed nursing staff responsible for direct resident care and indicate which shifts the numbers corresponded to for facility census for 4 of 4 survey days.

Inspectors wroteBased on interviews and record review the facility failed to ensure that a resident requiring dialysis received services consistent with the professional standards of practice and the comprehensive person-centered care plan for 1 of 2 residents sample who receive dialysis services (Resident #95).