Lonoke Health and Rehab Center, LLC

Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure the minimum data set (MDS) accurately reflected on section A1500 the preadmission screening and assessment resident record (PASRR) a serious mental illness and/or intellectual disability affecting 2 (Residents #4 and #44) sampled residents with a level II PASRR.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan for 2 (Resident #26 and #44) of 3 sampled residents to ensure residents received appropriate care.

Inspectors wroteBased on observation, record review and interview, it was determined the facility failed to properly lift and lower residents with the legs open on a mechanical lift for 1 (Resident #28).

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that 2 (Resident #14 and #17) sampled resident received peri care in a manner that was sanitary to promote good hygiene and/or prevent infection.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to ensure oxygen was administered at the physician ordered rate for 2 (Resident #26 and #50) residents to prevent respiratory complications.

Inspectors wroteBased on record review and interviews, the facility failed ensure the system used for records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation was implemented for one (Resident #33) sampled resident.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written quantified recipe and menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 10 residents who received pureed diets and 17 residents who received enhanced food diets from 1 of 1 kitchen according to a list provided by the Dietary Manager on 07/23/2024 at 1:33 pm.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the nutritive value and flavor that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 9 residents who receive pureed meal trays from 1 of 1 kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 9 residents who received pureed diet.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure dirty trash cans were stored away from the food storage racks to prevent potential cross contamination, to ensure the ice machine and ice scoop were maintained in clean and sanitary condition to prevent potential growth of harmful bacteria that could be transferred to the residents food, failed to ensure opened food items in the refrigerator, freezer, and storage room were covered, sealed, and dated to maintain freshness and prevent potential cross contamination, that expired food items foods were promptly removed from stock to maintain freshness and prevent potential cross contamination, failed to ensure dietary staff practiced good hand washing techniques to potential cross contamination of food and clean dishes, and failed to ensure hot food item was maintained at the required temperature on the stove [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure staff used proper hand hygiene while providing peri care to 1 (Resident #17) sampled resident. The facility failed to provide hand hygiene during meal service to prevent cross contamination for 3 sampled (Residents #16, #24, #66).

Inspectors wroteBased on interviews and record reviews the facility failed to ensure quarterly statements were provided to residents who are their own trust account representative and to properly record each transaction for one (Resident #28) sampled resident. This practice has the potential to affect 20 sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure resident's personal and medical records were protected. This failed practice had the potential to affect all 75 residents.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to incorporate the PASRR level II evaluation into the care plan of 2 of 2 sampled (Resident #4, and Resident #44) to ensure residents received any recommended services.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement interventions put in place to prevent weight loss.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items stored in the refrigerator and freezer were covered and sealed; leftover food items were prepared and used to maintain food quality; dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen; 1 of 2 ice scoop holders and 1 of 2 ice machines were maintained in a clean and sanitary condition and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 64 residents who received meals from the kitchen (total census: 69) as documented on a list provided by the Dietary Supervisor on 06/29/23 at 8:33 AM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the enteral feeding bag and the water flush bag were dated and timed for 2 Residents, (Residents #4 and #25) and failed to ensure proper procedure was followed when attempting to resolve clogging prior to water flush and medication administration for 1 (Resident #22) of 3 (Residents #4, #22 and #25) sampled residents who received tube feedings according to a list provided by the Director of Nursing (DON) on 06/28/23 at 1:06 PM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written quantified recipe and menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 10 residents who received pureed diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 06/28/23.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that call light was within reach for 1 (Resident #25) of 5 (Residents #4, #25, #46, #49 and #62) sampled residents who resided on the 100 Hall and had the ability to utilize their call lights according to a list provided by the Administrator on 06/29/23 at 9:50 AM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff followed standard precautions for infection control during medication administration via peg tube to prevent potential spread of infection for 1 (Resident #22) of 3 (Residents #4, #22, and #25) sampled residents who received medications via peg tube according to a list provided by the Director of Nursing (DON) on 06/28/23 at 1:06 PM.