Pine Bluff Transitional Care

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the 400-hall shower room was maintained in a clean and sanitary condition for residents' use in one of four shower rooms located at the facility.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to store medications at proper temperatures to preserve the integrity of the medications for one of one medication refrigerator observed.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a resident received prescribed and requested pain medication for one (Resident #1) of one resident reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility had a full-time Director of Nursing (DON) to promote effective leadership and nursing care oversite, with the potential to affect all 60 residents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure an allegation of physical abuse was reported to the State Survey Agency within the required timeframe of two hours for 1 (Resident #15) of 2 residents reviewed for physical abuse allegations.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure hand hygiene was performed to prevent cross contamination and the risk for infection during incontinence care for one (Resident #15) of one resident reviewed.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure residents on the secure unit were free from abuse and failed to develop and implement an effective plan to ensure a resident (Resident #6), with a history of aggressive behaviors, did not initiate altercations with other residents on the secure unit. This resulted in multiple altercations, putting all residents on the secure unit at risk for serious harm, serious injury, serious impairment, or death. The Immediate Jeopardy (IJ) began on 04/09/2025 at 07:15 PM, when it was discovered that Resident #6 did not have adequate measures or interventions in place to protect the other residents on the secure unit from altercations. The IJ template was presented to the Administrator on 04/09/2025 at 07:15 PM by the survey team.

Inspectors wroteBased on observations, interviews, record review, and facility policy review the facility failed to ensure entrance/exit doors to the secured unit were functioning properly to safeguard residents on the secured unit and prevent resident on the secured unit from eloping from the facility. The facility to ensure Resident #3 had a wander guard in place at all times, as part of the facility plan to safeguard the resident from eloping from the facility without staff knowledge. The facility failed to ensure Resident #3 did not elope from the facility. These findings have been determined to have resulted in Immediate Jeopardy as defined at 42 CFR §488.301. The Administrator was informed of the Immediate Jeopardy on 04/09/2025 at 11:25 AM. The facility provided a plan of removal on 04/09/2025 and was approved on 04/17/2025 at 03:05 PM.

Inspectors wroteBased on interviews, record review, and facility policy review the facility failed to ensure that the facility was sufficiently staffed to ensure residents residing in the facility received quality of care. This failed practice had the potential to affect every resident residing in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to report to the State Survey Agency an elopement for 1 (Resident #3) of 3 sample residents reviewed for elopement risk and failed to report altercations between residents that resulted in injury or had the potential to result in injury for 4 (Resident #1, #6, #12, #13) of 7 sample residents reviewed for abuse.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that physician's orders for wound care were followed for 2 (Resident #17, Resident #18) of 2 sampled residents reviewed for facility acquired pressure ulcer/injuries.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen was free of pests; kitchen floor was free of dirt and, grease; food items stored in the refrigerator and freezer were covered, sealed, and dated; leftover foods were used in a manner to maintain food quality; expired dairy products was promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; ice machine was maintained in clean and sanitary condition and dietary staff washed their hands before handling clean equipment when contaminated, dairy product was maintained at 41 degrees Fahrenheit or below and hot food items were maintained at above 135 degrees Fahrenheit on the steam table.

Inspectors wroteBased on interview, the facility failed to develop and implement a facility assessment. This failed practice had the potential to affect all the residents residing in the facility. The total census was 63.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the antibiotic stewardship program was consistently implemented for 1 (Resident #13) sampled resident who was taking an antibiotic.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure an individual was designated as the Infection Preventionist (IP), who had time to monitor and manage the infection prevention and control program.

Inspectors wroteBased on observation, interviews, record review, facility document review, facility policy preview, it was determined the facility failed to ensure residents were provided privacy during care provided for surgically created airway (tracheostomy/trach) care for 1 (Resident #13) of 1 sample mix resident; and to ensure collection bags for resident's indwelling catheters are kept in a privacy bag for 1 (Resident #216) of 1 sample mix residents.

Inspectors wroteBased on record review, interview, facility document review, facility policy review, it was determined that the facility failed to ensure an incident of an injury of unknown source was reported to the Administrator within 2 hours of discovery, which resulted in a delay in initiating an investigation and protective measures, and in reporting to the Office of Long-Term Care (OLTC) and other agencies in accordance with state law for 2 (Resident #50 and #59) of 2 (Residents # 50, and #59) sample mix residents.

Inspectors wroteBased on record review, interview, facility document review, and facility policy review, it was determined the facility failed to ensure an incident of an injury of unknown origin was immediately and thoroughly investigated, failed to ensure protective measures were consistently implemented and maintained for 2 (Resident #50, and #59) of 2 sample mix resident investigated.

Inspectors wroteBased on facility document review and interview, it was determined the facility failed to electronically transmit encoded accurate and complete Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days to provide accurate and up-to-date information for quality measures for 2 (Residents #215, #47) of 2 sampled residents whose MDS assessments were reviewed.

Inspectors wroteBased on record review, interview, facility document review, facility policy review, it was determined that the facility failed to ensure physician's orders were followed for 1 (Resident #16) of 1 sample mix resident with a wound and orders for skin evaluations weekly; to accurately assess the quarterly Minimum Data Set (MDS) to reflect to accurate drug class for the medication Risperdal for 1 (Resident #8) or 1 sample mix residents.

Inspectors wroteBased on observation, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure the comprehensive care plan addressed individualized appropriate care and services for 4 (Resident #45, #13, #35, #21) of 4 sample mix residents reviewed for care plan.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were revised to reflect the most recent care needs for 3 (Residents #13, #16, and #21) sampled residents whose care plans were reviewed.

Inspectors wroteBased on observation, interview, record review, facility document review, facility policy review, the facility failed to ensure female residents had hair removed from their face for 1 (Resident #35) of 1 sample mix resident to promote good hygiene; ensure male residents had been kept clean shaved for 1 (Resident #45) of 1 sample mix residents to promote good grooming; and to ensure that 1 (Resident #32) of 1 sample mix residents received regular scheduled baths and/or showers .

Inspectors wroteBased on observation, interview, record review, and facility document review, it was determined the facility failed to ensure residents who have physician orders for weekly skin evaluations had their skin evaluated for 4 (Resident #13, #35, #63, #366) of 4 sample mix residents with orders for weekly skin evaluations; and to ensure residents with a contracture had a treatment in place to prevent further decline in accordance with professional standards of practice for 1 (Resident #13) of 1 sample mix residents.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure a mechanical lift was properly used to for 1 (Resident #21) sampled resident reviewed for mechanical lift transfer, and failed to ensure residents were assessed to smoke during the facility designate smoke break times for 1 (Resident #13) of 1 sample mix resident reviewed for smoking.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy reviews the facility failed to ensure incontinence care was provided in a clean and sanitary manner to promote cleanliness for 2 (Resident #32 and #33) sampled residents.

Inspectors wroteBased on observation, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure surgically created airway/ tracheostomy care was provided as physician ordered to prevent possible respiratory infections for 1 (Resident #13) of 1 residents with a tracheostomy; to ensure respiratory supplies were properly stored and readily available for 2 (Resident #13, #32) for 2 sample mix residents.

Inspectors wroteBased on interviews and facility policy review the facility failed to ensure the facility had full-time Director of Nursing (DON) coverage.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure daily staffing was posted visible for resident and visitor with all the required components.

Inspectors wroteBased on record review, and interview, the facility failed to accurately account for a controlled medication after administration for 1 (Resident #50) resident who was reviewed for pharmaceutical services and failed to ensure pharmaceuticals available for the residents during medication administration were dispensed with the accurate dosage for 1 (Resident #63) sampled resident reviewed for medication dosages.

Inspectors wroteBased on record review and interview, the facility failed to ensure a pharmacist recommendations for psychotropic medications were addressed for 3 (Residents #8, #50 and #57) sampled residents reviewed for medication regimen review recommendations.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5 percent (%) during the medication administration observation of 4 (Residents #31, #36, #37 and #54) of 4 sampled residents who received medications from 1 Registered Nurse (RN) and 1 Licensed Practical Nurse (LPN). 29 opportunities of medication administration were observed and 7 of the 29 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 24.14%.

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 1 meal observed.

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 residents who required pureed diets for 1 of 1 meal observed.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure enhance barrier precautions were consistently implemented during care for 1 (Resident #31) sampled resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube; failed to ensure a water management program included the necessary components; failed to ensure laundry was transported in a manner to decrease the potential for contamination; failed to ensure the required personal protective equipment (PPE) was used during a resident care activity for 2 (Residents #33 and #35) sampled residents: Resident #33, during incontinent care and Resident #35, during care of and opening in the neck leading to the wind pipe (Tracheostomy); [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a pneumococcal vaccine was provided for 1 (Resident #59) of 5 (Resident's #13, #16, #31, #33, and #59) sampled residents and failed to provide documentation of education provided to a resident after an influenza vaccination was declined for 1 (Resident #33) of 5 (Resident's 13, #16, #31, #33, and #59) sample residents reviewed for immunizations.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure 1 (Resident #265) sampled resident was safe to self-administer medications.

Inspectors wroteBased on interviews and facility policy review, the facility failed to ensure residents received mail on Saturdays.

Inspectors wroteBased on record review and interview, the facility failed to notify the Ombudsman of a resident's transfer to the hospital for 1 (Resident #57) sampled resident reviewed for hospitalization.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to complete timely quarterly assessments for 1 (Resident #215) of 1 sampled resident reviewed for resident assessments.

Inspectors wroteBased on record review, interview, facility document review, and facility policy review, it was determined that the facility failed to ensure physician's orders were followed for 1 (Resident #16) of 1 sample mix resident with a wound and orders for skin evaluations weekly.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a Percutaneous Endoscopic Gastrostomy (PEG) tube was properly checked for placement before fluids and medications were administered, and failed to ensure the enteral feeding rate was set per the physician's orders for 1 (Resident #31) sampled resident reviewed for enteral feeding.

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure Monthly Medication Regimens (MMR) were completed at least monthly for 1 (Resident #8) sampled resident.

Inspectors wroteBased on observations, interviews, record review, and the facility failed to ensure care and services were provided to prevent pressure ulcer development for 2 (Residents #10 and #11) of 3 sampled residents reviewed for pressure ulcers and/or skin concerns. Specifically, the facility failed to monitor the resident's skin by not following physician orders for dressing changes.

Inspectors wroteBased on observation and interview, the facility failed to ensure a Director of Nursing (DON) was employed full-time.

Inspectors wroteBased on observations, interviews, document review, and policy review, the facility failed to maintain an effective pest control program throughout the entire facility and in one of one kitchen as evidenced by the presence of flies in the kitchen, dining room, resident rooms, as well as hallways.

Inspectors wroteBased on interview and record review the facility failed to ensure a discharge summary was completed on 1(Resident #3) of 4 (Resident #3, Resident #4, Resident #5, and Resident 8) discharged sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to ensure food was served in a timely manner for 1 (Resident #5) of 2 (Residents #5 and #6) sampled residents observed in the dining room.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to keep smoking materials secured and provide adequate supervision during all smoke breaks to prevent potential injury for one (Resident #1) of one sampled resident reviewed for smoking.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who had Medicaid coverage with Trust Funds managed by the facility were able to have funds available on the weekends and after hours. The failed practice had the potential to affect 52 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who receive Medicaid benefits and/or their responsible parties were notified when the amount in their resident Trust Fund account was within $200 of the maximum Medicaid limit for 12 Residents sampled.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) worked at least 8 consecutive hours a day, 7 days a week, each week. The failed practice has the potential to affect 69 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure completion and follow up on the pharmacy medication regimen review [MRR] recommendations for four (Resident #17, #18, #20, and #185) of four (Resident #17, #18, #20, #185) sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure food item stored in the refrigerator and freezer were covered, sealed, and dated; leftover foods were used in a manner to maintain food quality; expired dairy products was promptly removed / discarded on or before the expiration or use by date to prevent the growth of bacteria; [...]

Inspectors wroteBased on interview and policy review, the facility failed to develop and implement a Quality Assurance Performance Improvement (QAPI), plan that includes identification of problems, implementation of corrective actions, documentation, review, analyze and tracking of the data.

Inspectors wroteBased on observation and interview the facility failed to ensure that staff wore Personal Protective Equipment (PPE) in the transmission-based precaution rooms for 2 residents (#184, #226); the facility failed to have proper signage on isolation room [ROOM NUMBER] and failed to clean the glucometers according to the manufactures guidelines on hall 200 which had the ability to effect (11) residents who reside on the hall.

Inspectors wroteBased on interview and record review the facility failed to screen, educate, and offer Covid-19 immunization and to maintain documentation for facility staff and residents. This failed practice had the potential to affect all residents who reside in the facility and all staff employed by this facility. On 11/29/2023 at 3:30 PM RN #1 stated they did not have documentation for Covid 19 immunizations given to any of the residents. On 11/29/23 03:47 PM when asked about Covid 19 education and vaccine for staff, the Administrator stated, We have not been doing this, we were unaware this was still a requirement since the pandemic is over. When asked for a Covid 19 vaccine policy RN#1 stated she was unable to find it.

Inspectors wroteBased on interview and record review, the facility failed to ensure regulated in-services were provided.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate/comfortable water temperatures in two (Hall 400 and Hall 600) of four (Hall 200, Hall 400, Hall 500, and Hall 600) bathing areas. The failed practice had the potential to affect 67 residents who have the potential to be bathed/showered on Hall 400 or 600.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents were assessed for smoking, that oxygen was maintained securely in a safe manner and hazardous chemicals were secured in a locked container.

Inspectors wroteBased on observation record review, and Interview, the facility failed to ensure Psychotropic medications had an appropriate diagnosis for 1 of 1 sampled Resident (#20 and #185).

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 2 of 2 meals observed. These failed practices had the potential to affect 6 residents who received mechanical soft diets and 8 residents who received pureed diets and residents who received fortified foods from the kitchen according to a list provided by the Assistant Dietary Supervisor (DS).

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 residents who required pureed diets for 3 of 3 meals observed. This failed practice had the potential to affect 8 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure resident received physician ordered Fortified foods for 1 (Resident #21) sampled resident who were to receive fortified foods. This failed practice had the potential to affect 22 residents, who required fortified foods with all meals, as identified by a list provided by the Certified Supervisor on 11/28/2023 at 10:01 AM.

Inspectors wroteBased on interview and record review the facility failed to provide influenza and/or pneumococcal immunizations as required or appropriate for residents. This failed practice had the potential to affect all 70 residents who reside in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an effective pest control program was maintained to keep the facility free of pests. This failed practice had the potential to affect 69 residents according to the list provided by the Dietary Supervisor on 11/28/2023.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure activities were regularly provided, resident activity participation was regularly evaluated and documented, and plans for activities were revised to meet residents' individual interests and needs to promote quality of life for 1 (Residents #2) of 14 residents who required 1:1 activities.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing, nasal cannulas, and humidified water were properly changed, dated, and bagged in a closed container to prevent infections for 1 resident (#239) who received oxygen, and the facility failed to ensure nebulizer mask was contained and bagged properly.

Inspectors wroteBased on interview, the facility failed to ensure a policy was developed regarding use and storage of foods that were brought to residents by family and other visitors, to ensure safe and sanitary storage, handling, and consumption for the residents who resided in 1 of 1 facility. This failed practice had the potential to affect 11 residents who had food brought in by family.

Inspectors wroteBased on observation, interview and record review, the facility failed to update resident assessments for three (R#1, #2 and #3) of three (R#1, #2 and #3) sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement an individual care plan for three (Resident #1, #2 and #3) of three (Resident #1, #2 and #3) sampled residents.