St. Johns Place of Arkansas, LLC

Inspectors wroteBased on interviews, record reviews, facility document review, facility policy review, it was determined that the facility failed to identify and act upon interruptions in monthly funds being deposited into a resident's trust fund after assuming responsibility to act as a fiduciary of the resident's funds for one (Resident #1) of three residents.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure proper hand hygiene was consistently implemented during incontinence care for one (Resident #54) of one resident reviewed for bowel and bladder incontinence.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure required components were included in the facility assessment dated [DATE].

Inspectors wroteBased on record review and interview, the facility failed to provide evidence that notice of transfers or discharges were sent to the state Ombudsman for residents transferred out of the facility to a local hospital for one (Resident #74) of two residents reviewed for hospitalization.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure foods stored in the freezer were covered and sealed to maintain freshness and decrease the potential for cross contamination who received meals from 1 of1 main kitchen; 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; hot food items were not maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 67 residents who received meals from the Kitchen (Total Census: 69), according to the list provided by the Dietary Manager on 06/12/2024 at 9:40 AM.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents with a trust account had access to their personal funds after business hours and on weekends. This failed practice had the potential to affect 64 residents who had trust accounts managed by the facility; and failed to ensure resident trust account funds were reimbursed back to the resident/resident representative within 30 days of discharge this failed practice affected one resident. 1. On 06/12/2024 at 9:50 AM, the surveyor asked Resident #38 who handles their money. Resident #38 indicated the facility. The surveyor asked Resident #38 if the resident was able to get money on the weekends? Resident #38 stated No, the [Business Office Manager (BOM)] goes to the bank on Tuesday, so we have to request money on Monday. 2. [...]

Inspectors wroteBased on observation, interviews and facility policy review, the facility failed to ensure activities were provided to the Residents on the secured unit despite having an activities calendar in place designed for Residents with cognitive impairment.

Inspectors wroteBased observations, interviews, and facility policy review, the facility failed to ensure medication carts were locked and secure when untended and out of the line of sight of the nurse and controlled medications were stored in separately locked, permanently affixed compartment in the refrigerator to prevent misappropriation of medications.

Inspectors wroteBased on observation, interviews and facility policy reviews, the facility failed to ensure 1 (Resident #44) sampled resident was not misdiagnosed with a psychological disorder and receive treatment with medication for a condition that was not present.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure a housekeeping cart used to store harmful chemicals was locked when not in use by staff.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure fluids were maintained within reach to promote good hydration for 1 (Resident #1) of 1 sample mix resident.

Inspectors wroteBased on observations, interviews, and facility policy reviews, the facility failed to ensure 1 (Resident #44) sampled Resident was free from unnecessary psychotropic medication.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 22 residents who received regular diets and 7 residents who received pureed diets as documented on a list provided by the Dietary Manager on 06/10/2024 at 9:40 AM.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the kitchen vents were cleaned to provide a sanitary environment for food preparation, the Dish Washing Room, kitchen walls, door frames and baseboards were free of rotten wood, the chipped walls were replaced, the food items stored in the refrigerator was covered or sealed to prevent potential food borne illness for the residents who received meal trays from I of I kitchen, and the ice machine and ice scoop holder were maintained in clean and sanitary conditions 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. These failed practices had the potential to affect 62 residents who received meals from the kitchen (total census: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that all essential areas of the building were in good repair. This failed practice had the potential to affect 61 residents who receive a meal tray from the kitchen, as documented on a list provided by the Assistant Director of Nursing (ADON) on 06/01/23 at 9:45 AM.

Inspectors wroteBased on observations, record review, and interview, the facility failed to follow Physician's Orders by changing the respiratory equipment weekly for 2 (Residents #8 and #33) of 8 (#8, #9, #12, #24, #26, #33, #39 and #54) sample mix residents that were reviewed for Oxygen therapy.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the fortified food was prepared and served according to the planned written Quantified recipe to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 29 residents who received fortified foods from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 06/02/23.

Inspectors wroteBased on record review, observation, and interview, the facility failed to maintain acceptable parameters for nutritional status for 1 (Resident #43) of 11 (#2, #7, #9, #25, #32, #35, #38, #39, #43, #48 and #49) sampled residents who are at risk for weight loss.