The Springs of Pine Bluff

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that the kitchen air vent was cleaned; the kitchen floor was free of chips, debris, dirt, rust, and stains, and floor tiles were replaced; food items stored in the freezer were covered or sealed; the ice machine was maintained in a clean and sanitary condition in one of one kitchen, and dietary staff washed their hands before handling clean equipment or food items for two of two meals observed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure nail care was provided for one (Resident #5) of one resident reviewed for nail care and failed to ensure a bath or shower was provided for one (Resident #386) of one resident reviewed for baths/showers.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident and resident representative were included in care planning meetings for one (Resident #63) of one resident, reviewed for care plan meetings and failed to ensure a care plan was revised to reflect the code status of Do Not Resuscitate (DNR) for a resident under hospice care for one (Resident #63) of one resident reviewed for hospice care.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the necessary care and services were provided to a resident with a non-pressure related skin issue for one (Resident #1) of two residents reviewed for non-pressure related skin issues.

Inspectors wroteBased on interviews and record review the facility failed to ensure one (Resident #62) of five residents reviewed for medications did not receive an unnecessary medication.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure required vaccinations were administered to three (Resident #6, #52, and #63) of five sampled residents reviewed for immunizations.

Inspectors wrote[NAME] Deputy Based on observation, record review, review of the glucometer manual, review of facility policies, and staff interviews, the facility failed to ensure staff performed proper handwashing, adhered to Enhanced Barrier Precautions (EBP), and correctly disinfected the facility glucometer for two (Resident #2 and #7) of seven residents sampled for infection control.

Inspectors wroteBased on observation and interview, the facility failed to ensure 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; ceiling tiles door frames and floor tiles were free of chips, stains and rust and were maintained in clean sanitary conditions, foods stored in the dry storage area refrigerator and freezer were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; foods were dated when opened to assure first in, first out usage to prevent potential for food bone illness; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were stored in the med cart with identifiers on the medication cup to identify the resident or to identify the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meal observed. This failed practice had the potential to affect 16 residents who receive meal trays in their rooms on the 100 Hall, 8 residents who receive meal trays on the 200 hall, 16 residents who receive meal trays in their room on the 300 hall, 11 residents who receive meal trays in their room on 400 Hall, 8 residents who receive meal trays in their room on 500 Hall.

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 2 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Personal Protective Equipment (PPE) was used before entering a room labeled as contact precautions to decrease the potential for cross contamination for 1 (Resident #172) of 1 sampled resident who had contact isolation precautions in place.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not self-administered without a physician order and an interdisciplinary team (IDT) assessment that determined it was safe for 1 (Resident #275) of 1 sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fingernails were cleaned to promote good personal hygiene and grooming for 1 (Resident #28) of 1 sampled resident who required assistance with nail care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary catheter tube was not directly touching the floor to decrease the potential for contamination or trauma for 1 (Resident #172) of 1 sampled resident who had a urinary catheter in place.

Inspectors wroteSurveyor: [NAME], [NAME] Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status at the time of assessment for 2 (Resident #1 and #48) of 25 (Residents #1, #2, #5, #8, #11, #15, #16, #24, #25, #26, #27, #28, #31, #33, #37, #38, #42, #43, #48, #58, #61, #62, #63, #64 and #120) sampled residents whose MDSs were reviewed

Inspectors wroteBased on observation, interview, and record review the facility failed ensure care plans were reviewed and revised to include risks, goals, and interventions for 1 (Resident #1) of 2 (Residents #1 and #62) sampled residents who were at risk for elopement and 1 (Resident #48) of 6 (Residents #2, #15, #38, #48, #63 and #120) case mix residents who had pressure ulcers according to the lists provided by the Director of Nursing (DON) on 03/24/23 at 8:51 AM.

Inspectors wroteBased on interview, and record review, the facility failed to ensure assessments and monitoring were conducted and documented in accordance with accepted standards of nursing practice for 2 (Residents #1 and #48) of 17 (Residents #1, #2, #8, #25, #31, #37, #42, #43, #45, #47, #48, #58, #62, #63, #64, #68 and #120) sampled residents who required quarterly assessments.

Inspectors wroteBased on observation, and interview, the facility failed to ensure a clean, homelike environment was maintained for 1 (Resident #28) of 25 (Resident #1, #2, #5, #8, #11, #15, #16, #24, #25, #26, #27, #28, #31, #33, #37, #38, #42, #43, #48, #58, #61, #62, #63, #64 and #120) sampled residents whose rooms were observed.