PINE BLUFF, AR- TRINITY VILLAGE MEDICAL CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following highlighted decencies listed below were found in a public survey.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observation and interview, the facility failed to ensure potentially hazardous material was stored in a secured manner for 1 (Resident #8) of 1 sampled resident.

Honor the resident’s right to organize and participate in resident/family groups in the facility.

Based on interviews, and review of Resident Council Meeting Minutes, the facility failed to ensure resident concerns and complaints were allowed to be voiced through grievances for 5 (Resident #1, #7, #10, #47, and #51) 5 sampled residents.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on observation, interview, and record review, the facility failed to promptly notify the responsible party/family member of changes in condition and transfer to the hospital for 1 (Resident #11) of 1 sampled resident.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Based on observation, interview, and record review, the facility failed to ensure weekly skin assessments were conducted for 1 (Resident #44) of 1 sampled resident.

Provide enough food/fluids to maintain a resident’s health.

Based on observation, interview, and record review the facility failed to ensure residents who received nutrition and hydration through percutaneous gastronomy (PEG) tube received care and services to prevent the potential of dehydration for 1 (Resident #38) of 1 sampled resident.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a secure location under the manufacturer’s specified conditions, to prevent accidental ingestion and possible injury.

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, interview and record review, the facility failed to ensure food was prepared and served in accordance with the planned, written menu and recipe to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 65 residents who received a diet from the kitchen according to the list provided by the dietary manager dated 8/24/2023.

Have a plan that describes the process for conducting QAPI and QAA activities.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with distributing and serving food in a sanitary manner, and with the implementation of Infection Control procedures. These failed practices had the potential to affect 65 residents who receive trays in the facility as identified on the Resident Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 08/21/23.