Pine Bluff Transitional Care

In the surveyor’s words

From the most serious findings on record at Pine Bluff Transitional Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 18, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Apr 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF727Jun 16, 2025

  Based 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. The findings include: A review of the Facility Assessment, dated 06/2025, revealed the DON position was documented as vacant. During an interview on 06/10/2025 at 1:20 PM, the Administrator said, we do not have a DON. The Administrator also stated they were not sure when the DON left the facility, and that nobody was working in the role as the DON at this time. […]

• No harm, potential for more than minimal, widespreadF725Apr 18, 2025

  Based 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. The finding include: A review of the facility assessment and after an interview with the Administrator it was brought to our attention that the facility staff plan was for a full-time Director of Nursing (DON) and Assistant Director of Nursing (ADON), 2-3 charge nurses for each shift LPN/RN, 15 staff members on the day shift 7a-3p, 9 Certified Nursing Assistants only on the evening shift, and 8 staff members on the night shift. […]

• No harm, potential for more than minimal, widespreadF812Oct 14, 2024

  Based 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. The findings are: 1. […]