Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Barnes Healthcare during CMS and state inspections, most recent first.
A facility failed to accurately complete MDS assessments, leading to incorrect documentation of medication use and diagnoses for several residents. Errors included misclassification of NSAIDs as anticoagulants, incorrect recording of weight changes, and failure to assess a resident for smoking. These inaccuracies could affect medication administration and care plans.
The facility failed to complete PASRRs for three residents with mental health diagnoses, including schizophrenia and schizoaffective disorder, prior to their admission. The MDS Coordinator and DON confirmed the lack of necessary documentation and submission of Level II PASRRs, indicating a deficiency in the facility's preadmission screening process.
The facility failed to document and complete person-centered care plans for several residents, leading to deficiencies in care and safety. A resident with severe cognitive impairment and a history of falls did not have updated interventions in their care plan following multiple falls. Another resident's care plan was missing critical information, such as medication warnings and diagnoses. Observations revealed a lack of necessary documentation and interventions in care plans, highlighting systemic issues in care planning and documentation.
The facility failed to conduct smoking assessments for two residents, one with COPD and another with cognitive impairment, both observed smoking without aprons. A resident with contractures was not provided with a hand roll as required, and a resident with psoriasis did not receive the specialized shampoo ordered. The DON confirmed these deficiencies.
A resident with Down syndrome, seizures, and dysphagia experienced significant weight loss due to inadequate nutrition and hydration in an LTC facility. The facility's policy required assistance with meals, but documentation revealed numerous instances of missing records for eating, fluids, and supplements. Interviews with staff highlighted gaps in communication and documentation practices, with the DON acknowledging the importance of accurate records for resident health.
The facility was found deficient in maintaining proper food storage and hygiene practices. Observations revealed uncovered and undated food items in the freezer, improper storage of soy sauce, and unsanitary kitchen conditions. Dietary staff failed to follow hand hygiene protocols, handling clean equipment and food without washing hands after contamination. These actions violated the facility's policy on preventing foodborne illness.
The facility failed to maintain clean bed linens for two residents, leading to a deficiency in providing a safe, clean, and comfortable environment. One resident had a bed with a dried yellowish-brown stain, while another had a bed with various unknown substances and stains. Staff interviews confirmed that linens are usually changed on shower days or when soiled, but the linens in these cases were not changed despite being visibly dirty. The DON and Administrator acknowledged the oversight.
A facility failed to complete a Preadmission Screening and Resident Review (PASRR) for a resident with schizophrenia, vascular dementia, and other mental health diagnoses. The resident was admitted without a proper PASRR, and the facility lacked a policy for conducting these assessments. The Director of Nursing confirmed the oversight, and the resident's care plan did not address PASRR, despite severe cognitive impairment noted in assessments.
A facility failed to include a resident with severe cognitive impairment and their family in the care planning process. Despite the resident's complex medical conditions, there was no documentation of family invitations or meeting notes, and the facility lacked a policy for care planning. Staff interviews confirmed the absence of records and involvement, leading to the deficiency.
A facility failed to provide appropriate foot care treatment for a resident with a history of down syndrome and other conditions. Despite an order for Povidone-Iodine solution to be applied to the resident's left foot toenails daily, the treatment was only documented once, and there was no further documentation from February to May. The DON could not explain the lack of documentation, and the care plan did not include interventions for the toenail treatment.
A facility failed to ensure a resident's medication regimen was free from unnecessary medications without adequate indications for use. The resident, with chronic kidney disease stage 3, had three medications prescribed without proper indications documented. The MDS Coordinator highlighted the importance of linking medications to diagnoses to ensure appropriate care.
The facility did not adhere to the planned menu, serving incorrect portions and omitting items for residents on special diets. A dietary staff member used a #12 scoop instead of the required 4 ounces for yogurt baked chicken and did not serve a pureed dinner roll, with no substitutions provided. Staff admitted to not reviewing the menu to ensure correct serving sizes.
A CNA placed dirty meal trays on a cart with clean trays during meal service, violating infection control protocols. The DON confirmed this practice as an infection control issue, contrary to the facility's policy requiring staff training to prevent cross-contamination.
The facility failed to provide quarterly trust account statements to 34 residents, as required by their policy. Interviews revealed that several residents did not receive these statements, and the Director of the Business Office Manager confirmed the oversight. One resident reported difficulty accessing funds for nearly a year, and another had to repeatedly request account balances. This indicates a systemic issue in managing resident trust accounts.
A facility failed to protect residents from misappropriation of funds, affecting 34 residents. Staff mishandled funds, leading to fraudulent charges totaling $181,384.19. Residents reported not receiving quarterly statements and difficulties accessing their funds, with discrepancies in amounts received. The facility's lack of audits and oversight allowed the issue to persist.
Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for several residents, leading to incorrect documentation of medication use and diagnoses. For instance, Resident #5 was documented as using an anticoagulant, but the medication was actually an antiplatelet. Similarly, Resident #25 and Resident #16 were also incorrectly coded for anticoagulant use when they were on NSAID medications. These inaccuracies in the MDS could potentially affect the administration of medications and the overall care plan for these residents. Resident #27's MDS was marked incorrectly for both anticoagulant and hypnotic use. The resident was actually taking an NSAID for cerebral infarction and an over-the-counter supplement for insomnia, neither of which were accurately reflected in the MDS. Additionally, Resident #41 was documented as having a significant weight loss and anticoagulant use, but the resident had actually experienced a weight gain and was on an NSAID for DVT prophylaxis. These errors in the MDS could lead to inappropriate care interventions and monitoring. Furthermore, Resident #14 was not assessed for smoking, despite having a care plan that indicated a risk for potential injuries related to smoking. The MDS did not reflect the resident's tobacco use, which was confirmed by the Director of Nursing and the MDS Coordinator. Resident #22 was also incorrectly documented as having schizophrenia instead of schizoaffective disorder. These documentation errors highlight a lack of accuracy in the facility's assessment processes, which could impact the residents' safety and care management.
Failure to Complete PASRR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) was completed prior to admission for three residents, leading to deficiencies in providing the necessary care and services in the most appropriate setting. Resident #16 was admitted with diagnoses of schizophrenia and intellectual developmental disorder (IDD), but there was no documentation of a Level II PASRR or exemption in the electronic chart. The MDS Coordinator confirmed that the last PASRR documentation was from 2018, and the Director of Nursing (DON) acknowledged that a PASRR should have been submitted for the resident's schizophrenia diagnosis. Resident #22 was admitted with a diagnosis of schizoaffective disorder, but similar to Resident #16, there was no documentation of a Level II PASRR or exemption. The MDS Coordinator indicated that the last PASRR documentation was from 2018, and the DON confirmed that a PASRR should have been submitted for the resident's schizoaffective diagnosis. This lack of documentation and submission of PASRRs indicates a failure in the facility's process for ensuring appropriate preadmission screening. Resident #32 was admitted with multiple diagnoses, including schizophrenia and vascular dementia, but the PASRR documentation indicated the resident was a non-PASRR client, with only a diagnosis of mild neurocognitive disorder. The DON confirmed that no PASRR had been completed after the initial determination, despite the resident's admission with significant mental health diagnoses. This oversight in the PASRR process for Resident #32 further highlights the facility's failure to comply with regulatory requirements for preadmission screening and resident review.
Deficiencies in Care Planning and Documentation
Penalty
Summary
The facility failed to document and complete person-centered care plans for several residents, leading to deficiencies in care and safety. Resident #32, who had severe cognitive impairment and a history of falls, did not have updated interventions in their care plan following multiple falls. The care plan lacked immediate action interventions for falls that occurred on specific dates, and there were no tasks developed for fall interventions in the resident's daily living task list. Resident #22's care plan was missing critical information, such as the medication and black box warning for a diuretic, as well as the diagnosis of edema and schizoaffective disorder. Similarly, Resident #27's care plan did not include black box warnings for medications, and there was a lack of documentation regarding contracture management, despite the resident having a contracture in the left hand. Observations revealed that the resident did not have a hand roll or device in place, and refusals to use the hand roll were not documented or reported to the nurse. Resident #3's care plan was outdated, noting discontinued psychotropic medications and lacking black box warnings for current medications. Resident #7's care plan also failed to reference black box warnings or symptoms to monitor. Resident #14, who had a history of repeated falls, did not have fall interventions listed on the care plan for numerous falls, and no interventions were observed in the resident's room. Interviews with staff confirmed the absence of necessary documentation and interventions in the care plans, highlighting a systemic issue in care planning and documentation within the facility.
Deficiencies in Smoking Assessments, Contracture Care, and Shampoo Use
Penalty
Summary
The facility failed to ensure that residents who smoke have a smoking assessment, as evidenced by the cases of two residents. One resident, diagnosed with chronic obstructive pulmonary disease (COPD), was observed smoking without a smoking apron and had no smoking assessment documented. Another resident with moderate cognitive impairment and a history of smoking inside the building was also observed smoking without a smoking apron, and no recent smoking assessment was completed. The Director of Nursing confirmed that smoking assessments were not conducted as required. Additionally, the facility did not ensure the use of hand rolls for a resident with contractures. This resident, who had severe cognitive impairment and a history of cerebral infarction, was observed multiple times without a hand roll or device in their left hand, despite care plan interventions requiring its use. The certified nursing assistant acknowledged the resident's refusal to use the hand roll but did not document these refusals or report them to the nurse. Furthermore, the facility failed to use specialized shampoo as ordered for a resident with psoriasis. The resident's care plan required the use of ketoconazole shampoo during showers, but the Treatment Administration Record showed no documentation of its use. The Director of Nursing and the Treatment Nurse confirmed that the shampoo should have been used and documented during showers, but this was not done.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to provide adequate nutrition and hydration for a resident, identified as Resident #47, who was dependent on staff for assistance with meals. The resident, who had diagnoses including Down syndrome, seizures, abnormal weight loss, and dysphagia, experienced significant weight loss from 170.4 pounds to 124.8 pounds over a period of several months. The facility's policy required that residents receive assistance with meals to meet their individual needs, but documentation revealed numerous instances where nutrition and hydration tasks were not recorded. Specifically, there were 18 instances of missing documentation for eating, 17 for fluids, and 15 for supplements in May 2024. Additionally, snacks were only documented as being offered six times. Interviews with facility staff, including an LPN, a CNA, and the DON, highlighted gaps in communication and documentation practices. The LPN noted that CNAs were responsible for documenting nutrition and hydration, but nurses did not have access to this charting unless an alert was triggered. The CNA emphasized the importance of documentation for alerting nurses to potential issues, while the DON acknowledged the missing documentation and its importance for resident health and well-being. The DON also noted that the resident preferred snack foods over meals from the kitchen and had stopped eating prior to discharge.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to maintain proper food storage and hygiene practices in the kitchen, leading to several deficiencies. Observations revealed that various food items in the freezer and storage areas were not covered, sealed, or dated, including hamburger patties, catfish, cod fish, veggie sausage, black bean burgers, biscuits, dinner rolls, and a vegetable blend. Additionally, an opened gallon of soy sauce was not refrigerated as per the manufacturer's specifications. The kitchen environment was also found to be unsanitary, with chipped and stained walls and floors, loose ceiling tiles, and a missing floor tile near the dishwashing machine. Furthermore, the ice machine in the breakroom had a layer of black and gray residue, which was used by CNAs and kitchen staff for resident beverages. The facility's dietary staff failed to adhere to proper hand hygiene practices, as observed during meal preparation. Dietary staff members were seen handling clean equipment and food without washing their hands after touching contaminated surfaces. This included instances where staff members touched dirty objects, such as oven doors and cartons of drinks, and then handled clean equipment or food items without washing their hands. The facility's policy on preventing foodborne illness, which requires employees to wash their hands before handling food and after engaging in activities that contaminate the hands, was not followed. These lapses in hygiene and food safety practices contributed to the deficiencies identified during the survey.
Failure to Maintain Clean Bed Linens for Residents
Penalty
Summary
The facility failed to maintain clean bed linens for two residents, leading to a deficiency in providing a safe, clean, and comfortable homelike environment. Resident #28, who has diagnoses of bipolar disorder, depressive episodes, stroke, and psychosis, was observed with a dried yellowish-brown stain in the center of their bed linen. Resident #36, diagnosed with Alzheimer's disease, dementia, and schizophrenia, had a bed covered with a blue bedspread that had a white unknown substance scattered on top, a dried smeared white stain on a folded blue blanket, and brownish stains along the middle third of the linen. Additionally, the second bed in Resident #36's room contained unknown substances of black and brown specks and black spots scattered along the bed. Interviews with facility staff, including CNAs, an LPN, an RN, the DON, and the Administrator, revealed that bed linens are typically changed on shower days or when soiled. However, the staff confirmed that the linens in the residents' rooms were not changed despite being visibly dirty. The facility's infection control policy emphasizes maintaining a safe, sanitary, and comfortable environment, but the failure to change soiled linens for these residents indicates a lapse in adhering to these guidelines. The DON and Administrator acknowledged that the linens should have been changed, confirming the deficiency in maintaining a clean environment for the residents.
Failure to Complete PASRR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) was completed for a resident with significant mental health diagnoses. The resident, admitted on July 13, 2020, had diagnoses including schizophrenia, vascular dementia, mood disorder, anxiety disorder, and psychosis. However, the PASRR conducted on May 19, 2020, prior to admission, only listed a mild neurocognitive disorder and did not acknowledge the resident's history of mental illness, specifically schizophrenia. This oversight was confirmed by the Director of Nursing (DON), who also acknowledged that no subsequent PASRR had been completed after the initial one. The facility did not have a policy in place for conducting PASRRs, as confirmed by the DON. The resident's care plan, initiated on May 21, 2024, included various interventions for managing behavioral disturbances related to their mental health conditions but did not mention PASRR. The quarterly Minimum Data Set (MDS) assessment indicated severe cognitive impairment, yet the initial admission MDS did not reflect the schizophrenia diagnosis. This lack of proper PASRR documentation and follow-up represents a deficiency in the facility's admission and ongoing assessment processes.
Failure to Include Family and Resident in Care Planning
Penalty
Summary
The facility failed to ensure the inclusion of the family or responsible party and the resident in the care plan process for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including Down syndrome, abnormal weight loss, seizures, dysphagia, anxiety disorder, and insomnia, had a care plan initiated without documented participation from the resident or family. The quarterly Minimum Data Set (MDS) indicated severe cognitive impairment, and the care plan was marked for resident and family participation, yet no evidence of such participation was found. Interviews with facility staff revealed that care plan meetings were organized by the Social Director (SD) and the MDS Coordinator, but there was no documentation of family invitations or meeting notes for the resident. The SD was unable to provide records of family invitations or care plan meeting documentation prior to June 2024. The facility also lacked a policy for the care planning process, contributing to the deficiency in ensuring family and resident involvement in care planning.
Failure to Provide Appropriate Foot Care Treatment
Penalty
Summary
The facility failed to provide appropriate foot care treatment for a resident with a history of down syndrome, seizures, abnormal weight loss, and dysphagia. The resident was admitted with a slight risk for impaired skin integrity and pressure ulcers. The care plan did not include interventions for treatment to the left foot, specifically the first and second toenail, despite an existing order for Povidone-Iodine solution to be applied topically every 24 hours as needed until healed. The Treatment Administration Record (TAR) indicated that the treatment was only provided once, on the day the order was made, and there was no further documentation of the treatment being administered from February to May. The Director of Nursing (DON) was unable to explain why the Povidone-Iodine treatment was not documented on the TAR, noting that the treatment nurse was not employed at the facility during the resident's stay. The DON confirmed that the nurses should have signed off on the TAR if the treatment was provided. Progress notes from January indicated that the resident's toenails were removed and cleaned with Povidone-Iodine, with no signs of redness, swelling, pain, or drainage. However, subsequent skin observation tools did not mention the condition of the toenails, and there was no further documentation regarding the left foot treatment.
Failure to Document Indications for Medications
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications without adequate indications for use. The resident, who was admitted with chronic kidney disease stage 3, was found to have three medications prescribed without proper indications documented in their order summary. These medications included an antidepressant, a thyroid hormone, and an antidiabetic medication. The resident was cognitively intact, as indicated by a BIMS score of 15. During an interview, the MDS Coordinator emphasized the importance of linking each medication to a diagnosis to ensure appropriate care, noting that the absence of such links could impact resident care.
Failure to Follow Menu and Serve Correct Portions
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned, written menu, which did not meet the nutritional needs of the residents during one of the two meals observed. On January 6, 2025, a dietary staff member used a #12 scoop, serving 3 ounces of mechanical soft yogurt baked chicken instead of the 4 ounces indicated on the menu, resulting in a 1-ounce discrepancy. Additionally, for the pureed diet, the same scoop size was used, and no pureed wheat dinner roll was served, with no substitutions provided. When questioned, a dietary staff member stated they were instructed by a previous manager not to serve bread to residents on pureed diets and confirmed no extra food items were given in place of the dinner rolls. Another dietary staff member admitted to not reviewing the menu beforehand to ensure correct serving sizes and confirmed serving only one portion per resident.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during meal service, as observed on January 6, 2025. A Certified Nursing Assistant (CNA) was seen placing dirty meal trays, which had been used by residents, onto a meal transport cart that still contained four clean trays intended for other residents. This action was confirmed by the CNA during an interview, acknowledging that dirty trays should not be placed with clean ones due to the risk of cross-contamination. The Director of Nursing (DON) also confirmed that the practice of placing dirty trays with clean ones is an infection control issue. The facility's infection control policy, last revised in July 2014, emphasizes maintaining a safe and sanitary environment to prevent and manage the transmission of infections. The policy mandates that all personnel be trained on these infection control practices upon hire and periodically thereafter. Despite these guidelines, the observed actions during the lunch meal service indicate a lapse in following the established infection control protocols.
Failure to Provide Quarterly Trust Account Statements
Penalty
Summary
The facility failed to provide quarterly statements of the trust accounts managed by the facility to 34 out of 41 residents reviewed. This deficiency was identified through a combination of record reviews, resident and staff interviews, and facility document and policy reviews. The facility's policy, titled 'Resident Trust Fund Policy,' mandates that accurate records of residents' money be kept and made available upon request, with quarterly statements of financial transactions to be provided to residents and mailed to their responsible parties. However, multiple residents, including Residents #11, #7, #10, #13, #15, and #5, confirmed during interviews that they had not received these quarterly statements. The Director of the Business Office Manager (DBOM) acknowledged that residents and/or their representatives had not received the required quarterly statements for an unspecified duration. Resident #15 reported having requested account balances multiple times from the Business Office Manager (BOM) without success. Additionally, Resident #5 expressed difficulty in accessing funds from their account for nearly a year after admission and mentioned that the Social Service Director (SSD) provided account balance information on a sticky note upon request. These findings indicate a systemic issue in the facility's management of resident trust accounts, resulting in a lack of transparency and communication with residents regarding their financial transactions.
Misappropriation of Resident Funds
Penalty
Summary
The facility failed to protect residents from the misappropriation of their funds, affecting 34 out of 41 residents reviewed. The facility's policies on managing the Resident Trust Account were not adequately followed, leading to fraudulent charges totaling $181,384.19. The misappropriation involved the mishandling of funds by staff members, including the Social Service Director (SSD) and the Business Office Manager (BOM), who were responsible for managing and distributing residents' money. The facility's internal controls, such as the reconciliation of the Resident Trust Account Petty Cash Box and the requirement for accurate record-keeping, were not effectively implemented. Interviews with residents revealed that many did not receive quarterly statements and experienced difficulties accessing their funds. For instance, one resident reported not receiving money for almost a year after admission, while another resident noted discrepancies in the amount of money received compared to what was requested. The facility's failure to provide residents with accurate account balances and timely access to their funds contributed to the financial exploitation of the residents. The investigation uncovered that fraudulent charges were often linked to stimulus checks received by residents, with receipts either missing or photocopied. The facility's lack of regular audits and oversight allowed the misappropriation to continue unchecked for several years. The Director of Business Office Management confirmed that no audits had been conducted in over a year, highlighting a significant lapse in the facility's financial oversight and accountability processes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lonoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lonoke Health And Rehab Center, Llc | 1.7 mi | ★★★★★ | 7 | 0 |
| Chambers Health And Rehabilitation | 9.1 mi | ★★★★★ | 5 | 0 |
| Woodland Hills Healthcare And Rehabilitation | 14.1 mi | ★★★★★ | 0 | 0 |
| Spring Creek Health & Rehab | 14.5 mi | ★★★★★ | 0 | 0 |
| Cabot Health And Rehab, Llc | 15.6 mi | ★★★★★ | 1 | 0 |
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