Inspection Reports for
Alcoa Pines Health and Rehabilitation
3300 Alcoa Road, Benton, AR, 72015
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 30, 2025
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to ensure proper physician orders for oxygen therapy, dietary staff hand hygiene, and appropriate handling of an indwelling urinary catheter.
Complaint Details
The investigation was complaint-driven, focusing on oxygen therapy without physician orders, improper hand hygiene by dietary staff, and improper handling of urinary catheter equipment. The report documents observations, interviews, and policy reviews confirming these issues.
Findings
The facility failed to ensure a physician's order was in place before administering oxygen therapy to a resident, dietary staff did not wash hands between dirty and clean tasks or before handling clean equipment, and the urinary catheter bag was improperly placed touching the floor and hung on a trash can, risking infection.
Deficiencies (3)
Failed to ensure a physician's order for oxygen was in place before administering oxygen to Resident #59.
Dietary staff failed to wash hands between dirty and clean tasks and before handling clean equipment during meal service.
Failed to provide appropriate handling and placement of an indwelling urinary catheter to prevent contamination and complications.
Report Facts
Oxygen flow rate: 4
Urinary catheter insertion time: 1310
Assessment Reference Date: May 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #6 | Stated responsibility for ensuring physician orders were in the electronic health record and confirmed no oxygen order was present for Resident #59. | |
| Licensed Practical Nurse (LPN) #7 | Indicated importance of ensuring orders were in the chart and confirmed responsibility for order entry. | |
| Director of Nursing | Confirmed nurse responsibility for entering orders into the EHR and importance of order accuracy for resident care. | |
| Dietary Aide (DA) #3 | Observed handling food and drink items with bare hands without hand hygiene. | |
| Dietary Aide (DA) #2 | Observed handling food and drink items without washing hands. | |
| Dietary Aide (DA) #4 | Observed handling beverages without washing hands. | |
| Dietary Aide (DA) #5 | Observed handling clean plates with unwashed hands and long polished nails. | |
| Licensed Practical Nurse (LPN) #8 | Provided urinary catheter care and stated catheter bag should not touch floor or be hung on trash can. | |
| Certified Nursing Assistant (CNA) #9 | Stated catheter bag should be below bladder and not hung on trash can or floor. | |
| Certified Nursing Assistant (CNA) #10 | Reported training on catheter care and infection control practices. |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 20, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to update resident care plans for diabetes management, inadequate use of wander management devices, improper maintenance of oxygen equipment, expired medication not removed, lack of duration on psychotropic and antibiotic orders, unsafe food handling and storage practices, and unsecured hazardous chemical storage areas.
Deficiencies (9)
Failed to update resident care plan to reflect diagnosis of Diabetes with insulin usage for Resident #11.
Failed to ensure a wander management device was in place for Resident #35, increasing elopement risk.
Failed to provide maintenance to oxygen equipment in accordance with facility policy for Resident #29.
Failed to ensure expired medication was removed from medication cart for Resident #11.
Failed to ensure psychotropic medication PRN orders had duration for Resident #71.
Failed to ensure meals were served at safe and appetizing temperatures and maintained appearance for multiple residents.
Failed to ensure dietary staff washed hands before handling clean equipment or food and refrigerator temperature was maintained at 41°F or below.
Failed to implement antibiotic stewardship program consistently; antibiotic prescribed without duration for Resident #35.
Failed to ensure housekeeping storage room door was locked to prevent resident access to hazardous chemicals.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 16
Residents affected: 19
Residents affected: 19
Residents affected: 25
Residents affected: 79
Residents affected: 3
Residents affected: 14
Residents affected: 4
Residents affected: 1
Residents affected: 22
Medication doses administered: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #2 | Named in medication cart expired medication finding and diabetes care plan deficiency | |
| Assistant Director of Nursing (ADON) #1 | Interviewed regarding diabetes care plan, oxygen equipment maintenance, psychotropic medication orders, and wander management device | |
| Minimum Data Set (MDS) Coordinator | Interviewed regarding care plan updates and insulin order | |
| Certified Nursing Assistant (CNA) #3 | Interviewed regarding missing wander management device | |
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding missing wander management device | |
| Dietary Employee (DE) #2 | Observed handling food without washing hands | |
| Dietary Employee (DE) #3 | Observed handling clean bowls without washing hands | |
| Dietary Employee (DE) #4 | Observed handling utensils without washing hands | |
| Dietary Supervisor | Provided facility handwashing policy and observed food temperatures | |
| Housekeeping Director | Interviewed regarding housekeeping storage room door security | |
| Assistant Director of Nursing (ADON) #2 | Interviewed regarding antibiotic stewardship program and antibiotic order review |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 27, 2023
Visit Reason
The inspection was conducted due to complaints regarding misappropriation of residents' personal funds held in trust accounts and failure to ensure adequate supervision during resident transfers.
Complaint Details
The complaint investigation substantiated findings of misappropriation of trust fund monies for Residents #4, #5, and #6, and failure to provide adequate staff assistance during transfer for Resident #1, resulting in injury.
Findings
The facility was found to have mishandled trust fund accounts for three residents resulting in financial discrepancies and reimbursements. Additionally, the facility failed to provide two-person assistance during transfers for a resident requiring such support, resulting in a fracture injury. The facility implemented corrective actions including segregation of duties and staff inservicing.
Deficiencies (4)
Misappropriation of personal funds from Resident #6 Trust Fund Account totaling $4,262.00 plus unauthorized cash withdrawals of $689.36.
Misappropriation of personal funds from Resident #5 Trust Fund Account totaling $2,332.00 with partial reimbursement after write-off of $1,711.24.
Misappropriation of personal funds from Resident #4 Trust Fund Account totaling $1,400.00 with reimbursement to resident or representative.
Failure to ensure two staff members were present when transferring Resident #1 who required two-person assistance, resulting in a tibia/fibula fracture.
Report Facts
Mishandled funds Resident #6: 4262
Unauthorized cash withdrawals Resident #6: 689.36
Reimbursement amount Resident #6: 4951.36
Mishandled funds Resident #5: 2332
Write-off amount Resident #5: 1711.24
Reimbursement amount Resident #5: 620.76
Mishandled funds Resident #4: 1400
Number of residents requiring two-person assist: 1
Number of residents affected by trust fund misappropriation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Occupational Therapy Assistant #1 | Occupational Therapy Assistant | Interviewed confirming Resident #1 required two-person assistance for transfers |
| Director of Nursing | Director of Nursing (DON) | Confirmed Resident #1 required two-person assistance for transfers prior to injury |
| Administrator | Facility Administrator | Confirmed Resident #1 required two-person assistance and described audit findings related to trust fund misappropriation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide scheduled showers or baths to residents.
Complaint Details
The complaint investigation found that Resident #2 did not receive scheduled showers on 05/06/23, 05/13/23, and the Saturday prior to the survey due to insufficient staffing and unclear responsibilities among nursing assistants and CNAs. The issue was substantiated with interviews and record review.
Findings
The facility failed to ensure that Resident #2 received scheduled showers on assigned days due to staffing shortages and confusion among staff about shower assignments. Nurse Assistants were not allowed to give showers without a CNA present, and on the day in question, no showers were given because there were insufficient CNAs.
Deficiencies (1)
Failure to provide scheduled showers or baths to Resident #2 on assigned days due to staffing issues and procedural confusion.
Report Facts
Residents sampled: 2
Scheduled shower days missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided bathing log and discussed shower responsibilities and staffing issues |
| Certified Nursing Assistant #1 | CNA | Reported working alone and inability to provide showers on Saturday |
| Nurse Assistant #1 | NA | Reported confusion about shower assignments and lack of computer system knowledge |
| Nurse Assistant #2 | NA | Reported inability to complete scheduled showers due to insufficient CNAs |
| Administrator | Administrator | Confirmed CNAs are responsible for showers and discussed staffing protocols |
Inspection Report
Census: 78
Deficiencies: 6
Date: Jan 19, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, notification of transfers, accident prevention, staff competencies, medication administration, and infection control at Alcoa Pines Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to serve meals simultaneously to residents at the same table, inadequate written notification for resident transfers, unsafe sharps container management, insufficient supervision on the Secure Unit, medication errors exceeding 5%, and lapses in infection prevention practices such as improper mask use and contaminated ice scoop handling.
Deficiencies (6)
Failed to ensure lunch was served at the same time for all residents sitting at the same table to promote dignity and respect.
Failed to provide timely and understandable written notification to resident or representative regarding reason for hospital transfer.
Sharps containers were overfilled and not emptied timely, posing injury risk.
Residents on Secure Unit were left unattended without supervision at times.
Medication error rate was 15.38%, exceeding the 5% threshold, including wrong eye administration and missed doses.
Failed to ensure infection control practices including proper mask wearing and clean handling of ice scoop.
Report Facts
Residents affected: 78
Medication errors: 4
Medication administration opportunities: 26
Residents sampled: 27
Residents affected by transfer notification deficiency: 1
Residents on Secure Unit: 7
Residents CNA #5 responsible for: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Interviewed regarding meal service timing discrepancies. |
| Dietary Supervisor | Interviewed regarding meal service timing discrepancies. | |
| Business Office Manager | BOM | Interviewed regarding transfer notification documentation for Resident #72. |
| Director of Nursing | DON | Interviewed regarding transfer notification, sharps container procedures, supervision on Secure Unit, and medication administration. |
| Certified Nursing Assistant #5 | CNA | Observed leaving residents unattended on Secure Unit and interviewed about supervision. |
| Licensed Practical Nurse #1 | LPN | Interviewed about supervision on Secure Unit and risks of residents being unsupervised. |
| Licensed Practical Nurse #4 | LPN | Involved in medication errors during medication pass. |
| Certified Nursing Assistant #4 | CNA | Observed improper ice scoop handling and mask wearing. |
| Certified Nursing Assistant #2 | CNA | Observed improper mask wearing. |
| Scheduling Coordinator | Interviewed about staffing levels on Secure Unit. |
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