Deficiencies (last 4 years)
Deficiencies (over 4 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 4
Date: Mar 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, and food safety at Ashton Place Health and Rehab, LLC.
Findings
The facility failed to ensure proper treatment and care for Resident #103 regarding the use of a right-hand splint as ordered, failed to maintain food safety standards including proper hand hygiene and food temperature control, and failed to implement adequate infection prevention practices including hand hygiene when passing ice and proper use of enhanced barrier precautions during feeding tube care.
Deficiencies (4)
Failure to ensure Resident #103 received right-hand splint treatments as ordered, with staff documenting splint placement when it was not applied.
Failure to follow manufacturer specifications for food storage and maintain proper food temperatures; dietary staff failed to wash hands and change gloves appropriately.
Failure to ensure staff performed hand hygiene while passing ice to residents, risking cross contamination.
Failure to ensure enhanced barrier precautions were followed during feeding tube care, specifically not wearing a gown during flushing of Resident #103's feeding tube.
Report Facts
Observation count: 4
Hamburger buns: 7
Temperature: 45
Temperature: 61
Feeding tube flush volume: 30
Feeding tube rate: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Confirmed not applying right-hand splint but documented it was applied |
| LPN #7 | Licensed Practical Nurse | Observed not wearing gown during feeding tube flush; acknowledged mistake |
| Director of Physical Therapy/Occupational Therapy | Director of PT/OT | Interviewed regarding hand splint orders and therapy services for Resident #103 |
| Administrator | Facility Administrator | Provided policy information and expectations for splint application and infection control |
| Director of Nursing | Director of Nursing (DON) | Explained nursing expectations for splint application and infection control procedures |
| Medical Director | Medical Director | Confirmed physician order for hand splint and expectations for nursing compliance |
| Certified Nursing Assistant #10 | CNA | Stated would not intervene if splint was seen in resident's room assuming therapy responsibility |
| Dietary Manager | Dietary Manager | Interviewed about food storage and temperature control issues |
| Dietary Staff DC #3 | Dietary Cook | Observed failing to wash hands before handling food and gloves |
| Dietary Staff DC #4 | Dietary Cook | Observed improper hand hygiene and food handling practices |
| Dietary Aide #5 | Dietary Aide | Observed handling clean equipment with contaminated hands |
| Certified Nursing Assistant #1 | CNA | Observed failing to use hand sanitizer appropriately when passing ice |
| MDS/Infection Preventionist Nurse | MDS/IP Nurse | Interviewed about hand hygiene expectations when passing ice |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 27, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to provide appropriate treatment and care, specifically related to a resident not receiving prescribed right-hand splint treatments, food safety violations, and infection prevention and control practices.
Complaint Details
The investigation was complaint-driven, focusing on allegations that Resident #103 was not receiving the prescribed right-hand splint treatment, improper food handling and storage practices, and inadequate infection control measures including hand hygiene and feeding tube care.
Findings
The facility failed to ensure Resident #103 received the ordered right-hand splint treatments, with nursing staff documenting splint placement when it was not applied. Dietary staff failed to follow manufacturer specifications and proper hand hygiene, resulting in potential food contamination. Infection control practices were inadequate, including failure to perform hand hygiene when passing ice and failure to wear gowns during feeding tube care, increasing infection risk.
Deficiencies (4)
Failure to provide right-hand splint treatments as ordered for Resident #103, with staff documenting splint placement when it was not applied.
Failure to follow manufacturer specifications for food storage and improper hand hygiene by dietary staff, risking food contamination.
Failure to perform proper hand hygiene when passing ice to residents, risking spread of infection.
Failure to wear gown during feeding tube flushing as required by enhanced barrier precautions, risking infection transmission.
Report Facts
Observation dates: 4
Hamburger buns: 7
Temperature of sandwiches: 45
Temperature of chef salad: 61
Feeding tube flush volume: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Confirmed she was Resident #103's nurse and admitted to charting splint placement when it was not applied |
| LPN #7 | Licensed Practical Nurse | Observed charting splint placement when not applied; interviewed about feeding tube care and enhanced barrier precautions |
| Director of Physical Therapy/Occupational Therapy | Interviewed regarding splint orders and therapy services for Resident #103 | |
| Physical Therapy Assistant (PTA) | Interviewed about Resident #103's splint use | |
| Administrator | Interviewed about policies on splint use, feeding tube care, and hand hygiene | |
| Director of Nursing (DON) | Interviewed about nursing expectations for splint placement and infection control | |
| Certified Nursing Assistant (CNA) #10 | Interviewed about splint use and enhanced barrier precautions | |
| Dietary Manager | Interviewed about food storage and temperature control | |
| Dietary [NAME] (DC) #3 | Dietary Staff | Observed and interviewed regarding hand hygiene and food handling |
| Dietary DC #4 | Dietary Staff | Observed and interviewed regarding food handling and hygiene |
| Dietary Aide (DA) #5 | Dietary Staff | Observed handling food and glasses without proper hand hygiene |
| Certified Nursing Assistant (CNA) #1 | Observed passing ice without proper hand hygiene | |
| Medical Director | Interviewed about expectations for splint use and infection control practices | |
| Minimum Data Set/Infection Preventionist (MDS/IP) Nurse | Interviewed about hand hygiene expectations and documentation of enhanced barrier precautions |
Inspection Report
Routine
Deficiencies: 7
Date: Jan 5, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident privacy, accident hazards, medication administration, medication storage, food safety, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy regarding medication carts, unsafe storage of lotions and personal items, significant medication administration errors related to timing of insulin and meals, expired medications stored in medication carts, improper food storage in the kitchen, failure to follow infection control protocols for COVID-19, and unsafe, damaged wheelchair equipment requiring maintenance.
Deficiencies (7)
Failed to ensure medication carts were locked and screens closed to protect resident privacy.
Allowed lotions, perfumes, and powders to be accessible to residents, posing accident hazards.
Failed to ensure timely administration of meals/snacks after NovoLog insulin, risking hypoglycemia for Resident #104.
Stored expired medications in medication carts, risking resident safety.
Failed to ensure foods in dry pantry were properly sealed, dated, and stored.
Failed to implement infection control precautions including proper PPE use and hand hygiene before entering COVID-19 positive resident room.
Failed to maintain safe, functional, and comfortable environment due to cracked and torn wheelchair arms causing potential injury.
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 112
Residents affected: 114
Residents affected: 3
Medication expiration date: Dec 30, 2023
Medication fill date: Dec 30, 2022
Capillary blood glucose reading: 310
Insulin dose: 4
Time delay: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Observed leaving medication cart unlocked and screen up; interviewed about medication cart security and insulin administration timing |
| Licensed Practical Nurse #2 | LPN | Interviewed about medication cart security |
| Licensed Practical Nurse #3 | LPN | Observed administering insulin to Resident #104 without timely meal/snack |
| Licensed Practical Nurse #5 | LPN | Interviewed about timing of meal/snack after NovoLog insulin |
| Licensed Practical Nurse #6 | LPN | Interviewed about expired medication removal |
| Director of Nursing | DON | Interviewed multiple times regarding medication cart security, medication administration, expired medications, infection control, and maintenance issues |
| Certified Nursing Assistant #2 | CNA | Observed and interviewed regarding failure to use proper PPE and hand hygiene entering COVID-19 positive resident room |
| Infection Control Preventionist | ICP | Interviewed about proper PPE and hand hygiene for COVID-19 positive resident care |
| Maintenance Supervisor | MS | Interviewed about maintenance protocols and equipment repair |
| Dietary Manager | Interviewed about unsafe food storage in kitchen | |
| Administrator | Interviewed about maintenance audits and policies |
Inspection Report
Routine
Deficiencies: 7
Date: Jan 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, accident hazards, medication administration, medication storage, food safety, infection control, and facility maintenance at Ashton Place Health and Rehab, LLC.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy regarding medication carts, unsafe storage of lotions and powders accessible to residents, significant medication administration errors related to timing of insulin and meals, expired medications stored in medication carts, improper food storage in the kitchen, failure to follow infection control protocols for COVID-19 isolation, and unsafe, damaged wheelchair equipment posing risk to residents.
Deficiencies (7)
Failed to ensure medication cart was locked and screen closed to protect resident privacy.
Failed to ensure lotions, perfumes, and powders were stored out of reach to prevent accidents for 5 residents.
Failed to follow physician orders and manufacturer's guidelines for NovoLog insulin administration timing, risking significant medication error for 1 resident.
Failed to ensure medications were stored properly and expired medications were removed from medication carts for 1 resident.
Failed to ensure foods in dry pantry were properly sealed, dated, and stored in kitchen affecting all residents.
Failed to implement infection control precautions including proper PPE use and hand hygiene before entering COVID-19 positive resident room for 1 resident.
Failed to maintain safe, functional, sanitary, and comfortable environment due to damaged wheelchair armrests affecting 3 residents.
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 112
Residents affected: 114
Residents affected: 3
Medication dosage: 4
Medication expiration date: Dec 30, 2023
Medication pill count: 21
Time delay: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication cart privacy deficiency and medication timing interview |
| Licensed Practical Nurse #2 | LPN | Named in medication cart privacy deficiency interview |
| Licensed Practical Nurse #3 | LPN | Observed administering insulin incorrectly |
| Licensed Practical Nurse #5 | LPN | Interviewed about insulin timing and medication administration |
| Licensed Practical Nurse #6 | LPN | Interviewed about expired medication removal |
| Director of Nursing | DON | Interviewed regarding medication cart privacy, medication timing, expired medications, infection control, and maintenance issues |
| Certified Nursing Assistant #2 | CNA | Observed and interviewed regarding failure to use proper PPE and hand hygiene in COVID-19 isolation |
| Infection Control Preventionist | ICP | Interviewed about infection control PPE requirements |
| Dietary Manager | Dietary Manager | Interviewed about unsafe food storage |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about maintenance protocols and equipment repair |
| Administrator | Administrator | Interviewed about maintenance policies and procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure a resident received ordered urinalysis with culture as prescribed by the physician.
Complaint Details
The complaint investigation found that the ordered urinalysis with culture for Resident #1 was not completed as required. The facility lacked documentation and policy regarding following physician orders. The Director of Nursing and Assistant Director of Nursing confirmed these findings during interviews.
Findings
The facility failed to obtain the ordered urinalysis with culture for Resident #1 on multiple dates, with no documentation of the tests being completed or results reported. Interviews confirmed the tests were not performed due to the resident's inability to urinate and lack of policy for following physician orders.
Deficiencies (1)
Failure to provide appropriate treatment and care according to physician orders for urinalysis with culture for Resident #1.
Report Facts
Physician orders for UA with culture: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to obtain urinalysis and lack of policy |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding notification procedures if UA not obtained |
| Medical Records/LPN | Medical Records/LPN | Confirmed no UA lab results reported for Resident #1 |
Inspection Report
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
The inspection was conducted to assess compliance with physician orders and ensure appropriate treatment and care were provided to residents, specifically regarding ordered urinalysis with culture tests.
Findings
The facility failed to ensure that Resident #1 received the ordered urinalysis with culture as per physician orders dated 07/31/2023, 08/03/2023, and 08/07/2023. Documentation was lacking, and the urinalysis was not completed due to the resident's inability to urinate. There was no policy concerning following physician orders.
Deficiencies (1)
Failure to provide appropriate treatment and care according to physician orders for urinalysis with culture for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the failure to obtain urinalysis and lack of policy concerning physician orders. | |
| Assistant Director of Nursing | Interviewed regarding notification procedures if urinalysis is not obtained within 24-48 hours. | |
| Medical Records/LPN | Confirmed no urinalysis lab results were reported for Resident #1. |
Inspection Report
Routine
Census: 94
Deficiencies: 6
Date: Sep 15, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, food safety, staffing qualifications, and facility operations.
Findings
The facility was found deficient in multiple areas including inadequate personal hygiene care (unclean fingernails), improper catheter care (catheter bags touching the floor), poor food preparation and storage practices, lack of a qualified social worker, and inadequate infection control measures in the laundry room.
Deficiencies (6)
Failed to ensure residents' fingernails were cleaned and trimmed to promote good personal hygiene and grooming.
Failed to ensure Foley catheter drainage bags were secured to prevent touching the floor to prevent infection.
Failed to ensure pureed food items were blended to a smooth, lump free consistency.
Failed to ensure foods stored in kitchen were dated, discarded spoiled items, maintained thermometers, and ensured dietary employees wore masks properly.
Failed to employ a qualified full-time social worker with a minimum of a bachelor's degree.
Failed to ensure negative air pressure between clean and dirty sides of laundry room to prevent cross contamination.
Report Facts
Residents affected: 94
Residents on pureed diet: 3
Residents with indwelling Foley catheters: 9
Residents with unclean fingernails: 18
Beds: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided lists of residents and information about facility policies | |
| Certified Nursing Assistant (CNA) #1 | Described resident's fingernail condition and care practices | |
| Licensed Practical Nurse (LPN) #1 | Provided information about resident's diabetic status and nail care responsibilities | |
| Dietary Manager (DM) | Described food preparation and storage practices, mask wearing, and food safety | |
| Dietary Employee (DE) #5 | Prepared pureed food and described blending process | |
| Administrator | Discussed social worker staffing and facility policies | |
| Laundry Supervisor | Discussed laundry room air pressure and infection control | |
| Maintenance Supervisor | Discussed awareness of laundry room air pressure issues |
Inspection Report
Routine
Census: 94
Deficiencies: 6
Date: Sep 15, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, dietary services, social work staffing, and facility operations at Ashton Place Health and Rehab, LLC.
Findings
The facility was found deficient in multiple areas including inadequate personal hygiene care (unclean and untrimmed fingernails for residents), improper catheter care (Foley catheter drainage bags touching the floor), poor food preparation and storage practices (improperly blended pureed food, expired and undated food items, dietary staff not properly wearing masks), lack of a qualified social worker for a facility with more than 120 beds, and failure to maintain negative air pressure between clean and dirty sides of the laundry room to prevent cross contamination.
Deficiencies (6)
Failed to ensure residents' fingernails were cleaned and trimmed to promote good personal hygiene and grooming.
Failed to ensure Foley catheter drainage bags were secured to prevent touching the floor to prevent infection.
Failed to ensure pureed food items were blended to a smooth, lump free consistency.
Failed to ensure foods stored in kitchen were dated, discarded spoiled items, maintained thermometers, and dietary employees wore masks properly; ice machine was not clean.
Failed to employ a qualified full-time social worker with a minimum of a bachelor's degree for a facility with more than 120 beds.
Failed to ensure negative air pressure between clean and dirty sides of laundry room to prevent cross contamination.
Report Facts
Residents affected: 94
Residents affected: 91
Residents affected: 18
Residents affected: 9
Residents affected: 3
Residents affected: 94
Beds: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in catheter bag touching floor finding and resident nail care finding |
| CNA #1 | Certified Nursing Assistant | Named in resident nail care deficiency |
| Director of Nursing | Director of Nursing (DON) | Provided lists of residents, policies, and information during inspection |
| Dietary Manager | Dietary Manager (DM) | Named in food preparation and storage deficiencies |
| Dietary Employee #5 | Dietary Employee | Observed preparing pureed food with improper consistency |
| Administrator | Facility Administrator | Interviewed regarding social worker staffing and other findings |
| Laundry Supervisor | Laundry Supervisor | Named in laundry room negative air pressure deficiency |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding laundry room air flow issue |
Viewing
Loading inspection reports...
