Inspection Reports for
Bailey Creek Health and Rehab
1621 East 42nd St, Texarkana, AR, 71854
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
74 residents
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Census: 74
Deficiencies: 9
Date: Sep 6, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including resident rights, safety, medication management, nutrition, infection control, and staff training.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity during transport, lack of timely notification for hospital transfers and bed hold policies, unsecured cleaning carts and hazardous equipment, improper medication storage, failure to follow planned menus, poor food safety and hygiene practices, inadequate infection control PPE use, and insufficient dementia training for nursing aides.
Deficiencies (9)
Failed to ensure privacy and dignity of residents during transport from shower, with resident exposed.
Failed to provide timely written notification of hospital transfer reason to resident or representative.
Failed to provide written notification of bed hold policy to resident or representative upon hospital transfer.
Failed to ensure cleaning carts were locked to prevent resident access to chemicals; hazardous broken air conditioner frame not repaired.
Failed to ensure medications were stored locked and not left unattended or at bedside.
Failed to prepare and serve meals according to planned menu portions for pureed, mechanical soft, and regular diets.
Failed to maintain ice scoop holder clean, seal opened food items, and ensure dietary staff practiced proper hand hygiene.
Failed to ensure staff wore appropriate PPE (gowns) when providing care to resident on Enhanced Barrier Precautions.
Failed to provide dementia training to all nursing aides to meet resident care needs.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 5
Residents affected: 20
Residents affected: 47
Total census: 74
Residents affected: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #9 | CNA | Confirmed resident should have been covered during transport from shower |
| Certified Nursing Assistant #10 | CNA | Confirmed residents should be covered during transport from shower |
| Certified Nursing Assistant #11 | CNA | Confirmed sheet should be used to cover residents during transport |
| Director of Nursing | DON | Confirmed staff expectations for covering residents during transport and medication storage policies |
| Registered Nurse #7 | RN | Confirmed hazardous broken air conditioner and medication storage concerns |
| Registered Nurse #8 | RN | Confirmed treatment cart should be locked when unattended |
| Dietary Employee #2 | Dietary Cook | Observed improper meal portioning and poor hand hygiene |
| Dietary Employee #3 | Dietary Cook/Aide | Observed improper meal portioning and poor hand hygiene |
| Dietary Employee #4 | Dietary Aide | Observed poor hand hygiene |
| Licensed Practical Nurse #1 | LPN | Observed not wearing gown during care of resident on Enhanced Barrier Precautions |
| Certified Nursing Assistant #12 | CNA | Reported no dementia training received |
| Certified Nursing Assistant #13 | CNA | Reported no dementia training received |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Feb 27, 2024
Visit Reason
The investigation was conducted due to allegations of verbal abuse by a Certified Nursing Assistant (CNA #1) towards multiple residents, including threats and inappropriate behavior, reported by residents and staff.
Complaint Details
The complaint investigation involved allegations that CNA #1 verbally abused Residents #2, #3, and #4, including threats of physical assault and discriminatory behavior. The facility concluded the incident was unsubstantiated, but residents reported continued verbal mistreatment and dissatisfaction with the investigation outcome.
Findings
The facility failed to thoroughly investigate allegations of verbal abuse involving CNA #1 towards Residents #2, #3, and #4, placing all 62 residents at risk. The investigation was deemed unsubstantiated by the facility, but residents reported ongoing issues and dissatisfaction with the handling of the complaints.
Deficiencies (1)
Failed to ensure an allegation of verbal abuse was thoroughly investigated for 3 residents, placing all residents at risk for verbal abuse.
Report Facts
Residents affected: 3
Residents at risk: 62
BIMS scores: 15
BIMS scores: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident #1 that occurred in November 2023. The investigation focused on whether staff followed the resident's care plan to prevent accidents.
Complaint Details
The complaint investigation was substantiated based on the findings that staff did not follow the care plan requiring two-person assistance for Resident #1, leading to a fall on 11/17/2023. The resident was found on the floor with a head injury and later passed away on 1/26/2024 related to electrolyte imbalance. Witness statements confirmed the CNA was providing care alone despite the care plan.
Findings
The facility failed to ensure residents were free from accidents by allowing staff to not follow Resident #1's care plan, which required two-person assistance for bed mobility, dressing, and toileting. A fall occurred on 11/17/2023 when a CNA provided care alone, resulting in the resident falling out of bed and sustaining a head injury. The care plan was not consistently followed, and documentation was incomplete.
Deficiencies (1)
Failure to ensure residents were free from accidents by not following Resident #1's care plan requiring two-person assistance, resulting in a fall and injury.
Report Facts
Date of fall incident: Nov 17, 2023
Date of survey completion: Jan 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Prepared progress note documenting Resident #1's fall and hospital transfer |
| CNA #1 | Certified Nursing Aide | Witness to the fall and provided care alone contrary to care plan |
| Director of Nursing | Director of Nursing | Created nursing incident and accident follow-up note and commented on care plan adherence |
| Administrator | Administrator | Provided documents and statements regarding the fall and care plan |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, and safety at Bailey Creek Health and Rehab.
Findings
The facility was found deficient in maintaining a clean and safe environment, including dirty air-conditioning/heating units and corroded sinks. Care planning deficiencies were noted for oxygen use for a resident. Additionally, inadequate personal hygiene care was observed, specifically untrimmed and unclean fingernails for some residents. The facility also failed to post required oxygen in use signage for a resident using oxygen therapy.
Deficiencies (4)
Failed to provide a clean, comfortable, safe homelike environment; dirty AC/HT units and corroded sinks observed in multiple rooms.
Failed to develop and implement a comprehensive person-centered care plan for oxygen use for one resident.
Failed to ensure fingernails were clean, groomed, and free from jagged edges for two residents dependent on staff for fingernail care.
Failed to post signage indicating oxygen in use for one resident with physician order for oxygen.
Report Facts
Residents sampled for oxygen use care plan: 5
Residents sampled for fingernail care: 14
Residents affected by fingernail care deficiency: 2
Residents affected by oxygen signage deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Described fingernail care responsibilities and interactions with Resident #26 regarding nail trimming. |
| Director of Nursing | Director of Nursing | Provided information on responsibilities for nail care and oxygen signage. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Discussed oxygen use and signage importance for Resident #5. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Commented on Resident #8's refusal of nail care and importance of nail hygiene. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Described condition of Resident #8's nails. |
Inspection Report
Routine
Census: 63
Deficiencies: 5
Date: Jul 29, 2022
Visit Reason
The inspection was conducted to evaluate compliance with health and safety regulations related to maintaining a safe, clean, and homelike environment, as well as food safety and sanitation practices in the facility's kitchen.
Findings
The facility failed to maintain the bath and shower rooms and resident rooms in good repair, with issues such as stained ceiling tiles, broken tiles, and cluttered bathrooms posing potential hazards. Additionally, the kitchen had multiple sanitation violations including uncovered food items, unwashed hands by staff, rust and residue on equipment, and contaminated ice scoop holders, all posing risks of foodborne illness.
Deficiencies (5)
Failure to maintain bath and shower rooms and resident rooms in good repair, including stained ceiling tiles, broken tiles, and cluttered bathrooms.
Failure to ensure staff washed hands before handling clean equipment and food, leading to potential foodborne illness.
Food items stored uncovered or unsealed in refrigerator and freezer, risking cross contamination.
Kitchen vents and equipment had rust and residue, compromising sanitary conditions.
Ice scoop holder contaminated with black residue and standing water, risking contamination of ice used by residents.
Report Facts
Residents affected: 62
Total census: 63
Date survey completed: Jul 29, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Interviewed regarding food storage and sanitation issues | |
| Dietary Employee #1 | Observed handling glasses without washing hands | |
| Dietary Employee #2 | Observed contaminating gloves by handling phone before food | |
| Dietary Employee #3 | Observed contaminating gloves while handling food | |
| Certified Nursing Assistant #1 | Distributed ice to residents and described ice chest condition | |
| Housekeeper #1 | Interviewed about bathroom access and conditions | |
| Administrator | Shown areas of disrepair and notified of findings |
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