Inspection Reports for
Colonel Glenn Health and Rehab, LLC
13700 David O. Dodd Road, Little Rock, AR, 72210
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
16.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
213% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Deficiencies: 1
Date: Dec 4, 2025
Visit Reason
The inspection was conducted to review the facility's infection prevention and control program, specifically regarding the failure to prevent the spread of a rash, later identified as scabies, among residents on different floors and halls.
Findings
The facility failed to prevent the spread of a rash/scabies among multiple residents across different floors and halls. The rash was present since July 2025 but was not properly identified or controlled until November 2025 after Resident #1 was diagnosed with scabies. Multiple residents were affected, and interventions such as isolation and treatment with antiparasitic medications were delayed. Staff interviews revealed inconsistent infection control practices and delayed implementation of contact isolation and PPE use. The facility policy and CDC guidelines were reviewed, highlighting gaps in early detection and prevention.
Deficiencies (1)
Failure to provide and implement an effective infection prevention and control program to prevent the spread of scabies among residents.
Report Facts
Residents affected with rash/scabies: 28
Residents with rash in September: 3
Residents with rash in October: 8
Residents with rash in November: 26
Staff administration dates of antiparasitic cream: 9
Antihistamine administrations: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Provider #7 | Reported rash timeline and treatment delays | |
| Healthcare Provider #8 | Reported personal diagnosis of scabies and resident rash observations | |
| Certified Nursing Assistant (CNA) #2 | Certified Nursing Assistant | Recalled rash onset in July 2025 |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Reported treatment and quarantine practices in November 2025 |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Reported rash observations and treatment failures |
| Housekeeper #5 | Reported no isolation or special cleaning instructions | |
| Housekeeper #6 | Reported multiple affected rooms and delayed cleaning instructions | |
| Infection Preventionist (IP) | Infection Preventionist | Reported rash spread timeline and case counts |
| Advanced Practice Registered Nurse (APRN) | Advanced Practice Registered Nurse | Reported rash treatment and diagnostic challenges |
| Director of Nursing (DON) | Director of Nursing | Reported rash history, treatment efforts, and infection control measures |
| Medical Director (MD) | Medical Director | Reported rash management and diagnostic approach |
| Administrator | Administrator | Reported rash history, treatment timeline, and policy adherence |
Inspection Report
Deficiencies: 1
Date: Dec 4, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program following reports of a rash spreading among residents across multiple floors and halls.
Findings
The facility failed to prevent the spread of a rash, later diagnosed as scabies, among residents on different floors and halls. Multiple residents were diagnosed with rashes and scabies over several months, with delayed implementation of isolation and treatment measures. Staff interviews revealed inconsistent infection control practices and delayed recognition of scabies, resulting in actual harm to residents.
Deficiencies (1)
Failure to provide and implement an effective infection prevention and control program to prevent the spread of rash/scabies among residents.
Report Facts
Residents with rash cases: 28
Residents with rash cases: 3
Residents with rash cases: 8
Antihistamine administrations: 17
Dates of contact isolation start: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Provider #7 | Reported rash timeline and infection control practices | |
| Healthcare Provider #8 | Reported personal diagnosis of scabies and resident rash observations | |
| Certified Nursing Assistant (CNA) #2 | Certified Nursing Assistant | Recalled rash appearances starting July 2025 |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Reported treatment and quarantine practices in November 2025 |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Reported rash observations and infection control measures |
| Housekeeper #5 | Reported no isolation or special cleaning instructions given | |
| Housekeeper #6 | Reported multiple affected rooms and delayed cleaning instructions | |
| Infection Preventionist (IP) | Infection Preventionist | Reported rash spread timeline and infection control measures |
| Treatment Nurse | Reported rash presentations and treatment delays | |
| Advanced Practice Registered Nurse (APRN) | Advanced Practice Registered Nurse | Reported treatment challenges and rash diagnosis timeline |
| Director of Nursing (DON) | Director of Nursing | Reported rash history, treatment efforts, and infection control implementation |
| Medical Director (MD) | Medical Director | Reported rash diagnosis challenges and treatment approach |
| Administrator | Administrator | Reported rash timeline, treatment efforts, and policy adherence |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, fall prevention, urinary catheter care, food service, and nutritional needs.
Findings
The facility was found deficient in timely transmission of Minimum Data Set (MDS) assessments for multiple residents, failure to update care plans accurately, inadequate fall prevention interventions for a resident with multiple falls, improper urinary catheter care with drainage bags touching the floor, and food service issues including incorrect portion sizes, expired food items, improper food temperatures, and unsafe feeding practices for a cognitively impaired resident.
Deficiencies (6)
Failed to ensure minimum data set (MDS) assessments were transmitted after completion for 8 sampled residents.
Failed to update resident care plans to reflect accurate code status for 1 resident.
Failed to implement fall prevention interventions for 1 resident with multiple falls; alarm not working, no fall mats present.
Failed to ensure urinary catheter drainage bag was not directly touching the floor for 1 resident.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs; incorrect portion sizes served.
Failed to ensure expired food items were promptly discarded; dietary staff failed to wash hands between dirty and clean tasks; cold food items not held at safe temperatures; meals served at unsafe temperatures for 1 resident.
Report Facts
Residents with unsubmitted MDS assessments: 8
Number of falls for Resident #58: 13
Food temperature: 47
Food temperature: 49.8
Food temperature: 63
Food temperature: 92
Food temperature: 75.2
Food temperature: 79.9
Food temperature: 78.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Responsible for ensuring timely submission of MDS reports and care plan updates; interviewed regarding fall prevention and food service issues. |
| MDS Coordinator | Minimum Data Set Coordinator | Completed MDS assessments and responsible for submitting them; interviewed regarding unsubmitted MDS assessments. |
| LPN #5 | Licensed Practical Nurse | Reported alarm on Resident #58's bathroom door was not working and no fall mats were present. |
| RN #6 | Registered Nurse | Verified alarm was not working and no fall mats were present in Resident #58's room. |
| CNA #7 | Certified Nursing Assistant | Reported alarm was not working and verified no fall mats in Resident #58's room. |
| CNA #10 | Certified Nursing Assistant | Observed urinary drainage bag on floor and stated it should not be on the floor. |
| CNA #11 | Certified Nursing Assistant | Stated urinary drainage bag should not be on the floor and that CNAs or nurses are responsible for ensuring it is off the floor. |
| Dietary Cook/Dietary Manager Assistant #1 | Dietary Cook/Dietary Manager Assistant | Observed incorrect portion sizes served and unsafe food temperatures; interviewed about food preparation and reheating. |
| Dietary Manager | Dietary Manager | Interviewed about expired food items, portion sizes, and safe food temperatures. |
| Dietary Aide #4 | Dietary Aide | Observed serving food without washing hands after touching hair bead. |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Reported feeding practices for Resident #84 and warming of trays. |
| Family Paid Care Giver #8 | Family Paid Care Giver | Feeds Resident #84 and requested trays be left in room for feeding. |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, fall prevention, urinary catheter care, food service, and infection control at Colonel Glenn Health and Rehab, LLC.
Findings
The facility was found deficient in timely transmission of Minimum Data Set (MDS) assessments for multiple residents, failure to update care plans to reflect accurate code status, inadequate implementation of fall prevention interventions for a resident with multiple falls, improper urinary catheter care with drainage bags touching the floor, failure to serve meals according to planned menus and portion sizes, expired food items in storage, improper food handling and temperature control, and unsafe food service practices for a cognitively impaired resident.
Deficiencies (6)
Failed to ensure minimum data set (MDS) assessments were transmitted after completion for 8 sampled residents.
Failed to update resident care plans to reveal an accurate code status for 1 resident.
Failed to implement fall prevention interventions for 1 resident with multiple falls, including non-working alarms and absence of fall mats.
Failed to ensure a urinary catheter drainage bag was not directly touching the floor for 1 resident.
Failed to ensure meals were prepared and served according to the planned written menu, including incorrect portion sizes for oatmeal and cereal.
Failed to ensure expired food items were promptly removed or discarded, dietary staff washed hands appropriately, cold food items were held at safe temperatures, and meals were served at safe temperatures for 1 resident.
Report Facts
Residents with untransmitted MDS assessments: 8
Falls recorded for Resident #58: 13
Expired food items: 4
Food temperature: 47
Food temperature: 63
Food temperature: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Responsible for ensuring timely submission of MDS reports and care plan updates; interviewed regarding fall prevention and urinary catheter care. |
| MDS Coordinator | Minimum Data Set Coordinator | Completed MDS assessments and responsible for submitting MDS in a timely manner; interviewed regarding unsubmitted assessments. |
| LPN #5 | Licensed Practical Nurse | Reported no working alarm on Resident #58's bathroom door and absence of fall mats. |
| RN #6 | Registered Nurse | Verified alarm was not working and no fall mats present in Resident #58's room. |
| CNA #7 | Certified Nursing Assistant | Reported no alarm on bathroom door and no fall mats in Resident #58's room. |
| CNA #10 | Certified Nursing Assistant | Observed urinary drainage bag on floor and stated it should not be on the floor. |
| CNA #11 | Certified Nursing Assistant | Stated urinary drainage bag should not be on the floor and responsible for ensuring it is off the floor. |
| Dietary Cook/Dietary Manager Assistant #1 | Dietary Cook/Dietary Manager Assistant | Observed food temperatures and stated food should be fresh if not at safe temperature. |
| Dietary Manager | Dietary Manager | Interviewed about expired food items, portion sizes, and food temperature safety. |
| Dietary Aide #4 | Dietary Aide | Observed serving food and acknowledged improper hand hygiene. |
| CNA #9 | Certified Nursing Assistant | Reported procedure for warming resident trays and feeding Resident #84. |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with accurate resident assessments, specifically focusing on the accuracy of the Minimum Data Set (MDS) documentation related to falls and discharge with anticipation to return.
Findings
The facility failed to accurately assess and document falls for one resident (Resident #68) in the MDS and failed to update the MDS with a discharge with anticipation to return in a timely manner for another resident (Resident #32). The inaccuracies were confirmed through observation, record review, and interviews with staff.
Deficiencies (2)
Failure to accurately assess and document falls in the Minimum Data Set for Resident #68.
Failure to update the Minimum Data Set with a discharge with anticipation to return in a timely manner for Resident #32.
Report Facts
Residents discharged in last 120 days: 46
Falls documented for Resident #68: 11
Assessment Reference Dates reviewed: 3
Inspection Report
Routine
Deficiencies: 7
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Colonel Glenn Health and Rehab, LLC.
Findings
The facility was found deficient in multiple areas including accurate resident assessments, care planning, accident hazard prevention, incontinence care, respiratory care, food safety and sanitation, and call light accessibility in bathrooms. Deficiencies were generally of minimal harm but affected some or few residents.
Deficiencies (7)
Failure to accurately assess and code falls in the Minimum Data Set (MDS) for Resident #68 and failure to update MDS discharge with anticipation to return for Resident #32.
Failure to provide a hand roll as care planned for Resident #76 with limited range of motion.
Failure to ensure accident/hazard free environment due to presence of rubbing alcohol at Resident #10's bedside.
Failure to provide proper incontinence care for Resident #39, including failure to sanitize hands between glove changes.
Failure to administer oxygen at physician ordered flow rates for Residents #33 and #73 and improper storage of oxygen tubing for Resident #27.
Failure to maintain food safety and sanitation in the kitchen including uncovered food items, expired products, unclean ice machine, dirty vents and ceiling tiles, missing baseboards, improper hand hygiene by dietary staff, and serving food below required temperatures.
Failure to ensure call lights were accessible in bathrooms for Residents #3, #34, #86, and #399, including lack of pull strings to reach call lights in bathrooms.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 7
Residents affected: 1
Residents affected: 15
Residents affected: 94
Residents affected: 4
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Interviewed regarding Resident #32's condition and MDS discharge process |
| LPN #4 | Licensed Practical Nurse | Interviewed about oxygen flow rate for Resident #33 |
| LPN #1 | Licensed Practical Nurse | Interviewed about oxygen flow rate for Resident #73 and storage of oxygen tubing |
| CNA #1 | Certified Nursing Assistant | Observed providing incontinent care to Resident #39 |
| CNA #2 | Certified Nursing Assistant | Observed assisting with incontinent care for Resident #39 |
| CNA #4 | Certified Nursing Assistant | Responded to call light alert for Resident #3 |
| Dietary Employee #1 | Dietary Staff | Interviewed about ice machine cleaning and lemon juice use |
| Dietary Employee #2 | Dietary Staff | Observed contaminating gloves and improper food handling |
| Dietary Employee #3 | Dietary Staff | Observed contaminating hands and improper handling of clean pans |
| Maintenance Director | Maintenance Director | Interviewed about call light maintenance and accessibility |
| CNA #5 | Certified Nursing Assistant | Interviewed about call light accessibility in bathrooms |
| Administrator | Facility Administrator | Interviewed about call light accessibility and policies |
| Assistant Administrator | Assistant Administrator | Interviewed about call light policies |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with accurate resident assessments, specifically focusing on the accuracy of Minimum Data Set (MDS) coding related to falls and discharge documentation.
Findings
The facility failed to accurately assess and code falls for Resident #68 in the MDS, and failed to update the MDS with a discharge with anticipation to return in a timely manner for Resident #32. These inaccuracies could potentially affect resident care and compliance with regulatory requirements.
Deficiencies (2)
Failure to accurately assess and code falls in the Minimum Data Set for Resident #68.
Failure to update the Minimum Data Set with a discharge with anticipation to return in a timely manner for Resident #32.
Report Facts
Residents discharged in last 120 days: 46
Falls documented for Resident #68: 12
Assessment Reference Dates (ARD): 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Interviewed regarding Resident #32's condition and incomplete e-interact assessment |
| MDS Coordinator | Acknowledged miscoding of falls for Resident #68 and failure to complete discharge with anticipation to return form for Resident #32 | |
| Administrator | Interviewed about importance of accurate MDS coding and facility policies | |
| Nursing Consultant | Provided policy information related to MDS coding and discharge assessments |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Colonel Glenn Health and Rehab, LLC.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to provide care as planned (e.g., hand roll for limited mobility), unsafe environmental conditions (e.g., hazardous items accessible to residents), improper incontinence care, failure to administer oxygen at prescribed flow rates, unsanitary food storage and preparation conditions, and inadequate call light systems in resident bathrooms.
Deficiencies (7)
Failure to accurately assess and code resident falls in the Minimum Data Set (MDS).
Failure to provide a hand roll as care planned for a resident with limited range of motion.
Failure to maintain an accident/hazard free environment; rubbing alcohol found accessible to resident.
Failure to provide proper incontinence care, including hand hygiene between glove changes.
Failure to administer oxygen at the physician-ordered flow rate and improper storage of oxygen tubing.
Failure to maintain food safety standards including uncovered food, expired items, unsanitary kitchen conditions, improper hand hygiene by food handlers, and inadequate food temperature control.
Failure to ensure call lights in resident bathrooms were accessible with pull strings for residents at risk of falls.
Report Facts
Residents discharged in last 120 days: 46
Residents affected by inaccurate fall assessment: 1
Residents affected by missing hand roll: 1
Residents potentially affected by hazardous environment: 7
Residents affected by improper incontinence care: 4
Residents affected by oxygen flow rate issues: 15
Residents affected by call light accessibility issues: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in oxygen flow rate deficiency for Resident #33 |
| LPN #1 | Licensed Practical Nurse | Named in oxygen flow rate deficiency for Resident #73 |
| LPN #2 | Licensed Practical Nurse | Named in oxygen tubing storage deficiency |
| CNA #1 | Certified Nursing Assistant | Named in incontinence care deficiency |
| CNA #2 | Certified Nursing Assistant | Named in incontinence care deficiency |
| CNA #4 | Certified Nursing Assistant | Named in call light accessibility deficiency for Resident #3 |
| CNA #5 | Certified Nursing Assistant | Named in call light accessibility deficiency |
| Dietary Employee #1 | Dietary Employee | Named in food safety deficiencies |
| Dietary Employee #2 | Dietary Employee | Named in food safety deficiencies |
| Dietary Employee #3 | Dietary Employee | Named in food safety deficiencies |
Inspection Report
Routine
Deficiencies: 2
Date: Dec 28, 2023
Visit Reason
The inspection was conducted to assess compliance with resident rights related to dignity and respect, and to evaluate the infection prevention and control program, specifically regarding proper handling of enteral feeding equipment.
Findings
The facility failed to treat residents with respect and dignity, as evidenced by residents sitting in the day room wearing hospital gowns without appropriate covering. Additionally, the facility failed to ensure proper storage of the connector for an internal feeding tube for a resident, with the feeding tube disconnected and the end connection lying on the floor.
Deficiencies (2)
Failure to treat residents with respect and dignity, with residents observed sitting in hospital gowns in the day room without proper covering.
Failure to ensure the connector for an internal feeding was stored properly; feeding tube disconnected and end connection lying on the floor.
Report Facts
Enteral feeding rate: 82
Flush volume: 30
Resident BIMS scores: 5
Resident BIMS scores: 7
Resident BIMS scores: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Identified dignity issues related to residents wearing hospital gowns in the day room | |
| Director of Nursing (DON) | Acknowledged dignity issues and stated residents should not be sitting in hospital gowns in the day room; also stated nurses should unplug enteral feeding, not CNAs | |
| Licensed Practical Nurse (LPN) #2 | Responded to questions about enteral feeding disconnection for Resident #5 | |
| Certified Nursing Assistant (CNA) #1 | Asked about who unplugged Resident #5's feeding tube |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 28, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident dignity, infection prevention, and care practices at Colonel Glenn Health and Rehab, LLC.
Findings
The facility failed to treat residents with respect and dignity, as evidenced by residents sitting in the day room wearing hospital gowns without proper covering. Additionally, the facility failed to ensure proper storage and handling of enteral feeding equipment for a resident, posing infection control risks.
Deficiencies (2)
Residents #3, #6, and #7 were observed sitting in the day room wearing hospital gowns without appropriate covering, constituting a dignity issue.
Resident #5's enteral feeding connector was found lying on the floor, indicating improper storage and handling of feeding equipment.
Report Facts
Enteral feeding rate: 82
Flush volume: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Identified dignity issues related to residents wearing hospital gowns in the day room |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding unplugging of Resident #5's enteral feeding |
| DON | Director of Nursing | Confirmed dignity issues and proper protocol for enteral feeding handling |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 18, 2023
Visit Reason
The inspection was conducted due to a complaint regarding failure to notify the resident's family about medication changes related to diabetic medications and failure to allow grievances regarding this issue.
Complaint Details
The complaint was substantiated that the resident's family was not notified about the discontinuation of medication and that grievances regarding this issue were not filed or addressed.
Findings
The facility failed to ensure that Resident #2's family was notified of the discontinuation of Aspart insulin and failed to document such notification. Additionally, the facility did not allow the resident's representative to voice grievances regarding the medication notification issue, and no grievance was recorded.
Deficiencies (2)
Failure to notify Resident #2's family of medication changes related to diabetic medications.
Failure to allow Resident #2's representative to voice grievances regarding discontinued medication notification.
Report Facts
Residents sampled: 5
Residents affected: 1
Grievance resolution timeframe: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Mentioned in relation to notification of family about medication change |
| Social Services Director | Interviewed regarding family complaint and grievance process | |
| Administrator | Interviewed regarding notification and grievance documentation | |
| Assistant Director of Nursing | Interviewed regarding notification of family about medication change |
Inspection Report
Deficiencies: 2
Date: Oct 18, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident notification of medication changes and grievance processes following a review of medication discontinuation and family notification concerns for Resident #2.
Findings
The facility failed to ensure that Resident #2's family was notified of changes to diabetic medication as required, and failed to document such notification. Additionally, the facility did not allow the resident's representative to voice grievances regarding the medication discontinuation, as no grievance was filed or documented.
Deficiencies (2)
Failure to notify Resident #2's family of medication changes related to diabetic medications.
Failure to allow Resident #2's representative to voice grievances regarding discontinued medication notification.
Report Facts
Residents sampled: 5
Residents affected: 1
Order Date: May 1, 2023
Order End Date: Sep 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Mentioned in relation to family notification of medication change |
| Social Services Director | Interviewed regarding family complaint and grievance process | |
| Administrator | Interviewed regarding notification and grievance documentation | |
| Assistant Director of Nursing | Interviewed regarding notification of medication changes |
Inspection Report
Routine
Deficiencies: 12
Date: Dec 22, 2022
Visit Reason
Routine inspection of Colonel Glenn Health and Rehab, LLC to assess compliance with regulatory requirements including resident assessments, care planning, medication management, dietary services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to complete significant change assessments, timely transmission of Minimum Data Set (MDS), accurate resident assessments and care planning, provision of personal hygiene and nail care, catheter care, hydration, oxygen therapy management, medication security, and dietary services including food safety and menu adherence.
Deficiencies (12)
Failed to complete a Significant Change in Status Minimum Data Set for Resident #9.
Failed to transmit Minimum Data Set within 14 days for Residents #53 and #80.
Failed to identify residents' positioning needs for Residents #73 and #35 with contractures.
Failed to revise Care Plan to meet resident needs for Resident #82 regarding oxygen therapy.
Failed to provide nail care for Resident #49 who was unable to perform activities of daily living.
Failed to provide care and services to address residents' positioning needs for Residents #73 and #35.
Failed to maintain urinary catheter drainage bags properly for Residents #70, #73, and #76.
Failed to ensure fluids were readily accessible to promote adequate hydration for Residents #70, #73, and #94.
Failed to ensure oxygen nasal cannula tubing was stored properly, oxygen signs posted, and tubing changed per orders for Residents #46, #63, and #82.
Failed to ensure diagnosis was relevant to medication ordered for Resident #16 on Seroquel.
Failed to ensure medications were locked and not left unattended in residents' rooms for Residents #58, #66, and #82.
Failed to follow menu for mechanical soft and pureed diets, and failed to maintain food safety and hygiene in dietary services.
Report Facts
Residents sampled: 116
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Interviewed regarding Significant Change in Status MDS and medication regimen review follow-up |
| Director of Nursing | Director of Nursing | Interviewed regarding care planning, catheter care, medication security, and oxygen therapy policies |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding catheter bag care and hydration |
| Dietary Manager | Dietary Manager | Interviewed regarding dietary menu adherence, food safety, and hand hygiene |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed and interviewed regarding oxygen therapy and medication security |
| Treatment Nurse | Treatment Nurse | Interviewed regarding medication left at bedside |
Inspection Report
Routine
Deficiencies: 13
Date: Dec 22, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident assessments, care planning, medication management, infection control, dietary services, and safety protocols.
Findings
The facility was found deficient in multiple areas including failure to complete significant change assessments, timely transmission of Minimum Data Sets, accurate resident assessments and care planning, proper catheter and oxygen care, medication management, dietary service compliance, and infection control practices in the kitchen.
Deficiencies (13)
Failed to complete a Significant Change in Status Minimum Data Set for 1 of 25 sampled residents.
Failed to transmit Minimum Data Set within 14 days of completion for 2 of 3 sampled residents.
Failed to identify residents' positioning needs for 2 of 10 sampled residents with limited range of motion or contractures.
Failed to revise resident Care Plan to meet residents' needs for 1 of 24 sampled residents.
Failed to provide nail care for 1 of 7 sampled residents dependent on assistance.
Failed to provide care and services to address residents' positioning needs for 2 of 10 sampled residents.
Failed to maintain urinary catheter drainage bag in privacy bag, off the floor, and below bladder level for 3 of 6 sampled residents with catheters.
Failed to ensure fluids were readily accessible to promote adequate hydration for 3 of 30 sampled residents.
Failed to ensure oxygen nasal cannula tubing was stored properly, oxygen signs posted, and tubing changed per orders for 4 of 6 sampled residents on oxygen therapy.
Failed to ensure diagnosis for medication was relevant to minimize potential complications for 1 of 3 sampled residents on antipsychotic medication.
Failed to ensure medications were locked in a secured cart and not left in residents' rooms for 3 sampled residents.
Failed to follow the menu for two meals observed for 7 residents on mechanical soft or pureed diets.
Failed to ensure food items were promptly removed or discarded after expiration, properly dated, covered or sealed; failed to maintain clean kitchen equipment and environment; failed to ensure proper hand hygiene and food handling by dietary staff; failed to secure facial hair in hairnet.
Report Facts
Residents sampled: 25
Residents sampled: 3
Residents sampled: 10
Residents sampled: 24
Residents sampled: 7
Residents sampled: 6
Residents sampled: 30
Residents sampled: 6
Residents sampled: 3
Residents sampled: 3
Residents affected: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #1 | MDS Coordinator | Interviewed regarding significant change assessments and MDS transmission |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding therapy and splint use for Resident #73 |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding oxygen care planning and MDS |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen care planning, catheter bag storage, medication security |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding catheter bag storage and nail care responsibility |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding catheter bag touching floor and privacy |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding catheter bag positioning for Resident #76 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed and interviewed regarding oxygen tubing and signage |
| Dietary Manager | Dietary Manager | Interviewed regarding menu adherence, food safety, and hand hygiene |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Interviewed regarding fluid intake and resident hydration |
| MDS Coordinator, Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding medication regimen review follow-up |
| Treatment Nurse | Treatment Nurse | Interviewed regarding unidentified cream left at bedside |
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