Inspection Reports for
Courtyard Rehabilitation and Health Center, LLC
2415 W. Hillsboro, El Dorado, AR, 71730
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
144% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Aug 29, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident care, medication security, food safety, infection control, and discharge notification at Courtyard Rehabilitation and Health Center, LLC.
Complaint Details
The visit was complaint-related, triggered by concerns about resident care, medication security, food safety, infection control, and discharge notification. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to keep call devices within reach for residents, failure to provide timely discharge notice, inaccurate resident assessments, improper care during enteral feeding, inadequate incontinence care, unsecured medication storage, poor food handling and sanitation practices, and failure to use proper infection control measures during high-contact care.
Deficiencies (8)
Failed to ensure call device was within reach for 2 sampled residents.
Failed to provide notice of discharge to 1 sampled resident or representative.
Failed to ensure Annual Minimum Data Set assessment was coded correctly for 1 sampled resident with serious mental illness.
Failed to ensure staff did not lower head of bed while resident was receiving continuous enteral feeding.
Failed to provide incontinence care in a manner to promote cleanliness for 1 sampled resident.
Failed to ensure medications and/or biologicals were securely locked away.
Failed to ensure food was thawed, stored, and sealed properly; expired food removed; prepared foods covered; dietary staff washed hands; meat slicer cleaned; and utensils clean.
Failed to ensure staff used appropriate infection control measures and donned proper PPE during high-contact care for 1 sampled resident.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated call device was not within reach of residents #8 and #63; confirmed infection control issues; confirmed medication cart should be locked; confirmed incontinence care deficiencies; confirmed staff should not lower head of bed during enteral feeding. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Stated call device was not within reach of Resident #8; stated medication cart should be locked. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Observed lowering head of bed during enteral feeding; provided incontinence care improperly; failed to don gown during high-contact care. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant (CNA) | Confirmed head of bed was lowered during enteral feeding; confirmed gown and gloves should be worn during care of Resident #8. |
| Dietary Aide #5 | Dietary Aide | Observed rinsing dishes and loading dishwasher; involved in dishwasher sanitizer testing. |
| Dietary Aide #7 | Dietary Aide | Observed covering food on steam table and thawing ground beef. |
Inspection Report
Routine
Deficiencies: 8
Date: Aug 29, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, medication storage, food safety, and accurate resident assessments at Courtyard Rehabilitation and Health Center, LLC.
Findings
The facility was found deficient in multiple areas including failure to keep call devices within reach of residents, failure to provide timely discharge notice, inaccurate resident assessments, unsafe feeding practices, inadequate incontinence care, unsecured medication storage, poor food handling and sanitation practices, and failure to implement proper infection control measures during high-contact care.
Deficiencies (8)
Failed to ensure call device was within reach for 2 sampled residents (#8 and #63).
Failed to provide notice of discharge to 1 sampled resident (#76) or resident representative.
Failed to ensure Annual Minimum Data Set (MDS) assessment was coded correctly for 1 sampled resident (#9) with serious mental illness.
Failed to ensure staff did not lower head of bed while Resident #8 was receiving continuous enteral feeding.
Failed to provide incontinence care in a manner to promote cleanliness for Resident #8.
Failed to ensure medications and/or biologicals were securely locked away.
Failed to ensure food safety practices including proper thawing, storage, covering, handwashing, cleaning of equipment, and utensil handling in the kitchen.
Failed to ensure staff used appropriate infection control measures and donned proper PPE during high-contact care for Resident #8.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated call device should be within reach; confirmed infection control issues and medication cart security |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Stated call device was not within reach of Resident #8; stated treatment cart should be locked |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Observed lowering head of bed during enteral feeding; provided incontinence care improperly; failed to don gown during high-contact care |
| Certified Nursing Assistant #2 | Certified Nursing Assistant (CNA) | Confirmed head of bed was lowered during enteral feeding; confirmed gown and gloves should be worn during care |
| Dietary Aide #5 | Dietary Aide | Observed rinsing dishes and loading dishwasher |
| Chemical Representative | Identified dishwasher sanitizer hose problem |
Inspection Report
Routine
Deficiencies: 7
Date: Sep 22, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication storage, nutrition, food safety, and hygiene at Courtyard Rehabilitation and Health Center, LLC.
Findings
The facility was found deficient in multiple areas including failure to implement care plans (e.g., hand roll placement), inadequate personal hygiene assistance (e.g., fingernail care), improper storage of controlled medications, failure to serve meals according to the planned menu and resident preferences, poor food temperature control, improper food preparation consistency, and unsanitary kitchen conditions including unclean equipment and expired or unsealed food items.
Deficiencies (7)
Failed to ensure a resident's hand roll was placed nightly as care planned.
Failed to ensure fingernails were regularly trimmed and cleaned for residents requiring assistance.
Failed to ensure refrigerated scheduled II-V controlled medications were maintained within a separately locked permanently affixed compartment.
Failed to ensure meals were prepared and served according to the planned written menu and resident preferences.
Failed to ensure meals were served at acceptable temperatures and maintained appearance to encourage nutritional intake.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to maintain the ice machine, food storage, kitchen equipment, and food handling practices in a clean and sanitary condition.
Report Facts
Residents with hand roll orders: 5
Residents requiring nail care assistance: 11
Residents affected by fingernail care deficiency: 2
Medication storage rooms inspected: 2
Meals observed: 2
Residents affected by pureed food consistency: 6
Food trays on unheated carts: 22
Food trays on unheated carts: 34
Expired food items observed: 3
Residents receiving meals from kitchen: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding hand roll placement and medication storage |
| LPN #3 | Licensed Practical Nurse | Interviewed and observed during medication storage room tour |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding hand roll placement |
| Dietary Employee #2 | Dietary Employee | Interviewed and observed during meal service and food preparation |
| Dietary Employee #3 | Dietary Employee | Observed during meal service and food preparation, handwashing practices |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed regarding residents' fingernail condition |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding residents' fingernail condition |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding ice machine cleaning and kitchen sanitation |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed regarding missed ice cream serving |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Confirmed resident food dislike |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding pureed food consistency |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding pureed food consistency |
Inspection Report
Routine
Deficiencies: 7
Date: Sep 22, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication storage, nutrition, food safety, and facility hygiene at Courtyard Rehabilitation and Health Center, LLC.
Findings
The facility was found deficient in multiple areas including failure to implement care plans for residents, inadequate personal hygiene care, improper storage of controlled medications, failure to serve meals according to the planned menu and resident preferences, poor food temperature control, improper food consistency for pureed diets, and unsanitary kitchen conditions including unclean equipment and expired or improperly stored food items.
Deficiencies (7)
Failed to ensure a resident's hand roll was placed in the hand nightly as care planned.
Failed to ensure fingernails were regularly trimmed and cleaned to promote good personal hygiene for 2 residents.
Failed to ensure refrigerated scheduled II-V controlled medications were maintained within a separately locked permanently affixed compartment.
Failed to ensure meals were prepared and served according to the planned written menu and resident preferences.
Failed to ensure meals were served at acceptable temperatures and maintained the appearance of a cold product.
Failed to ensure pureed food items were blended to a smooth, lump free consistency for residents requiring pureed diets.
Failed to maintain the ice machine and kitchen equipment in clean condition; failed to ensure food items were sealed, labeled, dated, and expired items removed; and failed to ensure dietary staff washed hands before handling food or equipment.
Report Facts
Residents with hand roll orders: 5
Residents requiring nail care assistance: 11
Residents affected by nail care deficiency: 2
Medication vials found unsecured: 2
Food trays on unheated cart: 22
Food trays on unheated cart: 34
Residents affected by kitchen sanitation issues: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding hand roll care and medication storage |
| CNA #2 | Certified Nursing Assistant | Interviewed about missing hand roll for Resident #62 |
| CNA #4 | Certified Nursing Assistant | Interviewed about residents' fingernail hygiene |
| LPN #2 | Licensed Practical Nurse | Interviewed about residents' fingernail hygiene |
| LPN #3 | Licensed Practical Nurse | Interviewed about medication storage |
| Dietary Employee #1 | Dietary Employee | Observed handling food without washing hands |
| Dietary Employee #2 | Dietary Employee | Interviewed about meal preparation and food consistency |
| Dietary Employee #3 | Dietary Employee | Observed handling food and equipment without washing hands |
| Dietary Supervisor | Dietary Supervisor | Interviewed about ice machine cleaning and kitchen sanitation |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed about missed ice cream serving |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Confirmed disliked food served to Resident #78 |
Inspection Report
Routine
Census: 70
Deficiencies: 4
Date: Jun 23, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, notification of transfers/discharges, personal hygiene, feeding tube care, food safety, and infection control practices.
Findings
The facility was found deficient in timely and proper notification of resident transfers to hospitals, inadequate personal hygiene care (nail trimming), failure to label enteral feeding bottles with time hung, improper food storage and handling practices including expired and unlabeled food items, and failure of dietary staff to follow proper hand washing and glove use procedures.
Deficiencies (4)
Failed to notify resident/representative in writing of reason for transfer/discharge in a language they understand for 2 of 7 sampled residents.
Failed to ensure fingernails were regularly trimmed and cleaned for 1 of 24 sampled residents requiring assistance.
Failed to ensure enteral feedings and water flushes had a label with the documented time they were hung for 1 of 2 sampled residents.
Failed to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards, including expired food items, uncovered meat, and improper hand hygiene by dietary staff.
Report Facts
Residents sampled for transfer notification: 7
Residents affected by transfer notification deficiency: 2
Residents sampled for nail care: 24
Residents affected by nail care deficiency: 1
Residents sampled for feeding tube labeling: 2
Residents affected by feeding tube labeling deficiency: 1
Total census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding responsibility for nail trimming and observations of resident's fingernails |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Interviewed regarding responsibility and timing for nail trimming |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Interviewed regarding knowledge of nail trimming responsibility |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed regarding responsibility and timing for nail trimming |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding labeling of enteral feeding formula and water flush |
| Dietary Employee #1 | Dietary Employee | Observed and interviewed regarding improper glove use and hand hygiene during food preparation |
| Dietary Employee #2 | Dietary Employee | Observed and interviewed regarding improper hand hygiene during food preparation |
| Dietary Employee #3 | Dietary Employee | Observed and interviewed regarding improper glove use and hand hygiene during food preparation |
| Dietary Manager | Dietary Manager | Interviewed regarding food dating, storage, and hand washing procedures |
| Administrator | Administrator | Interviewed regarding responsibility for notifying representatives of transfers |
| Nurse Consultant | Nurse Consultant | Interviewed regarding notification procedures for transfers |
Inspection Report
Routine
Census: 70
Deficiencies: 4
Date: Jun 23, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfer notifications, personal hygiene care, enteral feeding procedures, and food safety practices in the nursing home.
Findings
The facility failed to provide timely written notification of transfer reasons to residents or their representatives, ensure proper nail care for dependent residents, label enteral feeding bottles with the time hung, and maintain food safety standards including proper food dating, hand hygiene, and storage practices. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (4)
Failed to notify resident/representative in writing of reason for hospital transfer for 2 of 7 sampled residents.
Failed to ensure fingernails were regularly trimmed and cleaned for 1 of 24 sampled residents dependent on nail care.
Failed to label enteral feeding formula bottles with the time they were hung for 1 of 2 sampled residents with feeding tubes.
Failed to ensure food items were dated, expired food discarded, proper hand hygiene by dietary staff, and proper food storage in the kitchen affecting many residents.
Report Facts
Residents sampled for transfer notification: 7
Residents affected by transfer notification deficiency: 2
Residents sampled for nail care: 24
Residents affected by nail care deficiency: 1
Residents sampled for enteral feeding labeling: 2
Residents affected by enteral feeding labeling deficiency: 1
Total census: 70
Expired milk cartons found: 7
Expired food items found: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding responsibility and condition of resident's fingernails and enteral feeding labeling |
| Certified Nursing Assistant #5 | CNA | Interviewed about responsibility for trimming resident's nails |
| Certified Nursing Assistant #6 | CNA | Interviewed about responsibility for trimming resident's nails |
| Certified Nursing Assistant #4 | CNA | Interviewed about responsibility for trimming resident's nails |
| Licensed Practical Nurse #2 | LPN | Interviewed about enteral feeding labeling |
| Dietary Employee #1 | Dietary Staff | Observed and interviewed regarding improper glove use and hand hygiene during food preparation |
| Dietary Employee #2 | Dietary Staff | Observed and interviewed regarding improper hand hygiene during food preparation |
| Dietary Employee #3 | Dietary Staff | Observed and interviewed regarding improper glove use and hand hygiene during food preparation |
| Dietary Manager | Manager | Interviewed regarding food dating, expired food handling, and hand washing policy |
| Administrator | Administrator | Interviewed about responsibility for notifying representatives of transfer reasons |
| Nurse Consultant | Nurse Consultant | Interviewed about notification procedures for transfer reasons |
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