Inspection Reports for
Crestpark DeWitt, LLC
1325 Liberty Drive, DeWitt, AR 72042, AR, 72042
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
19.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
279% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Deficiencies: 14
Date: Oct 3, 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 residents' access to personal funds after hours, PASARR screening coordination, nail care provision, chemical hazard control, oxygen administration, pharmaceutical services including narcotic accounting, psychotropic medication management, medication error rates, medication labeling and storage, food safety practices, facility-wide assessment completeness, infection prevention and control including Legionella surveillance, and vaccination policies.
Deficiencies (14)
Failed to ensure residents with a trust account had access to their personal funds after business hours and on weekends.
Failed to coordinate with the state designated office to get a PASARR evaluation for a resident to ensure designated services.
Failed to ensure nail care was provided to toenails for a sampled resident.
Failed to ensure potential hazardous chemicals were secured and stored behind a locked door.
Failed to ensure oxygen was administered at the physician's ordered rate and failed to provide a policy for respiratory care.
Failed to accurately account for a controlled liquid narcotic, Lorazepam, after administration.
Failed to ensure an as needed psychotropic medication was not continued past 14 days without physician's documented rationale.
Failed to maintain a medication error rate of less than 5%, resulting in medication errors during medication pass.
Failed to ensure nurse checked heart rate prior to administration of Digoxin, resulting in a significant medication error.
Failed to consistently implement a system to accurately reconcile and dispose of a controlled liquid narcotic, Lorazepam, 90 days after opening.
Failed to ensure staff's hair was contained and proper hand hygiene was used while preparing and serving food.
Failed to include pertinent information in the facility-wide assessment to assure necessary care and resources were allocated.
Failed to maintain Legionella surveillance as part of the water management plan.
Failed to provide pneumonia vaccine for 2 of 5 residents reviewed for immunizations.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: Many
Residents affected: 36
Residents affected: Many
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Responsible for PASARR screening, narcotic log review, and interview statements related to multiple deficiencies |
| Registered Nurse #2 | Registered Nurse | Observed and interviewed regarding medication administration errors and narcotic counts |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Interviewed regarding nail care provision |
| Business Office Manager | Business Office Manager | Interviewed regarding residents' access to personal funds |
| Administrator | Administrator | Interviewed regarding personal funds policy and facility assessment |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed and observed regarding water temperature testing for Legionella surveillance |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and hygiene practices |
| Dietary Helper | Dietary Helper | Observed with hair out of bonnet during food preparation and serving |
| Registered Nurse #6 | Registered Nurse | Interviewed regarding oxygen administration |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Observed during narcotic count |
Inspection Report
Routine
Deficiencies: 14
Date: Oct 3, 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 to have multiple deficiencies including failure to ensure residents' access to personal funds after hours, incomplete PASARR screening, inadequate nail care, unsecured hazardous chemicals, improper oxygen administration, medication accounting discrepancies, psychotropic medication management issues, medication errors, food safety violations, incomplete facility assessment, inadequate Legionella surveillance, and failure to provide pneumonia vaccinations to some residents.
Deficiencies (14)
Failed to ensure residents with a trust account had access to their personal funds after business hours and on weekends.
Failed to coordinate with the state designated office to get a PASARR evaluation for a resident to ensure designated services.
Failed to ensure nail care was provided to toenails for a sampled resident.
Failed to ensure potential hazardous chemicals were secured and stored behind a locked door.
Failed to ensure oxygen was administered at the physician's ordered rate and failed to provide a policy for respiratory care.
Failed to accurately account for a controlled liquid narcotic, Lorazepam, after administration.
Failed to ensure an as needed psychotropic medication was not continued past 14 days without physician's documented rationale.
Failed to maintain a medication error rate of less than 5%, resulting in medication errors during medication pass.
Failed to ensure the nurse checked the heart rate prior to administration of Digoxin, resulting in a significant medication error.
Failed to consistently implement a system to reconcile and dispose of controlled liquid narcotic Lorazepam 90 days after opening.
Failed to ensure staff's hair was contained and proper hand hygiene was used during food preparation and serving.
Failed to include pertinent information in the facility assessment to assure necessary care and resources were allocated.
Failed to maintain Legionella surveillance as part of the water management plan.
Failed to provide pneumonia vaccine for 2 of 5 residents reviewed for immunizations.
Report Facts
Discrepancy in Lorazepam narcotic log: 2.25
Number of narcotic counts performed: 430
Number of occurrences with one signature instead of two: 29
Resident census: 36
Medication error rate threshold: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed and provided statements regarding PASARR, medication errors, narcotic discrepancies, oxygen policy, psychotropic medication, and narcotic disposal |
| Registered Nurse #2 | Registered Nurse | Observed administering medication with errors and involved in narcotic counts |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Interviewed regarding nail care for Resident #20 |
| Business Office Manager | Business Office Manager (BOM) | Interviewed regarding residents' access to personal funds |
| Administrator | Administrator | Interviewed regarding facility assessment and personal funds policy |
| Maintenance Supervisor | Maintenance Supervisor (MS) | Interviewed and tested water temperature for Legionella surveillance |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety violations |
| Registered Nurse #6 | Registered Nurse | Interviewed regarding oxygen administration |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Observed narcotic count with RN #2 |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home operations, including resident care, staffing, medication management, food safety, and facility cleanliness.
Findings
The facility was found deficient in multiple areas including failure to provide safe respiratory care, inadequate RN staffing coverage, improper use and monitoring of psychotropic medications, insecure medication storage, unsafe food handling and storage practices, malfunctioning kitchen dishwasher, and failure to maintain a clean and pest-free environment in resident rooms.
Deficiencies (7)
Failed to change oxygen and CPAP tubing as ordered for Resident #27.
Failed to ensure a Registered Nurse was on duty for 8 consecutive hours daily.
Failed to ensure PRN psychotropic medication was justified and evaluated within 14 days for Resident #37.
Medications, including narcotics, were not stored in locked compartments as required.
Failed to store, prepare, and serve food in a safe and sanitary manner, including use of dented cans, unsealed produce, dirty ice chests, and improper hand hygiene by dietary staff.
Kitchen dishwasher failed to reach required wash and rinse temperatures.
Resident rooms were not kept free of pest droppings, dead bugs, and cobwebs.
Report Facts
Dates with no RN on duty: 3
RN hours on 10/15/23: 5.98
Dishwasher wash temperatures: 88
Dishwasher rinse temperatures: 105
Dishwasher wash temperatures: 91
Dishwasher rinse temperatures: 111
Dishwasher wash temperatures: 99
Dishwasher rinse temperatures: 120
Medication order date: Jul 25, 2023
Physician order date range: Oct 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and verified findings related to RN staffing and medication storage. | |
| Licensed Practical Nurse #1 | Provided information about undated oxygen and CPAP tubing. | |
| Dietary Manager | Interviewed regarding food safety deficiencies and dishwasher malfunctions. | |
| Dietary Employee #1 | Observed handling food with contaminated scoop. | |
| Dietary Employee #2 | Observed scratching arms and face without handwashing before handling food. | |
| Licensed Practical Nurse #2 | Accompanied surveyor during room inspection for pest droppings. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations, including resident care, staffing, medication management, food safety, and facility cleanliness.
Findings
The facility was found to have multiple deficiencies including failure to change and date oxygen and CPAP tubing for a resident, inadequate RN staffing for required hours, improper monitoring of psychotropic medication use, unsecured storage of narcotics, unsafe food storage and handling practices, malfunctioning kitchen dishwasher, and unclean resident rooms with pest droppings and cobwebs.
Deficiencies (6)
Failed to change and date oxygen tubing and CPAP tubing for Resident #27 as ordered.
Failed to ensure a Registered Nurse was on duty for 8 consecutive hours a day seven days a week.
Failed to ensure PRN psychotropic medication use was justified and evaluated by a doctor for Resident #37.
Failed to store narcotics in a separately locked box inside the medication room refrigerator.
Failed to store, prepare, and serve food in a safe and sanitary manner including use of dented cans, unsealed produce, dirty ice chests, contaminated water in steam table, improper hand hygiene by dietary staff, and dishwasher not reaching required temperatures.
Failed to keep resident rooms free of pest droppings, dead bugs, and cobwebs to maintain a clean and homelike environment.
Report Facts
Deficiencies cited: 6
Dates with no RN on duty: 3
RN hours on 10/15/23: 5.98
Dishwasher wash temperatures: 88
Dishwasher rinse temperatures: 105
Dishwasher wash temperatures: 91
Dishwasher rinse temperatures: 111
Dishwasher wash temperatures: 99
Dishwasher rinse temperatures: 120
Cans of cut squash with dents: 8
Cans of pinto beans with dents: 4
Cans of ham unlabeled and undated: 4
Can of corned beef hash with dents: 1
Heads of Romaine lettuce in unsealed bag: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Verified findings related to RN staffing and medication monitoring; confirmed presence of cobwebs and pest droppings |
| LPN #1 | Licensed Practical Nurse | Reported no date on oxygen tubing and CPAP tubing dated 9/24/23 |
| LPN #2 | Licensed Practical Nurse | Described bugs observed under nightstand in resident room |
| Dietary Manager | Dietary Manager | Provided information on food storage, dishwasher malfunctions, hand hygiene of dietary employees, and cleaning responsibilities |
| Dietary Employee #1 | Dietary Employee | Observed dripping contaminated water into resident food |
| Dietary Employee #2 | Dietary Employee | Observed scratching arms and face then handling food without handwashing |
Inspection Report
Routine
Deficiencies: 8
Date: Jul 15, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, food safety, and COVID-19 reporting at Crestpark Dewitt, LLC nursing home.
Findings
The facility was found deficient in multiple areas including failure to complete required pre-admission screening (PASARR), incomplete and inaccurate care plans for residents, unsafe resident transfer practices, medication errors including administration of expired insulin and incorrect dosages, poor food storage and sanitation practices in the kitchen, inadequate infection control with unsanitized reusable thermometers, and failure to timely notify residents and families of COVID-19 positive cases.
Deficiencies (8)
Failed to ensure Preadmission Screening and Resident Review (PASARR) was completed for a resident requiring it.
Failed to develop and implement complete care plans addressing all resident needs including equipment and medication.
Failed to ensure safe resident transfer techniques, transferring a resident by lifting under the arms risking injury.
Failed to maintain medication error rate below 5%, with errors including expired insulin administration and incorrect medication dosage.
Failed to discard insulin vial 28 days after opening, risking use of expired medication.
Failed to ensure kitchen equipment cleanliness, proper food storage, and discard expired food items to prevent foodborne illness.
Failed to sanitize reusable thermometer between uses, risking cross contamination and infection spread.
Failed to notify residents and families timely of changes in COVID-19 status in the facility.
Report Facts
Medication error rate: 7.14
Residents affected by medication errors: 2
Residents affected by care plan deficiencies: 4
Residents affected by transfer deficiency: 1
Residents affected by PASARR deficiency: 1
Residents affected by infection control deficiency: 40
Employees affected by infection control deficiency: 62
Residents affected by food safety deficiency: 40
Residents affected by COVID-19 notification deficiency: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication error findings related to expired insulin administration. |
| DON | Director of Nursing | Named in multiple findings including medication errors, care plan deficiencies, infection control, and COVID-19 notification. |
| MDS Coordinator | Named in care plan deficiencies and related interviews. | |
| CNA #1 | Certified Nursing Assistant | Named in unsafe transfer practice and infection control deficiency. |
| CNA #2 | Certified Nursing Assistant | Named in unsafe transfer practice. |
| LPN #1 | Licensed Practical Nurse | Named in unsafe transfer practice. |
| Social Worker | Named in failure to document COVID-19 family notifications. | |
| Administrator | Named in oversight and interview regarding COVID-19 notification and other deficiencies. |
Inspection Report
Routine
Deficiencies: 10
Date: Jul 15, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including preadmission screening, care planning, medication administration, infection control, food safety, and COVID-19 reporting.
Findings
The facility was found deficient in multiple areas including failure to complete required preadmission screening (PASARR), incomplete and outdated individualized care plans, improper resident transfer techniques, medication errors including administration of expired insulin and incorrect dosages, unsanitary food storage and preparation conditions, inadequate infection control practices related to thermometer sanitation, and failure to timely notify residents and families of COVID-19 status changes.
Deficiencies (10)
Failed to ensure Preadmission Screening and Resident Review (PASARR) was completed for a resident requiring it.
Failed to develop and implement complete care plans meeting all resident needs with measurable timetables.
Failed to ensure individualized comprehensive care plans were developed, implemented, and revised for continuity of care for multiple residents.
Failed to ensure a resident transfer was not conducted by lifting under the arms, risking injury.
Failed to maintain medication error rates below 5%, resulting in errors affecting residents.
Failed to ensure expired medications were not administered, including insulin used beyond 28 days after opening.
Failed to ensure insulin vial was discarded 28 days after opening to prevent use and complications.
Failed to ensure kitchen equipment was clean, food was stored properly to prevent contamination, and expired food items were discarded.
Failed to ensure reusable thermometer was sanitized between uses to minimize cross contamination and infection spread.
Failed to ensure residents, families, or responsible parties were informed of changes in COVID-19 status by 5:00 PM the day after a positive test.
Report Facts
Medication error rate: 7.14
Residents affected: 40
Employees affected: 62
Date of survey completion: Jul 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication error findings related to expired insulin administration. |
| DON | Director of Nursing | Named in multiple findings including medication errors, care plan deficiencies, infection control, and COVID-19 notification. |
| MDS Coordinator | Named in care plan development and revision deficiencies. | |
| CNA #1 | Certified Nursing Assistant | Named in resident transfer and infection control deficiencies. |
| LPN #1 | Licensed Practical Nurse | Named in resident transfer deficiency. |
| CNA #2 | Certified Nursing Assistant | Named in resident transfer deficiency. |
| Social Worker | Named in COVID-19 notification deficiency. | |
| Administrator | Named in COVID-19 notification deficiency and overall facility oversight. |
Viewing
Loading inspection reports...
