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)
10.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
98% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
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
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
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. |
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