Inspection Reports for
Crestpark Stuttgart, LLC
707 West 20th Street, Stuttgart, AR, 72160
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
106% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
39% occupied
Based on a August 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 1
Date: Mar 27, 2025
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically focusing on staff hand hygiene practices during resident feeding.
Findings
The facility failed to ensure staff performed proper hand hygiene when feeding residents, affecting 4 residents observed requiring assistance with dining. Multiple observations documented staff not washing or sanitizing hands between feeding residents or after touching potentially contaminated surfaces.
Deficiencies (1)
Failure to ensure staff performed proper hand hygiene when feeding residents, affecting 4 residents observed requiring assistance with dining.
Report Facts
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager #11 | Dietary Manager | Stated staff should wash hands between residents when feeding and should not have cell phones or personal drinks at the resident's table |
| Director of Nursing | Director of Nursing | Verified staff should wash hands between resident contact and stated staff should not have personal beverages or cell phones while feeding residents |
Inspection Report
Routine
Census: 47
Deficiencies: 2
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care and facility safety, including call light accessibility and environmental cleanliness.
Findings
The facility failed to ensure call lights were within reach of three sampled residents, posing a risk for timely assistance. Additionally, the facility did not maintain clean air vents, with mold and black residue observed in multiple resident rooms and bathrooms, potentially risking airborne sickness.
Deficiencies (2)
Call lights were not placed within reach of 3 of 5 sampled residents, limiting their ability to call for assistance.
Air vents in resident rooms and bathrooms were coated with black substance and mold, posing a risk for airborne sickness.
Report Facts
Residents affected by call light deficiency: 3
Total residents in facility: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed confirming importance of call lights being in reach |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed confirming importance of call lights being in reach |
| Director of Nursing | Director of Nursing | Interviewed regarding policy on call lights; stated no specific policy or in-service |
| Housekeeping Supervisor | Housekeeping Supervisor | Described black substance on vents as smoke residue and dust/mold |
| Maintenance Director | Maintenance Director | Confirmed mold on vents and discussed cleaning and maintenance responsibility |
| Administrator | Administrator | Denied prior knowledge of black substance on vents and stated intent to address |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Jan 12, 2024
Visit Reason
The inspection was conducted due to complaint investigations and recertification survey focusing on medication errors, resident abuse, involuntary seclusion, financial mismanagement, and other regulatory compliance issues.
Complaint Details
The complaint investigation included allegations of involuntary seclusion, medication errors, failure to pay interest on trust accounts, failure to notify representatives of hospital transfers, and inadequate fall prevention. Immediate jeopardy was identified related to involuntary seclusion and fall prevention. The facility took corrective actions including termination of involved staff, staff training, and monitoring to remove immediate jeopardy.
Findings
The facility was found deficient in multiple areas including failure to prevent medication self-administration without physician orders, failure to pay interest on resident trust accounts, involuntary seclusion of a resident resulting in immediate jeopardy, failure to notify resident representatives of hospital transfers, incomplete care plans, inadequate fall prevention and monitoring, medication errors exceeding acceptable rates, unsafe medication storage, and food safety violations. Immediate jeopardy related to fall prevention and resident safety was identified and removed after corrective actions.
Deficiencies (13)
Allow residents to self-administer drugs only if clinically appropriate and with physician orders; failure to ensure this for Resident #44.
Failed to ensure resident trust accounts received monthly interest affecting Residents #198 and #23.
Involuntary seclusion of Resident #34 by staff holding door closed; immediate jeopardy to resident health or safety.
Failure to report founded abuse to CNA registry for Resident #34 incident.
Failure to notify Resident #34's representative and Ombudsman of hospital transfer and bed hold policy.
Care plans not reviewed or revised timely to reflect oxygen use, antidepressant, antipsychotic use, and fall risk for multiple residents.
Failure to provide regular nail care for Resident #18 requiring assistance.
Failure to ensure effective fall prevention program including monitoring and maintenance of anti-rollbacks for Resident #148 and others; resulted in immediate jeopardy.
Failure to date oxygen tubing and post Oxygen in Use signage for Resident #23 and others.
Medication error rate exceeded 5% with incomplete medication administration for Residents #14 and #148.
Medications left at bedside without physician order for Resident #7; narcotics stored unsecured in medication room refrigerator.
Food safety violations including improper thawing of raw meat, expired food items, dented cans, and cross contamination during meal preparation.
Quality Assurance and Performance Improvement program failed to prevent repeated medication errors and other deficiencies.
Report Facts
Medication error rate: 7.14
Residents affected by involuntary seclusion: 1
Residents affected by trust account interest failure: 2
Residents affected by fall prevention failure: 5
Residents affected by medication left at bedside: 1
Residents affected by oxygen tubing and signage failure: 4
Residents affected by nail care failure: 1
Residents affected by food safety violations: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error and oxygen signage findings |
| LPN #2 | Licensed Practical Nurse | Named in medication error finding |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding abuse incident and fall prevention |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding anti-rollbacks training |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding oxygen use and medication storage |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding abuse incident and fall prevention |
| CNA #4 | Certified Nursing Assistant | Interviewed regarding abuse incident |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding abuse incident |
| CNA #6 | Certified Nursing Assistant | Interviewed regarding anti-rollbacks |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication storage, oxygen signage, fall prevention, and abuse |
| Administrator | Administrator | Interviewed regarding abuse incident, QAPI, and corrective actions |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety violations |
| Maintenance | Maintenance Staff | Interviewed regarding anti-rollbacks maintenance |
Inspection Report
Routine
Census: 60
Deficiencies: 16
Date: Jan 6, 2023
Visit Reason
Routine inspection of Crestpark Stuttgart, LLC nursing home to assess compliance with regulatory requirements including resident rights, medication administration, environment, restraints, dietary services, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by posting care signs in resident rooms, medication administration errors and delays, privacy breaches during medication passes, environmental maintenance issues, improper use of physical restraints, dietary service errors including failure to follow tray cards and prepare pureed foods properly, inadequate food storage and sanitation practices, incomplete attendance and documentation in Quality Assurance meetings, improper laundry PPE use, and deficiencies in the Antibiotic Stewardship Program.
Deficiencies (16)
Facility failed to ensure staff avoided placing signs with residents' personal care information in areas visible to others, affecting dignity and respect.
Failed to ensure physician ordered medications were administered as ordered, including late medication passes and incomplete documentation.
Medication Administration Record binder was left open and medication cart unlocked when out of nurse's sight, risking privacy breaches.
Floor tiles were cracked with glue leaking, not cleaned timely, compromising a clean homelike environment.
Resident wheelchair was physically restrained by locking brakes during lunch without medical justification.
Medication cart was not locked during medication pass, risking accidents and medication security.
Catheter drainage bag was not maintained off the floor or in a privacy bag, risking infection and dignity.
Physician ordered pain medications were not administered timely and documentation was inaccurate.
Medication error rate was 20%, with medications given late or omitted, violating safe medication administration.
Resident preferences were not followed in dietary services; pureed foods were prepared improperly affecting nutrition and safety.
Pureed food items were not blended to a smooth, lump-free consistency, risking choking hazards.
Physician ordered mechanically altered diets were not followed, such as missing gravy on ground meat.
Foods in kitchen were not properly labeled, dated, or stored; spices were outdated; ice machine was dirty; kitchen vents and ceilings were dusty.
Quality Assessment and Assurance (QAA) committee meetings lacked required members including Medical Director and Director of Nursing, limiting meaningful participation.
Laundry staff shared disposable gowns, risking cross-contamination; facility lacked laundry policy.
Antibiotic Stewardship Program was incomplete; lacked protocols to ensure appropriate antibiotic use and monitoring of effectiveness; documentation and follow-up were inadequate.
Report Facts
Residents affected: 60
Medication errors: 5
Medication error rate: 20
Residents receiving antibiotics: 11
Residents receiving antibiotics: 13
Residents receiving antibiotics: 12
UTI infections: 3
UTI infections: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication administration delay and documentation deficiency |
| Director of Nursing | Director of Nursing | Named in medication administration oversight, antibiotic stewardship, and QAA meeting attendance |
| Administrator | Facility Administrator | Named in multiple interviews regarding policies, QAA meetings, and infection control |
| Dietary Manager | Dietary Manager | Named in dietary service deficiencies and kitchen sanitation issues |
| Laundry Employee #1 | Laundry Employee | Named in improper PPE use during laundry handling |
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