Inspection Reports for
Evergreen Living Center at Stagecoach
6907 Highway 5 North, Bryant, AR, 72022
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 31, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure staff followed a care plan requiring two staff members to perform a mechanical lift transfer for Resident #43, which resulted in a fractured femur.
Complaint Details
The complaint investigation found that a CNA performed a mechanical lift transfer alone on 01/26/2025 despite the care plan requiring two staff members. The resident was found with a swollen knee and later diagnosed with an acute angulated spiral fracture of the distal right femur. The CNA admitted to not seeking help due to short staffing and was suspended. The Medical Director did not consider the fracture to be Immediate Jeopardy and believed it was spontaneous.
Findings
The facility failed to follow the care plan requiring two staff members for mechanical lift transfers, leading to Resident #43 sustaining a right distal femur fracture. Staff were short-staffed, and a CNA performed the transfer alone without assistance or reporting the improper transfer. The facility initiated training and monitoring after the incident.
Deficiencies (1)
Failure to ensure staff followed a care plan requiring two staff members to perform a mechanical lift transfer for Resident #43.
Report Facts
Date of incident: Jan 26, 2025
Date of survey: Jan 31, 2025
Number of staff needing training: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Performed mechanical lift transfer alone on 1/26/2025, did not report improper transfer, suspended after incident |
| LPN #3 | Licensed Practical Nurse | Notified of resident's swollen knee and pain on 1/26/2025, coordinated hospice notification and x-ray |
| Director of Nursing | Director of Nursing (DON) | Conducted competencies and training on mechanical lift transfers, monitored staff compliance after incident |
| Registered Nurse #4 | Registered Nurse | Administered morphine for resident's pain on 1/26/2025 |
| Medical Director | Medical Director | Evaluated fracture and stated it was likely spontaneous, not Immediate Jeopardy |
Inspection Report
Routine
Census: 98
Deficiencies: 2
Date: Jan 31, 2025
Visit Reason
The inspection was conducted to assess compliance with care planning requirements for residents receiving hospice services and to evaluate the posting of daily nurse staffing information.
Findings
The facility failed to ensure that the Comprehensive Care Plan included necessary information about hospice services for one resident receiving hospice care. Additionally, the facility failed to post daily nurse staffing information in a clear and accessible format including required details such as facility name, date, census, and hours worked.
Deficiencies (2)
Failure to ensure the Comprehensive Care Plan contained necessary information to fully provide and coordinate care and services for a resident receiving hospice services.
Failure to post and make readily accessible daily nurse staffing information including facility name, date, total census, and actual hours worked by nursing staff.
Report Facts
Residents affected: 1
Residents affected: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding care plan for resident receiving hospice services | |
| Director of Nursing (DON) | Confirmed hospice services and care plan requirements; interviewed about nurse staffing posting | |
| Administrator | Interviewed about required information on posted nursing staffing schedule |
Inspection Report
Routine
Deficiencies: 10
Date: Jan 12, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, safety, infection control, medication management, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to coordinate pre-admission screening for mental health services, incomplete care plans addressing psychiatric diagnoses and tube feedings, inadequate personal hygiene care, unsecured hazardous areas, undated oxygen tubing, improper medication room key control, poor food preparation and storage practices, and inadequate infection prevention measures including lack of PPE and improper hand hygiene during resident feeding.
Deficiencies (10)
Failed to coordinate with the State Agency for Pre-admission Screening and Resident Review (PASARR) for appropriate mental health services for residents #59 and #40.
Failed to develop and implement a comprehensive care plan addressing anxiety and depression for Resident #22.
Failed to review and revise care plan to address tube feedings for Resident #43.
Failed to ensure fingernails were trimmed, cleaned, and free of jagged edges for Resident #18 dependent on staff for nail care.
Failed to ensure shower door on 400 Hall and cabinet on 100 Hall were locked to prevent accidental ingestion of harmful chemicals.
Failed to ensure oxygen tubing for Resident #10 was dated to reduce risk of infection.
Failed to restrict medication room keys to licensed staff only, allowing unlicensed personnel access.
Failed to serve meals in a manner that maintained palatability and appearance, with watery beef stroganoff and thick pureed bread.
Failed to ensure clean dishes and glasses were stored to prevent cross contamination; thickened liquids were not dated when opened; refrigerator temperature was above safe levels; and employees failed to wash hands and change gloves appropriately.
Failed to provide adequate PPE on isolation carts and ensure staff sanitized hands appropriately when assisting residents with meals, risking infection spread.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 7
Residents affected: 4
Residents affected: 89
Residents affected: 58
Residents affected: 20
Residents affected: 7
Temperature: 45
Received date: Dec 16, 2023
COVID residents: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Described medication orders and care plan usage for Resident #22 |
| Nurse Consultant #1 | Discussed PASARR process and oxygen tubing policy | |
| Nurse Consultant #2 | Provided in-service details on PASARR | |
| Director of Nursing | DON | Provided policies, answered questions on care plans, medication room access, PPE, and infection control |
| Assistant Director of Nursing | ADON | Provided policies and described care plan expectations |
| LPN #3 | Licensed Practical Nurse | Described nail care procedures and refusals for Resident #18 |
| CNA #3 | Certified Nursing Assistant | Described nail care assistance and refusals for Resident #18 |
| Dietary Employee #1 | Described food preparation methods | |
| Dietary Employee #3 | Described food appearance during meal service | |
| Certified Dietary Manager | Discussed thickened liquids dating policy | |
| Certified Nursing Assistant #4 | CNA | Reported missing PPE on isolation carts |
| Administrator | Provided PPE supplies and policies | |
| Infection Preventionist | IP | Discussed responsibilities for isolation cart maintenance |
| Certified Nursing Assistant #2 | CNA | Observed feeding residents without hand sanitizer use |
| Certified Nursing Assistant #1 | CNA | Observed pulling wheelchair and feeding residents without hand sanitizer use |
Inspection Report
Routine
Deficiencies: 8
Date: Oct 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, and facility environment.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints, failure to document gastrotomy tubes on MDS, inadequate incontinent care, failure to provide wound care as ordered, improper feeding tube medication administration, medication storage issues, unsafe medication handling, serving meals at unsafe temperatures, and unsafe storage of chemicals in resident bathrooms.
Deficiencies (8)
Failure to ensure residents were free from physical restraints as evidenced by locked wheels on a resident's wheelchair with a lap tray attached.
Failure to document gastrotomy tube on the Comprehensive Minimum Data Set for a resident with feeding tubes.
Failure to provide routine incontinent care and change clothing to maintain hygiene for dependent residents.
Failure to provide wound care according to physician's orders and failure to provide range of motion and repositioning every two hours as ordered.
Failure to verify feeding tube placement before administering medication.
Failure to ensure medications and biologicals were stored at correct temperatures and medications were left at bedside.
Failure to serve meals at acceptable temperatures to improve palatability and encourage nutritional intake.
Failure to maintain a safe environment by leaving chemicals accessible in resident bathrooms on the secured unit.
Report Facts
Residents affected by restraint deficiency: 1
Residents sampled with feeding tubes: 3
Residents affected by incontinent care deficiency: 2
Residents sampled with wound care orders: 4
Residents affected by feeding tube medication administration deficiency: 1
Residents affected by medication storage and handling deficiency: 1
Residents affected by unsafe environment on secured unit: 27
Residents affected by meal temperature deficiency: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Named in feeding tube medication administration and medication storage findings |
| Director of Nursing | DON | Interviewed regarding restraint use, feeding tube medication administration, and wound care |
| Certified Nursing Assistant #5 | CNA | Observed unlocking wheelchair brakes and interviewed about restraint use |
| Certified Nursing Assistant #6 | CNA | Interviewed about restraint device use |
| Certified Nursing Assistant #7 | CNA | Interviewed about restraint device use |
| Assistant Director of Nursing | ADON | Interviewed about medication refrigerator temperature |
| Dietary Supervisor | Provided meal temperature readings and interview | |
| Social Director | Interviewed about chemicals in resident bathrooms | |
| Administrator | Provided policies and education reports |
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