Inspection Reports for
Jamestown Nursing and Rehab, LLC
2001 Hampton Place, Rogers, AR, 72758
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
24
18
12
6
0
Inspection Report
Deficiencies: 1
Date: May 22, 2025
Visit Reason
The inspection was conducted to evaluate compliance with medication administration protocols, specifically focusing on the proper administration of insulin to residents.
Findings
The facility failed to follow the manufacturer's instructions during insulin administration for one resident, including not priming the insulin pen and not holding the dose plunger for the required count, which could result in incomplete dosing.
Deficiencies (1)
Failure to follow manufacturer's instructions during insulin administration, including not priming the insulin pen and not holding the dose plunger for the required count.
Report Facts
Residents sampled for medication administration: 4
Residents affected: 1
Nursing staff trained: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Observed improperly administering insulin pen to Resident #69 |
| Director of Nursing | Director of Nursing | Confirmed proper insulin pen administration procedure and facility expectations |
| Resident #69's Primary Care Physician | Primary Care Physician | Confirmed the insulin dose ordered and administration expectations |
Inspection Report
Inspection Report
Deficiencies: 7
Date: Dec 11, 2024
Visit Reason
The inspection was conducted due to concerns related to resident care, including refusal of wound care, pain management, and behavioral health issues, as well as staffing and medication management.
Findings
The facility was found to have immediate jeopardy related to failure to provide adequate care for a resident with severe wounds and refusal of care, inadequate staffing levels, medication administration issues including late medication delivery and missing controlled substances, failure to maintain secure medication storage, and failure to perform proper infection control practices during meal service.
Deficiencies (7)
Failure to protect residents from abuse and neglect resulting in immediate jeopardy due to maggot infestation in a resident's wound and failure to provide adequate care.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to assess, monitor, and treat wounds adequately.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Failure to provide appropriate treatment and services to residents with mental disorders or psychosocial adjustment difficulties, resulting in deterioration of mental and psychosocial health.
Failure to maintain an account of all controlled substances and maintain accurate records for controlled substances on medication carts; failure to administer medications within specified times for some residents.
Failure to keep medications safely secured on one medication cart, leaving medication cards and medication exposed and unattended.
Failure to perform hand hygiene during meal service in one dining room, risking infection transmission to residents.
Report Facts
Medication administration late occurrences: 3
Staffing shifts with insufficient staff: 74
Medication cart narcotic count discrepancies: 4
Resident pain assessments above zero: 9
Resident wound care refusals: 29
Resident wound care refusals: 30
Resident wound care refusals: 31
Resident wound care refusals: 30
Resident wound care refusals: 23
Medication administration late occurrences: 83
Medication administration late occurrences: 35
Medication administration late occurrences: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #14 | Licensed Practical Nurse | Named in relation to medication administration delays and staffing shortages. |
| SSDN | Social Services Discharge Nurse | Named in relation to medication administration delays and controlled substance documentation. |
| RN #12 | Registered Nurse | Observed leaving medication cart unlocked and medication card unattended. |
| NA #9 | Nursing Assistant | Observed serving meals without hand hygiene. |
| CNA #10 | Certified Nursing Assistant | Observed serving meals without hand hygiene and improper handling of milk carton. |
| F-ADON | Former Assistant Director of Nursing | Conducted in-service on narcotic counts and medication card verification. |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, hygiene, infection prevention, and hand hygiene practices at Jamestown Nursing and Rehab, LLC.
Findings
The facility failed to provide timely personal care to maintain hygiene for a resident with incontinence, and failed to ensure proper hand hygiene and glove use during meal service, medication administration, and incontinent care for multiple residents, increasing risk of infection and skin breakdown.
Deficiencies (2)
Failure to provide necessary services in a timely manner to maintain good hygiene for Resident #21 who was unable to carry out personal care without assistance.
Failure to perform hand hygiene and change gloves appropriately during meal service, medication administration, and incontinent care for multiple residents, leading to potential spread of infections.
Report Facts
Residents affected: 1
Residents affected: 5
BIMS scores: 15
BIMS scores: 2
BIMS scores: 3
BIMS scores: 15
BIMS scores: 5
SAMS score: 3
Medication dosage: 88
Medication dosage: 25
Inspection date: Jun 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #6 | Registered Nurse | Observed failing to perform hand hygiene during medication administration for Residents #69 and #392 |
| CNA #5 | Certified Nursing Assistant | Observed confirming wet sheets and discussing rounding every two hours for Resident #21 |
| CNA #7 | Certified Nursing Assistant | Observed failing to perform hand hygiene and glove changes during incontinent care for Resident #82 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding hand hygiene policies and rounding frequency |
| CNA Coordinator | CNA Coordinator | Provided course documentation for Care Academy training |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) / Infection Control Preventionist (ICP) | Interviewed regarding infection control practices and hand hygiene |
| Administrator | Administrator | Interviewed regarding hand hygiene and glove change policies |
Inspection Report
Routine
Deficiencies: 12
Date: Jun 13, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, privacy, care, safety, medication management, infection control, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meal service, privacy breaches with unattended personal health information, failure to coordinate PASARR evaluations, inadequate hygiene care, unsafe storage of chemicals and medications, improper medication documentation and storage, expired food items in the kitchen, failure to perform hand hygiene and glove changes during care and medication administration, and unsafe environmental conditions such as missing vinyl flooring and lack of night light covers.
Deficiencies (12)
Failure to ensure staff did not stand over residents during meal service to maintain dignity.
Failure to maintain privacy due to personal health information left unattended in public areas.
Failure to coordinate PASARR screening and evaluation for designated services.
Failure to provide timely hygiene care for incontinent resident.
Failure to maintain a safe environment by improper storage of chemicals, unattended razor blades, and lack of smoking assessment.
Oxygen order lacked parameters to prevent respiratory complications.
Failure to properly document receipt and disposition of controlled narcotics.
Medications and biologicals not stored in locked compartments; narcotic box not double locked.
Medications left unattended in resident rooms, including open bottles and sprays.
Expired food items found in storage and freezer areas.
Failure to perform hand hygiene and glove changes during meal service, medication administration, and incontinent care.
Unsafe environment due to missing vinyl flooring and lack of night light covers in resident rooms.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 5
Residents affected: 3
Residents affected: 3
Residents affected: 92
Residents affected: 5
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #6 | Registered Nurse | Observed failing to perform hand hygiene during medication administration |
| CNA #7 | Certified Nursing Assistant | Observed failing to perform hand hygiene and glove changes during incontinent care |
| CNA #3 | Certified Nursing Assistant | Observed failing to perform hand hygiene and glove changes during incontinent care |
| CNA #4 | Certified Nursing Assistant | Observed failing to perform hand hygiene and glove changes during incontinent care |
| CNA / Unit Manager | Certified Nursing Assistant / Unit Manager | Observed failing to perform hand hygiene during meal service |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for staff behavior and policies |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) / Infection Control Preventionist (ICP) | Interviewed regarding infection control practices |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Interviewed regarding medication and chemical storage |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Interviewed regarding medication and chemical storage |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding narcotic box lock and flooring hazards |
| Dietary Manager | Dietary Manager | Interviewed regarding expired food items |
| Administrator | Administrator | Interviewed regarding policies and procedures |
Inspection Report
Routine
Deficiencies: 9
Date: May 18, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, infection control, food safety, and facility operations at Jamestown Nursing and Rehab, LLC.
Findings
The facility was found deficient in multiple areas including failure to assist residents with dignity during meals, inadequate assessment for self-administration of medications, incomplete care plans, poor personal hygiene care for residents, unsafe storage of smokeless tobacco, lack of physician orders for oxygen administration, unsecured medications, improper food storage and handling, and failure to perform proper hand hygiene and infection control practices.
Deficiencies (9)
Failure to assist residents with meals to promote dignity and respect.
Failure to ensure residents were assessed to safely self-administer medications.
Failure to update individualized care plans for residents with new services or levels of care.
Failure to provide necessary grooming and personal hygiene care to a resident who was unable to perform ADLs.
Failure to ensure smokeless tobacco was stored securely and out of reach of cognitively impaired residents.
Failure to ensure residents had physician orders for oxygen administration and proper oxygen care planning.
Failure to ensure medication carts were locked and medications secured when unattended.
Failure to ensure food items were properly sealed, stored, and maintained at safe temperatures; failure to maintain clean ice machines; failure to perform hand hygiene during food handling.
Failure to perform hand hygiene before, during, and after resident care including meal assistance, IV line flushing, and catheter care.
Report Facts
Residents sampled: 32
Residents affected: 4
Residents affected: 8
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 105
Residents affected: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in findings related to oxygen administration and hand hygiene |
| LPN #4 | Licensed Practical Nurse | Named in findings related to oxygen administration and hand hygiene |
| CNA #5 | Certified Nursing Assistant | Named in findings related to meal assistance and hand hygiene |
| CNA #6 | Certified Nursing Assistant | Named in findings related to hand hygiene and catheter care |
| Director of Nursing | Director of Nursing | Interviewed regarding care planning, hand hygiene, and medication security |
| Administrator | Facility Administrator | Interviewed regarding medication security and storage of hazardous substances |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 10, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure that a resident (Resident #1) who was able to move independently did not leave the facility without staff monitoring, posing a risk of injury.
Complaint Details
The complaint investigation found that Resident #1 left the building multiple times without staff supervision. The facility was notified after the resident was found outside sitting in a wheelchair near the garage. The resident was cognitively intact but required limited assistance. The facility placed the resident on 15-minute checks and notified appropriate staff and family. The alarm on the exit door did not sound or was not heard during the incidents. The facility policy requires security systems to be on and routinely tested.
Findings
The facility failed to prevent Resident #1 from leaving the building unmonitored multiple times, despite alarms on exit doors and staff checks. Resident #1 was found outside the building on several occasions, with the longest time outside being approximately 14 minutes. The facility implemented every 15-minute checks after the incidents.
Deficiencies (1)
Failure to ensure Resident #1 did not leave the facility without staff monitoring, posing a risk of injury.
Report Facts
Time resident was outside: 14
BIMS score: 13
Date of incident: May 3, 2023
Frequency of checks: 15
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