Inspection Reports for
Katherines Place at Wedington
4405 West Persimmon Street, Fayetteville, AR, 72704
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
121% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
86% occupied
Based on a May 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of verbal abuse by a Certified Nursing Assistant (CNA) towards Resident #5 during a bed bath on 04/08/2025.
Complaint Details
The complaint involved an allegation by Resident #5 that a CNA called them a derogatory name during care on 04/08/2025. The allegation was reported to the Administrator in Training the same day but was not reported to the State Licensing Agency immediately as required. Investigations including interviews with CNAs, the Director of Nursing, Administrator, and Administrator in Training found no verbal abuse occurred. The resident changed the wording of the allegation during the investigation. The complaint was ultimately not substantiated as abuse.
Findings
The facility failed to timely report the alleged verbal abuse incident to the State Licensing Agency. After investigation, including interviews and witness statements, the Director of Nursing concluded that no verbal abuse occurred as the CNA was conversing about family members and not addressing the resident. The allegation was initially reported as 'big back' but later changed by the resident to 'fat ass'.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents reviewed for abuse: 5
Assessment Reference Date: Apr 13, 2025
Care Plan revision date: Mar 15, 2025
Date of incident: Apr 8, 2025
Date of interviews: Apr 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA #1) | Named in investigation regarding alleged verbal abuse incident | |
| Certified Nursing Assistant (CNA #2) | Named in investigation regarding alleged verbal abuse incident | |
| Director of Nursing (DON) | Conducted follow-up investigation and concluded no verbal abuse | |
| Administrator | Interviewed regarding reporting and investigation of abuse allegation | |
| Administrator in Training (AIT) | Initially notified of the incident and spoke to resident and staff |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2025
Visit Reason
The inspection was conducted due to an allegation of verbal abuse reported by Resident #5 during a bed bath on 04/08/2025.
Complaint Details
The complaint involved an allegation of verbal abuse by a CNA toward Resident #5 during a bed bath on 04/08/2025. The allegation was reported to the Administrator in Training on the same day but was not reported to the State Licensing Agency as required. Investigations by the DON and Administrator found no verbal abuse occurred. The resident's statements changed from 'big back' to 'fat ass' during the investigation. The complaint was ultimately not substantiated as abuse.
Findings
The facility failed to report the alleged verbal abuse incident to the State Licensing Agency within the required timeframe. After investigation, including interviews with staff and the resident, the Director of Nursing concluded there was no verbal abuse as the staff were conversing about family members and not the resident. The allegation was initially reported late and the resident's description of the incident changed over time.
Deficiencies (1)
Failure to timely report suspected abuse to the State Licensing Agency.
Report Facts
Residents reviewed for abuse: 5
Assessment Reference Date: Apr 13, 2025
Brief Interview of Mental Status (BIMS) score: 14
Date of incident: Apr 8, 2025
Date of interviews: Apr 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in verbal abuse allegation and investigation |
| CNA #2 | Certified Nursing Assistant | Witness and involved in investigation of verbal abuse allegation |
| Director of Nursing | Director of Nursing (DON) | Conducted follow-up investigation and concluded no verbal abuse |
| Administrator | Administrator | Oversaw reporting and investigation of abuse allegation |
| Administrator in Training | Administrator in Training (AIT) | Received initial report of abuse allegation and participated in investigation |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: May 16, 2024
Visit Reason
The inspection was conducted based on complaint investigations regarding failure to notify residents of bed hold following hospital transfers, incomplete care plans for high-risk medications and oxygen usage, improper wound care, medication regimen review lapses, food service issues, and infection control practices.
Complaint Details
The visit was complaint-driven, investigating allegations of failure to notify residents of bed hold after hospital transfers, incomplete care plans, improper wound and respiratory care, medication regimen review lapses, food service issues, and infection control deficiencies. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to send bed hold notification letters after hospital transfers, incomplete initiation and revision of care plans for residents' medications and oxygen therapy, failure to follow physician orders for wound care and respiratory care, inadequate medication regimen reviews, improper food handling and preparation, and lapses in infection prevention and control practices such as hand hygiene and aseptic technique during wound care.
Deficiencies (10)
Failure to send bed hold notification letter to resident and/or representative following hospital transfer for Resident #13.
Failure to initiate care plan interventions for oxygen usage and high-risk medications for Residents #13, #15, and #99.
Failure to revise care plans to reflect current physician orders for Residents #13, #15, and #46.
Failure to follow physician orders during wound care dressing changes for Residents #4 and #32, including not patting wound dry.
Failure to follow physician orders for changing oxygen tubing and humidifier bottle for Resident #99.
Failure to ensure monthly medication regimen review by licensed pharmacist for Resident #91.
Failure to maintain food at safe temperatures and palatable appearance during meal service.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failure to ensure dietary staff washed hands and changed gloves before handling food items, risking cross contamination.
Failure to perform proper hand hygiene and aseptic technique during wound care for Residents #4 and #32, including improper glove use and inadequate disinfection of equipment.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 11
Residents affected: 8
Residents affected: 13
Residents affected: 5
Residents affected: 25
Residents affected: 6
Residents affected: 9
Total census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Named in wound care and infection control deficiencies for improper hand hygiene and glove use |
| Licensed Practical Nurse #3 | LPN | Confirmed medication orders not identified on care plans for high-risk medications |
| Registered Nurse #1 | RN | Observed and confirmed oxygen tubing and humidifier bottle issues for Resident #99 |
| Director of Nursing | DON | Confirmed multiple care plan and infection control deficiencies; provided explanations during interviews |
| Business Office Manager | BOM | Confirmed failure to send bed hold notification letter for Resident #13 |
| Dietary Employee #1 | DE | Observed preparing pureed food with improper consistency |
| Dietary Employee #2 | DE | Observed handling food without proper hand hygiene |
| Dietary Employee #3 | DE | Observed handling food with contaminated gloves |
| Dietary Employee #4 | DE | Observed handling food with contaminated gloves |
Inspection Report
Routine
Deficiencies: 10
Date: May 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility operations at Katherine's Place at Wedington.
Findings
The facility was found deficient in multiple areas including failure to notify residents or representatives of bed hold after hospital transfers, incomplete care plans for high-risk medications and oxygen use, failure to revise care plans timely, improper wound care practices, failure to follow physician orders for wound care and oxygen equipment maintenance, inadequate medication regimen reviews, improper food handling and meal service practices, and lapses in infection prevention and control including hand hygiene during wound care.
Deficiencies (10)
Failed to ensure bed hold notification was sent to resident or representative following hospital transfer.
Failed to initiate care plan interventions for oxygen usage and high-risk medications for 3 residents.
Failed to revise resident care plans to reflect current physician orders for 3 residents.
Failed to follow physician's orders for wound care during dressing changes for 2 residents.
Failed to ensure physician's orders were followed for changing oxygen tubing and humidifier bottle for 1 resident.
Failed to ensure monthly medication regimen review was completed for 1 resident.
Failed to serve meals at safe temperatures and maintain palatability for residents receiving meal trays.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents on pureed diets.
Failed to ensure dietary staff washed hands and changed gloves before handling food items, risking cross contamination.
Failed to perform proper hand hygiene before and during wound care to maintain aseptic technique and prevent cross contamination for 2 residents.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 9
Residents affected: 103
Residents affected: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Named in wound care and hand hygiene deficiencies |
| Licensed Practical Nurse #3 | LPN | Confirmed medication care plan deficiencies |
| Registered Nurse #1 | RN | Observed oxygen care deficiencies |
| Director of Nursing | DON | Interviewed regarding multiple care plan, medication, and infection control deficiencies |
| Business Office Manager | BOM | Confirmed bed hold notification deficiency |
| Dietary Employee #1 | Dietary Staff | Observed preparing pureed food with improper consistency |
| Dietary Employee #2 | Dietary Staff | Observed handling food without proper hand hygiene |
| Dietary Employee #3 | Dietary Staff | Observed handling food without proper hand hygiene |
| Dietary Employee #4 | Dietary Staff | Observed handling food without proper hand hygiene |
Inspection Report
Routine
Census: 94
Deficiencies: 9
Date: May 18, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including call light accessibility, resident privacy, personal property access, care plan implementation, personal hygiene and grooming, food safety and sanitation, infection prevention practices, COVID-19 staff vaccination compliance, and pest control in the kitchen.
Deficiencies (9)
Call lights were not consistently within reach for residents, potentially affecting 77 residents.
Residents' confidential information was overheard by family members during shift change affecting 16 residents.
Residents were not allowed to have personal property within reach, affecting 94 residents.
Care plans were not fully implemented or accessible to staff for resident #245 with diet and nutritional needs.
Residents dependent on staff for nail care and shaving were not adequately groomed, affecting 90 residents for nail care and 39 for shaving.
Food items in the kitchen were not dated, kitchen appliances were unclean, and staff failed to wash hands properly, risking cross contamination affecting all 94 residents.
Toothbrushes for residents #36 and #87 were stored uncovered and unlabeled, risking infection transmission.
Staff COVID-19 vaccination compliance was incomplete, with some staff partially vaccinated or unvaccinated, and data submission to NHSN was not timely.
Pest control in the kitchen was inadequate as live roaches were observed, risking contamination affecting all residents served by the kitchen.
Report Facts
Residents affected by call light deficiency: 77
Residents affected by privacy breach: 16
Residents affected by personal property access issue: 94
Residents affected by care plan implementation deficiency: 1
Residents affected by grooming deficiencies (nail care): 90
Residents affected by grooming deficiencies (shaving): 39
Total residents receiving meals from kitchen: 94
Staff partially vaccinated for COVID-19: 3
Staff and residents tested positive for COVID-19 since 09/15/22: 34
Residents affected by pest control deficiency: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Assisted in call light placement for Resident #145 | |
| Certified Nursing Assistant #9 | Provided information on shaving and grooming process for residents #36 and #53 | |
| Certified Nursing Assistant #8 | Discussed toothbrush storage and labeling procedures | |
| Director of Nursing | Director of Nursing (DON) | Provided information on call light policy, care plans, resident grooming, toothbrush storage, and COVID-19 vaccination requirements |
| Administrator | Provided grievance logs, COVID-19 vaccination policy, and pest control reports | |
| Dietary Supervisor | Provided information on kitchen sanitation and food safety | |
| Dietary Employee #1 | Observed handling food without hand washing | |
| Dietary Employee #3 | Observed handling food and beverages without hand washing | |
| Licensed Practical Nurse #1 | Identified improperly stored toothbrush and stated it would be discarded | |
| Licensed Practical Nurse #2 | Assisted with fingernail care for Resident #346 | |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided matrix of residents affected and timesheets for staff vaccination status |
Inspection Report
Routine
Census: 94
Deficiencies: 9
Date: May 18, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for nursing home care, including resident rights, care plans, hygiene, infection control, food safety, and staff vaccination status.
Findings
The facility was found deficient in multiple areas including call light accessibility, confidentiality breaches during shift change, residents' personal property accessibility, care plan implementation, personal hygiene and grooming, food safety and sanitation, infection prevention practices, COVID-19 staff vaccination compliance, and pest control in the kitchen.
Deficiencies (9)
Failed to ensure call lights were within reach for residents to call for assistance.
Failed to maintain confidentiality of residents' personal and medical information during shift change.
Failed to allow residents to have personal property within reach to create a homelike environment.
Failed to ensure care plans were implemented and accessible to staff responsible for interventions.
Failed to ensure residents' fingernails were cleaned and trimmed and shaving/beard trimming services were regularly provided.
Failed to ensure food items were dated, kitchen appliances were clean, and staff washed hands properly to prevent cross contamination.
Failed to properly store and label residents' toothbrushes to prevent infection.
Failed to ensure all staff were fully vaccinated against COVID-19 and failed to submit vaccination data timely.
Failed to maintain a pest control program that effectively prevented pests in the kitchen.
Report Facts
Residents affected by call light deficiency: 77
Residents affected by confidentiality breach: 16
Residents affected by personal property accessibility issue: 94
Residents affected by care plan implementation deficiency: 1
Residents affected by hygiene and grooming deficiencies: 90
Residents affected by shaving and beard trimming deficiencies: 39
Total census: 94
Staff partially vaccinated: 3
Staff worked without full vaccination: 2
Residents tested positive for COVID-19 since 09/15/22: 18
Staff tested positive for COVID-19 since 09/15/22: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Assisted with call light placement for Resident #145 | |
| Certified Nursing Assistant #9 | Discussed personal property policy and shaving/nail care process | |
| Certified Nursing Assistant #8 | Discussed toothbrush storage and labeling | |
| Certified Nursing Assistant #2 | Described meal tray verification process | |
| Dietary Consultant | Described dietary staff meal tray verification | |
| Director of Nursing | DON | Provided information on call light policy, care plans, and resident care |
| Administrator | Provided grievance logs, policies, and COVID-19 vaccination information | |
| Licensed Practical Nurse #1 | LPN | Commented on toothbrush storage |
| Licensed Practical Nurse #2 | LPN | Described fingernail condition and care for Resident #346 |
| Assistant Director of Nursing | ADON | Provided matrix of residents affected and timesheets for staff vaccination |
| Dietary Supervisor | Provided food safety policy and observed kitchen conditions |
Inspection Report
Routine
Census: 87
Deficiencies: 3
Date: Jan 7, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication management, and food safety in the nursing home.
Findings
The facility was found deficient in conducting timely and accurate elopement risk assessments for a resident at risk of wandering, storing food improperly in medication refrigerators, failing to remove expired medications from stock, and maintaining food storage and kitchen sanitation standards, including uncovered and expired food items in the kitchen and freezer areas.
Deficiencies (3)
Failed to ensure elopement risk assessments were conducted and documented at least quarterly and as needed for a resident at risk of elopement.
Failed to ensure employee food and drink were not stored in medication refrigerators and expired medications were removed from stock to prevent accidental administration.
Failed to ensure food items stored in the storage area and freezer were sealed or covered; expired food items were promptly removed or discarded; and kitchen equipment and ice scoop holders were maintained in clean condition to prevent potential food borne illness.
Report Facts
Residents affected: 1
Residents affected: 86
Total Census: 87
Expired medication: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #3 | Provided statement regarding resident elopement incident and interventions | |
| Assistant Director of Nursing (ADON) | Interviewed about elopement risk assessment completion and medication storage issues | |
| Licensed Practical Nurse (LPN) #4 | Interviewed about expired medications on medication cart | |
| Dietary Supervisor | Interviewed about food storage, cleaning practices, and observations of food safety deficiencies | |
| Dietary Employee #1 | Observed handling leftover food and described mold on food item |
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 3
Date: Jan 7, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication management, and food safety in the nursing home.
Findings
The facility was found deficient in conducting timely and accurate elopement risk assessments for a resident at risk of wandering, storing employee food in medication refrigerators, maintaining medication carts free of expired medications, and ensuring proper food storage and sanitation in the kitchen and freezer areas. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failed to ensure elopement risk assessments were conducted and documented at least quarterly and as needed for a resident at risk for elopement.
Failed to ensure employee food and drink were not stored in medication refrigerators and expired medications were removed from medication carts.
Failed to ensure food items stored in the kitchen and freezer were sealed or covered, expired food items were promptly removed or discarded, and kitchen equipment and ice scoop holders were maintained in clean condition.
Report Facts
Elopement risk score: 9
Elopement risk score: 7
Expired medication: 1
Expired medication: 1
Resident census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Provided statement regarding resident's exit-seeking behavior |
| Assistant Director of Nursing | Assistant Director of Nursing | Signed elopement risk assessment and interviewed about assessment completion |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Checked medication cart containing expired medications |
| Dietary Supervisor | Interviewed regarding food storage, cleaning practices, and expired food items | |
| Dietary Employee #1 | Observed handling of leftover food items in kitchen |
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