Inspection Reports for
Lake Hamilton Health and Rehab
120 Pittman Rd, Hot Springs, AR, 71913
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 4
Date: May 21, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity and privacy, mobility care, food safety, infection control, and overall facility practices.
Findings
The facility was found deficient in maintaining resident privacy during care, ensuring proper use of mobility devices, maintaining sanitary food service conditions, and implementing infection prevention and control protocols including proper use of personal protective equipment and hand hygiene.
Deficiencies (4)
Failure to ensure privacy during personal care for 2 residents, with doors open and curtains/blinds not drawn.
Failure to ensure devices to prevent contracture and skin breakdown were applied for 1 resident with bilateral hand contractures.
Failure to maintain sanitary conditions of ice machine, remove expired food, maintain proper refrigerator temperatures, and ensure dietary staff hand hygiene.
Failure to implement Enhanced Barrier Precautions and proper hand hygiene for 3 residents on contact isolation or with wounds.
Report Facts
Residents observed for privacy care deficiency: 2
Resident sampled for mobility device deficiency: 1
Expired food items observed: 3
French dressing packages expired: 31
Refrigerator temperature: 44
Buttermilk temperature: 53.3
Half and half temperature: 47
Colony-forming units of VRE: 100000
Residents reviewed for Enhanced Barrier Precautions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #6 | Observed providing care without gown to Resident #8 on contact isolation | |
| Assistant Director of Nursing (ADON) | Observed administering medication without privacy curtain drawn | |
| Director of Nursing (DON) | Interviewed regarding privacy and infection control policies | |
| Certified Nursing Assistant (CNA) #9 | Observed not changing gloves during incontinence care | |
| Treatment Nurse | Observed performing wound care without gown and hand hygiene | |
| Dietary Manager (DM) | Interviewed about ice machine cleaning and food safety | |
| Dietary Staff (DC #1, DC #2, DC #4, DA #3, DA #5) | Observed improper hand hygiene and food handling practices |
Inspection Report
Routine
Deficiencies: 10
Date: Apr 12, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements in various areas including resident rights, medication management, care planning, safety, respiratory care, pharmaceutical services, medication error rates, medication storage, food service, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure staff dignity during feeding assistance, protection of resident privacy, development of complete care plans for residents on specific medications, safety hazards in bathrooms, improper administration of oxygen by unlicensed staff, inaccurate narcotic counts and documentation, medication errors exceeding 5%, improper medication storage and self-administration practices, inadequate supervision during nebulizer treatments, and food safety issues including improper food temperatures and poor hygiene practices in the kitchen.
Deficiencies (10)
Staff failed to sit face to face with residents during feeding assistance, compromising dignity for 1 resident.
Facility failed to protect resident privacy by leaving medication cards with identifiable information visible on an unattended medication cart.
Care plans did not address use of antibiotics, anticoagulants, and insulin for 3 residents, risking coordination of care.
Unlocked public bathroom lacked pull cord on call light, risking resident safety for 9 residents.
Certified Nursing Assistant improperly administered oxygen, which is considered a medication and must be administered by licensed staff.
Stock narcotics were not accurately counted or documented upon receipt, risking medication errors and diversion.
Medication error rate exceeded 5% due to incorrect dosages administered to 2 residents.
Medications were stored at bedside without approved self-administration rights; lack of supervision during nebulizer treatment; refrigerated narcotics not stored in permanently affixed box.
Meals were served at unsafe temperatures on multiple halls, risking palatability and nutritional intake for many residents.
Food items in freezer were uncovered, unsealed, and undated; dietary staff failed to wash hands before handling clean equipment, risking foodborne illness.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 9
Residents affected: 1
Residents affected: 74
Medication error rate: 5.88
Residents affected: 2
Residents affected: 3
Residents affected: 15
Residents affected: 25
Residents affected: 17
Residents affected: 17
Residents affected: 73
Total census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #3 | CNA | Observed standing while feeding resident, violating dignity standards |
| Licensed Practical Nurse #3 | LPN | Confirmed HIPAA violation and medication storage issues |
| Director of Nursing | DON | Interviewed regarding feeding assistance, medication documentation, and medication storage |
| Nurse Consultant | Provided clarifications on feeding assistance, medication administration, call light policy, and medication storage | |
| Licensed Practical Nurse #1 | LPN | Interviewed about oxygen administration and medication errors |
| Licensed Practical Nurse #2 | LPN | Involved in narcotic count and documentation |
| Licensed Practical Nurse #3 | LPN | Observed medication at bedside and nebulizer treatment supervision |
| Dietary Employee #1 | DE | Observed handling food trays and ice without proper hand hygiene |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 28, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements for nursing home care, including resident safety, care planning, staffing, medication management, infection control, and other standards.
Findings
The facility was found deficient in multiple areas including improper storage of resident hygiene items, inadequate documentation and monitoring of physical restraints, incomplete care plans for residents with indwelling catheters, insufficient activities for cognitively impaired residents, improper respiratory care and oxygen orders, inadequate staffing levels, inappropriate antibiotic use, and failure to follow proper hand hygiene during meal service.
Deficiencies (8)
Failed to ensure resident personal hygiene items were stored in a sanitary manner in resident bathrooms.
Failed to document medical symptoms requiring physical restraints and failed to demonstrate ongoing monitoring and evaluation for restraint use for one resident.
Failed to complete a comprehensive care plan including care for indwelling catheters for one resident.
Failed to provide activities designed to meet the interests and support the physical, mental, and psychosocial wellbeing of one resident.
Failed to provide safe and appropriate respiratory care including lack of physician order for supplemental oxygen and improper storage of nebulizer equipment.
Failed to ensure safe staffing levels to meet resident needs and to prevent use of restraints for two residents.
Failed to ensure residents receiving antibiotics did not receive them for excessive duration without adequate monitoring and indication.
Failed to ensure staff washed hands or changed gloves between residents while serving beverages, risking potential foodborne illness.
Report Facts
Residents with seatbelt alarms: 6
Residents with pressure alarms: 25
Residents sampled: 30
Residents affected by hand hygiene deficiency: 24
Certified Nursing Assistants (CNA) staffing ratios: 12
Certified Nursing Assistants (CNA) staffing ratios: 8
Certified Nursing Assistants (CNA) staffing ratios: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Named in hand hygiene deficiency during meal service |
| Certified Nursing Assistant #2 | CNA | Named in restraint use finding for Resident #71 |
| Certified Nursing Assistant #3 | CNA | Named in hygiene item storage and respiratory care findings |
| Certified Nursing Assistant #4 | CNA | Assisted Resident #71 with seatbelt restraint |
| Certified Nursing Assistant #5 | CNA | Reported staffing and alarm use concerns |
| Licensed Practical Nurse #1 | LPN | Provided information on respiratory equipment care |
| Licensed Practical Nurse #2 | LPN | Provided information on oxygen orders and catheter care |
| Director of Nursing | DON | Provided multiple statements on restraint use, staffing, respiratory care, and hand hygiene |
| Assistant Administrator | Assistant Administrator | Provided statements on hygiene item storage and staffing |
| Activity Director | Activity Director | Provided information on activities for cognitively impaired residents |
| Pharmacy Consultant | Pharmacy Consultant | Interviewed regarding antibiotic use and prescribing practices |
| Infection Preventionist | Infection Preventionist | Provided information on respiratory equipment storage and antibiotic stewardship |
| Administrator | Administrator | Provided policy documents and statements on respiratory care and hand hygiene |
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