Inspection Reports for
Lakewood Therapy and Living Center
260 Lakepark Drive, Hot Springs, AR 71901, AR, 71901
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
58% occupied
Based on a February 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 8
Date: Jan 9, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, confidentiality, care planning, discharge procedures, wound care, staffing postings, and psychotropic medication management at The Springs of Red Oak nursing home.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during transport, protect confidentiality of personal medical information, coordinate PASARR assessments, develop comprehensive care plans for tobacco use, complete discharge summaries, provide consistent wound care documentation, post nurse staffing information daily, and ensure proper documentation for psychotropic medication dose reductions.
Deficiencies (8)
Failed to ensure dignity was maintained for Resident #21 during transport while not fully covered.
Failed to ensure confidentiality of personal and medical information for Resident #21 due to an unattended, unlocked tablet displaying sensitive information.
Failed to coordinate PASARR level II evaluation and incorporate recommendations into care planning for Resident #46.
Failed to develop a comprehensive care plan addressing tobacco use and related monitoring for Resident #55.
Failed to develop a discharge summary including recapitalization of stay, final status, and medication reconciliation for Resident #111.
Failed to ensure wound care treatment for pressure ulcer on Resident #39 was documented as completed daily per physician's order.
Failed to post nurse staffing information daily with current date, facility name, staff hours, and resident census.
Failed to ensure gradual dose reductions and proper documentation for psychotropic medication use beyond 14 days for Resident #43.
Report Facts
Assessment Reference Date: Nov 8, 2024
Assessment Reference Date: Nov 11, 2024
Assessment Reference Date: Nov 17, 2024
Assessment Reference Date: Oct 20, 2024
Assessment Reference Date: Nov 20, 2024
BIMS Score: 10
BIMS Score: 6
BIMS Score: 15
BIMS Score: 12
BIMS Score: 4
Medication Dose: 2
Medication Dose: 1
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, confidentiality, PASARR coordination, care planning, discharge summary, wound care, staffing posting, and psychotropic medication documentation. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed pushing Resident #21 while not fully covered, acknowledged dignity issue. |
| Administrator Consultant | Administrator Consultant | Stated facility was unable to locate PASARR level II evaluation report for Resident #46. |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator | Confirmed Resident #55 smoked tobacco and care plan did not address smoking. |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided policy titled Care Planning - Interdisciplinary Team. |
| Nurse Consultant | Nurse Consultant | Stated tablets should be locked to protect resident information and commented on PASARR tag. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 9, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, confidentiality, PASARR coordination, care planning, discharge summaries, wound care, nurse staffing postings, and psychotropic medication management at The Springs of Red Oak nursing facility.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during transport, protect confidentiality of medical information, coordinate PASARR assessments, develop comprehensive care plans for tobacco use, complete discharge summaries, provide consistent wound care documentation, post nurse staffing information daily, and ensure proper documentation for psychotropic medication dose reductions.
Deficiencies (8)
Failed to ensure dignity was maintained for Resident #21 during transport while not fully covered.
Failed to ensure confidentiality of personal and medical information for Resident #21 due to an unattended, unlocked tablet displaying sensitive information.
Failed to coordinate with state authority regarding PASARR level II evaluation for Resident #46, potentially affecting care.
Failed to develop a comprehensive care plan addressing tobacco use and related monitoring for Resident #55.
Failed to develop a discharge summary including recapitalization, final status, and medication reconciliation for Resident #111.
Failed to ensure wound care treatment for pressure ulcer on Resident #39 was documented as completed daily per physician's order.
Failed to post nurse staffing information daily including facility name, current date, staff hours, and resident census.
Failed to ensure gradual dose reductions and proper documentation for psychotropic medication use beyond 14 days for Resident #43.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, confidentiality, PASARR, care plans, discharge summaries, wound care, staffing postings, and psychotropic medication documentation. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed pushing Resident #21 not fully covered, acknowledged dignity issue. |
| Administrator Consultant | Administrator Consultant | Stated facility was unable to locate PASARR level II evaluation report for Resident #46. |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator | Confirmed Resident #55 smoked tobacco and care plan did not address smoking. |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided policy titled Care Planning - Interdisciplinary Team. |
| Nurse Consultant | Nurse Consultant | Stated tablet should be locked to protect resident's personal and medical information. |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and safety in the nursing home facility.
Findings
The facility was found deficient in multiple areas including improper catheter care leading to potential infection risks, failure to ensure correct oxygen dosage administration, inadequate medication labeling and storage practices, lack of a water management program to prevent Legionella, and failure to document pneumococcal vaccinations for eligible residents.
Deficiencies (5)
Failed to ensure indwelling catheter tubing was anchored properly and catheter bags were not touching the floor, increasing infection risk.
Failed to ensure parameters were in place to administer correct oxygen dosage for a resident.
Failed to ensure multi-dose insulin vials were dated when opened and expired medications were removed to prevent administration errors.
Failed to develop and implement a water management program to minimize risk of Legionella and other waterborne pathogens.
Failed to ensure pneumococcal immunizations were administered and documented for eligible residents.
Report Facts
Residents affected: 38
Residents sampled: 5
Open multi-dose insulin vial dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Discussed insulin vial dating and medication cart checks |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Provided information on catheter securing and oxygen administration |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Confirmed catheter bag placement and catheter securing practices |
| Director of Nursing | Director of Nursing | Provided explanations on catheter care, oxygen administration, medication policies, and vaccination documentation |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding water management and Legionella prevention |
| Administrator | Administrator | Provided policies and information on water management and vaccination protocols |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility safety at The Springs of Red Oak nursing home.
Findings
The facility was found deficient in multiple areas including improper catheter care leading to potential infection risk, inadequate oxygen therapy documentation, failure to date multi-dose insulin vials and remove expired medications, lack of a water management program to prevent Legionella, and failure to ensure pneumococcal vaccinations were administered and documented for eligible residents.
Deficiencies (5)
Failed to ensure indwelling catheter tubing was anchored properly and catheter bags were not touching the floor, increasing infection risk.
Failed to ensure oxygen therapy parameters were established and documented to enable correct dosage administration.
Failed to date multi-dose insulin vials when opened and remove expired medications from medication carts.
Failed to develop and implement a water management program to minimize risk of Legionella and other waterborne pathogens.
Failed to ensure pneumococcal immunizations were administered and documented for eligible residents.
Report Facts
Residents affected: 38
Residents sampled: 5
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Confirmed catheter bag placement on floor and catheter tubing not secured | |
| Licensed Practical Nurse (LPN) #2 | Provided information on catheter securing procedures and oxygen therapy documentation | |
| Director of Nursing (DON) | Provided explanations on catheter care, oxygen therapy, medication storage policies, and vaccination documentation | |
| Licensed Practical Nurse (LPN) #1 | Observed with medication cart and questioned about insulin vial dating and expired medications | |
| Maintenance Supervisor | Interviewed about water management and Legionella prevention | |
| Administrator | Provided policies and information regarding Legionella prevention and vaccination protocols |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 3
Date: Feb 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall with major injury involving Resident #1 during off-loading from the facility transport van on 12/4/2023, and failure to timely report the incident as required.
Complaint Details
The complaint investigation was substantiated. Resident #1 fell from a manual wheelchair during off-loading from the facility van on 12/4/2023, resulting in a back injury requiring hospital treatment and surgery. The facility failed to report the incident within the required 2-hour timeframe and failed to ensure safe transport procedures. Immediate Jeopardy was identified and later removed after in-services and corrective actions.
Findings
The facility failed to timely report a major injury fall incident involving Resident #1 and failed to ensure safe off-loading procedures from the transport van, resulting in Immediate Jeopardy to resident health and safety. Additionally, the facility failed to review and revise care plans timely for wound care for Residents #1 and #3.
Deficiencies (3)
Failed to timely report suspected abuse, neglect, or theft involving a fall with major injury for Resident #1.
Failed to review and revise the care plan and reassess effectiveness of interventions for Residents #1 and #3.
Failed to ensure safe off-loading of Resident #1 from facility transportation van, resulting in fall and back injury with Immediate Jeopardy.
Report Facts
Residents affected: 1
Residents affected: 2
Census: 46
Dates of in-services: 12/4/2023 and 1/30/2024 in-services provided related to lift operation and securing residents
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Documented progress note and incident report regarding Resident #1's fall | |
| Certified Nursing Assistant (CNA) #1 / Van Driver | Witnessed and involved in Resident #1's fall from wheelchair during off-loading | |
| Director of Nursing (DON) | Interviewed regarding investigation and care plan revisions | |
| Administrator | Interviewed regarding incident and investigation | |
| MDS Nurse | Interviewed regarding care plan revisions and incident response |
Inspection Report
Census: 46
Deficiencies: 3
Date: Feb 8, 2024
Visit Reason
The inspection was conducted to investigate multiple deficiencies related to resident care, including failure to timely report a fall with major injury, failure to review and revise care plans for wound care, and failure to ensure safe off-loading of a resident from the facility transportation van.
Findings
The facility failed to report a major injury fall within the required timeframe, did not revise care plans to reflect new wound care treatments for sampled residents, and allowed a resident to fall from a wheelchair during off-loading from the facility van, resulting in immediate jeopardy to resident health and safety.
Deficiencies (3)
Failure to timely report suspected abuse, neglect, or theft involving a fall with major injury within 2 hours for Resident #1.
Failure to review and revise the care plan and reassess effectiveness of interventions for wound care for Residents #1 and #3.
Failure to ensure safe off-loading of Resident #1 from the facility transportation van, resulting in a fall and back injury with past Immediate Jeopardy.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 46
Residents affected: 1
Deficiency citation date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Documented progress note and incident report regarding Resident #1's fall |
| CNA #1 | Certified Nursing Assistant/Van Driver | Witnessed and involved in Resident #1's fall from the van |
| Director of Nursing | Director of Nursing | Provided investigation information and policy on care plan revisions |
| Administrator | Administrator | Conducted investigation and provided statements regarding Resident #1's fall |
| MDS Nurse | MDS Nurse | Provided information on care plan revision responsibilities and recalled incident |
Inspection Report
Deficiencies: 1
Date: Jun 6, 2023
Visit Reason
The inspection was conducted to assess the accuracy of resident assessments, specifically to verify if the presence of feeding tubes was correctly documented on the Minimum Data Set (MDS) for sampled residents.
Findings
The facility failed to ensure that the presence of a feeding tube was accurately coded on the MDS for one resident. Interviews and record reviews confirmed that Resident #1 had a feeding tube that was not documented on multiple MDS assessments, despite staff acknowledging its presence.
Deficiencies (1)
Failure to ensure the presence of a feeding tube was accurately coded on the Minimum Data Set (MDS) for Resident #1.
Report Facts
Residents sampled: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Interviewed regarding residents with feeding tubes | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about Resident #1's feeding tube | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about Resident #1's feeding tube | |
| Registered Nurse (RN) #1 | Interviewed about Resident #1's feeding tube | |
| MDS Coordinator | Interviewed about documentation of feeding tube on MDS |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 6, 2023
Visit Reason
The inspection was conducted to assess the accuracy of resident assessments, specifically to verify the correct coding of the presence of feeding tubes on the Minimum Data Set (MDS) for sampled residents.
Findings
The facility failed to ensure that the presence of a feeding tube was accurately documented on the MDS for one resident. Interviews and record reviews confirmed the resident had a feeding tube, but it was not coded on the MDS as required by the RAI manual.
Deficiencies (1)
Failure to ensure the presence of a feeding tube was accurately coded on the Minimum Data Set (MDS) for one resident.
Report Facts
Residents sampled: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Interviewed regarding residents with feeding tubes | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about familiarity with Resident #1 and feeding tube status | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about Resident #1's feeding tube status | |
| Registered Nurse (RN) #1 | Interviewed about Resident #1's feeding tube and medication administration | |
| MDS Coordinator | Interviewed about documentation of feeding tube on MDS |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the completion of a Significant Change in Status Minimum Data Set (MDS) within 14 days when a resident's status changes significantly, specifically related to hospice care enrollment.
Findings
The facility failed to complete a Significant Change in Status MDS within 14 days for one sampled resident (Resident #3) who began receiving hospice care, potentially affecting 10 residents receiving hospice care. The Quarterly MDS did not document hospice care, and the Care Plan did not address hospice care as required.
Deficiencies (1)
Failure to complete a Significant Change in Status Minimum Data Set (MDS) within 14 days of determining the status change was significant for a resident who received Hospice Care.
Report Facts
Residents affected: 10
Assessment Reference Date: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding hospice care status and MDS completion | |
| Director of Nursing (DON) | Provided confirmation on policy regarding Significant Change MDS completion |
Inspection Report
Deficiencies: 1
Date: Apr 24, 2023
Visit Reason
The inspection was conducted to assess whether the facility completed a Significant Change in Status Minimum Data Set (MDS) within 14 days of determining a significant change in condition for a resident who received Hospice Care.
Findings
The facility failed to complete a Significant Change in Status MDS within 14 days for one sampled resident receiving Hospice Care, despite knowledge of the requirement by staff. This deficiency had the potential to affect 10 residents receiving Hospice Care.
Deficiencies (1)
Failure to complete a Significant Change in Status Minimum Data Set (MDS) within 14 days of determining a significant change in condition for Resident #3 receiving Hospice Care.
Report Facts
Residents affected: 10
Inspection Report
Routine
Census: 37
Deficiencies: 6
Date: Dec 8, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care planning, hygiene, food preparation, and facility maintenance at The Springs of Red Oak nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy regarding catheter bags, inadequate maintenance and housekeeping leading to unsafe environmental conditions, failure to update care plans timely, poor personal hygiene care, improper food preparation consistency, and lapses in food safety and sanitation practices.
Deficiencies (6)
Failure to provide privacy by not covering a urinary catheter bag for 1 resident.
Failure to maintain sanitary, orderly, and safe environment including broken blinds, missing floor tiles, loose handrails, and exposed sharp edges.
Failure to review and revise care plan and reassess effectiveness of interventions for 1 resident using a seat belt in wheelchair.
Failure to ensure fingernails were clean, groomed, and free from jagged edges for 1 resident dependent on staff.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency for 1 meal observed.
Failure to follow food safety practices including hand washing, sealing foods, removing expired products, and maintaining ice machine cleanliness.
Report Facts
Residents affected: 1
Residents affected: 37
Residents affected: 1
Residents affected: 36
Residents affected: 7
Total census: 37
Expired food product count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding catheter bag privacy |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding catheter bag privacy |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding resident fingernail care |
| Dietary Supervisor | Observed preparing pureed food and interviewed about food consistency and safety | |
| Dietary Employee #1 | Observed handling food without proper hand washing | |
| Dietary Employee #2 | Observed improper hand drying and food preparation | |
| Maintenance Director | Interviewed regarding facility maintenance issues | |
| Director of Nursing | DON | Provided information and documents related to care plans and facility practices |
| Regional Consultant | Interviewed regarding food consistency and facility policies |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 6
Date: Dec 8, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and the quality of care provided at The Springs of Red Oak nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide privacy for residents with urinary catheters, inadequate maintenance and housekeeping leading to unsafe environmental conditions, failure to update care plans appropriately, poor personal hygiene care for residents, improper preparation of pureed food, and food safety violations in the kitchen.
Deficiencies (6)
Failure to provide privacy by not covering a urinary catheter bag for 1 resident.
Failure to maintain a safe, clean, and homelike environment due to broken blinds, missing floor tiles, loose handrails, and other hazards.
Failure to review and revise the care plan and reassess effectiveness of interventions for 1 resident using a seat belt in an electric wheelchair.
Failure to ensure fingernails were clean, groomed, and free from jagged edges for 1 resident dependent on staff for nail care.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failure to follow proper food safety practices including hand washing, sealing food in the refrigerator, removing expired food, and maintaining ice machines.
Report Facts
Residents affected: 1
Residents affected: 37
Residents affected: 1
Residents affected: 36
Residents affected: 7
Residents affected: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding catheter bag privacy |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding catheter bag privacy |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding resident fingernail care |
| Dietary Supervisor | Observed and interviewed regarding food preparation and safety | |
| Maintenance Director | Interviewed regarding environmental hazards and maintenance issues | |
| Regional Consultant | Interviewed regarding food consistency and hand washing policy |
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