Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication administration error involving Resident #76 receiving the wrong medication.
Complaint Details
The complaint investigation found that Resident #76 was given Resident #47's medication, including a statin medication despite an allergy. The medication error was reported by CMA #13, who was subsequently given one-on-one training and probation. The resident was monitored and sent to the Emergency Room after blood pressure dropped.
Findings
The facility failed to ensure the correct medication was administered to Resident #76, who received Resident #47's medication, including a statin medication despite an allergy. The error was caused by a Certified Medication Assistant (CMA #13) who pulled medications for two residents simultaneously and did not follow protocol. The resident was monitored and sent to the Emergency Room after the error was discovered.
Deficiencies (1)
Failed to ensure administration of correct medication to correct resident for 1 of 1 sample residents for medication administration.
Report Facts
Medication doses: 20
Medication doses: 5
Medication doses: 28
Training sessions: 4
Probation period: 30
Blood pressure reading: 140
Blood pressure reading: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA #13 | Certified Medication Assistant | Reported medication error and was given one-on-one training and probation |
| Assistant Director of Nursing | ADON | Confirmed monitoring and emergency response after medication error |
| Director of Nursing | DON | Confirmed medication error details, staff training, and protocol violations |
| CMA #14 | Certified Medication Assistant | Confirmed medication administration protocols |
| CMA #15 | Certified Medication Assistant | Confirmed medication administration protocols |
| Licensed Practicing Nurse #16 | Licensed Practicing Nurse | Confirmed medication administration protocols |
| Licensed Practicing Nurse #17 | Licensed Practicing Nurse | Confirmed medication administration protocols |
Inspection Report
Routine
Deficiencies: 6
Date: Oct 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication administration, environment cleanliness, nutrition, and food safety in the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to have advance directives on file for some residents, unclean resident rooms and equipment, medication administration errors involving wrong medications given to residents, failure to prepare and serve meals according to prescribed diets and menus, and inadequate food safety practices including poor hand hygiene and improper food storage.
Deficiencies (6)
Failed to formulate or have an acknowledgement of an advance directive on file for 2 of 8 sampled residents.
Failed to ensure 2 resident rooms were clean to maintain a homelike environment, including trash behind nightstands and unclean pedestal fans.
Failed to ensure administration of correct medication to correct resident for 1 of 1 sampled residents; medication error resulted in wrong medications given.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs for 2 of 2 meals observed.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for 1 of 2 meals observed.
Failed to ensure foods were covered or sealed in freezer/refrigerator; dietary staff failed to wash hands and change gloves properly; dietary staff and visitors failed to wear hair restraints in kitchen.
Report Facts
Residents sampled: 8
Residents affected: 2
Residents affected: 2
Residents affected: 1
Meals observed: 2
Meals observed: 2
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA #13 | Certified Medication Assistant | Named in medication error finding for administering wrong medications to Resident #76 |
| Admissions Director | Confirmed advance directive was overlooked for residents | |
| Administrator | Confirmed unclean pedestal fan and lack of fan cleaning policy | |
| Assistant Director of Nursing | ADON | Confirmed monitoring and response to medication error |
| Director of Nursing | DON | Confirmed medication administration issues and staff training |
| Housekeeper #11 | Reported trash behind nightstand in resident room | |
| Housekeeper #12 | Reported trash behind nightstand in resident room | |
| Dietary Aide #1 | Observed poor hand hygiene and food handling | |
| Dietary Aide #2 | Observed poor hand hygiene and food handling | |
| Dietary Aide #3 | Observed glove contamination and poor hand hygiene | |
| Dietary Aide #4 | Observed poor hand hygiene and food handling | |
| Dietary Aide #5 | Observed poor hand hygiene and food handling | |
| Dietary Aide #6 | Observed glove contamination and poor hand hygiene | |
| Dietary Aide #7 | Observed poor hand hygiene and food handling | |
| Dietary Aide #9 | Observed without beard restraint in kitchen | |
| Dietary Aide #11 | Observed without beard restraint in kitchen | |
| Dietary Manager | Commented on pureed food consistency issues | |
| Food and Beverage Director | Confirmed food preparation and serving deficiencies | |
| Infection Preventionist | Confirmed unclean pedestal fan and respiratory risk | |
| Licensed Practicing Nurse #16 | Confirmed medication administration procedures | |
| Licensed Practicing Nurse #17 | Confirmed medication administration procedures |
Inspection Report
Routine
Census: 113
Deficiencies: 7
Date: Aug 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and food safety at Methodist Health and Rehab.
Findings
The facility was found deficient in maintaining resident privacy during care, providing adequate nail care, proper positioning of residents, securing catheters, reviewing PRN medications timely, labeling and storing medications correctly, and ensuring food safety and sanitation practices in the kitchen including hand hygiene and ice machine cleanliness.
Deficiencies (7)
Failed to ensure privacy was maintained during incontinent care for Resident #105.
Failed to provide nail care to two residents dependent on staff for nail care.
Failed to properly position Resident #70 in bed to prevent pressure sores.
Failed to secure catheter to prevent trauma for Resident #3.
Failed to review PRN medication Hydroxyzine every 14 days for Resident #110.
Failed to ensure medications were dated when opened, resident names on insulin pens, and expired medications discarded in 3 of 5 medication carts.
Failed to ensure foods were properly covered, sealed, dated, and expired foods removed; failed to maintain ice machines clean; failed to ensure dietary staff washed hands before handling clean equipment or food.
Report Facts
Residents sampled: 23
Residents affected: 18
Residents affected: 4
Residents affected: 3
Residents affected: 112
Total census: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Named in privacy and catheter care findings | |
| Certified Nurse Aide #4 | Named in privacy finding | |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in nail care deficiency and interview |
| Certified Nurse Assistant #3 | Named in nail care deficiency | |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy, catheter care, medication, and positioning |
| Assistant Administrator | Interviewed regarding privacy and medication policies | |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication labeling and storage |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding medication labeling |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding medication administration |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding medication renewal |
| Dietary Supervisor | Interviewed regarding food storage and ice machine cleaning | |
| Dietary Employee #1 | Observed and interviewed regarding hand hygiene | |
| Dietary Employee #2 | Observed and interviewed regarding hand hygiene | |
| Dietary Employee #3 | Observed and interviewed regarding hand hygiene | |
| Dietary Employee #4 | Observed and interviewed regarding hand hygiene | |
| Maintenance Supervisor | Interviewed regarding ice machine cleaning frequency |
Inspection Report
Routine
Deficiencies: 11
Date: May 13, 2022
Visit Reason
Routine inspection to assess compliance with care standards including personal hygiene, pressure ulcer care, foot care, range of motion, respiratory care, medication administration, nutrition, food safety, meal service, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide adequate nail care for residents with diabetes, improper infection control during wound care, inadequate foot and toenail care, lack of interventions for contractures, improper oxygen therapy administration, medication errors related to insulin administration, failure to serve meals as per menu and in a timely manner, poor food preparation and handling practices, and failure to maintain infection control protocols including mask usage by staff.
Deficiencies (11)
Failure to ensure fingernails were regularly trimmed and cleaned for residents requiring assistance, especially diabetic residents.
Failure to ensure proper infection control technique during wound treatment, including not changing gloves and not sanitizing equipment.
Failure to provide appropriate foot and toenail care for residents dependent on such care.
Failure to implement interventions to prevent further decline in range of motion for resident with contractures.
Failure to ensure oxygen therapy was administered at prescribed flow rates and oxygen tubing was stored properly.
Failure to follow physician orders for sliding scale insulin administration, resulting in missed blood sugar checks and insulin doses.
Failure to serve meals in accordance with the planned menu and failure to serve meals in a timely manner.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency.
Failure to serve meals and snacks at consistent, scheduled times.
Failure to ensure proper food safety practices including hand hygiene, glove use, food storage, food temperature maintenance, and ice machine sanitation.
Failure to ensure staff wore face masks properly to prevent transmission of COVID-19 and other infections.
Report Facts
Residents affected by nail care deficiency: 4
Residents affected by wound care infection control deficiency: 1
Residents affected by foot care deficiency: 2
Residents affected by contracture care deficiency: 1
Residents affected by oxygen therapy deficiency: 4
Residents affected by insulin medication errors: 1
Residents affected by meal service timing deficiency: 102
Residents affected by pureed food consistency deficiency: 4
Residents affected by food safety deficiencies: 102
Residents affected by infection control mask deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in medication error finding related to insulin administration for Resident #21 |
| LPN #1 | Licensed Practical Nurse | Named in wound care and oxygen therapy findings |
| LPN #4 | Licensed Practical Nurse | Named in wound care infection control deficiency |
| Dietary Employee #4 | Named in meal service timing, food safety, and ice machine sanitation findings | |
| Dietary Employee #2 | Named in food temperature and food handling deficiencies | |
| Dietary Employee #3 | Named in food handling and hygiene deficiencies | |
| Certified Nursing Assistant #1 | Named in pureed food consistency observation | |
| CNA #2 | Certified Nursing Assistant | Named in infection control mask deficiency |
| CNA #3 | Certified Nursing Assistant | Named in infection control mask deficiency |
| DON | Director of Nursing | Named in multiple findings including nail care and medication administration |
Report
October 24, 2024
Report
October 24, 2024
Report
August 4, 2023
Report
May 13, 2022
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