Inspection Reports for
North Hills Life Care and Rehab
27 E. Appleby Road, Fayetteville, AR, 72703
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 4
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident privacy, medication administration, medication labeling and storage, infection prevention and control, and aseptic technique during care procedures.
Findings
The facility was found deficient in maintaining resident privacy during care, following physician orders for medication administration, proper medication labeling and storage, and infection prevention practices including hand hygiene and aseptic technique during dressing changes and IV tubing care. Several staff failed to follow protocols, and unauthorized personnel were given access to medication keys.
Deficiencies (4)
Failed to provide privacy during care for Resident #62 by not pulling the curtain or asking about comfort with spectators during a PICC line dressing change.
Failed to ensure physician orders were followed for flushing PICC line with normal saline before and after antibiotic administration for Resident #62.
Failed to write open dates on medications for 4 residents and maintained pharmacy packaging improperly for 1 resident; also failed to maintain possession of medication cart/room keys with authorized personnel.
Failed to ensure staff performed hand hygiene during meal assistance and failed to utilize Enhanced Barrier Precautions and aseptic technique during dressing removal and IV tubing care for Resident #62.
Report Facts
Deficiencies cited: 4
Medication flush volume ordered: 10
Medication flush volume used: 8.5
Medication flush volume used: 7
Heparin flush volume used: 5
PICC line dressing date: Aug 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Performed PICC line dressing change without privacy and failed to follow aseptic technique |
| Licensed Practical Nurse #9 | LPN | Administered antibiotic and flushes to Resident #62 but did not follow physician orders for flush volumes |
| Director of Nursing | DON | Provided statements regarding proper procedures and acknowledged deficiencies |
| Licensed Practical Nurse #2 | LPN | Handled medication cart keys improperly and failed to ensure medication labeling compliance |
| Certified Nursing Assistant #7 | CNA | Failed to perform hand hygiene during meal assistance |
| Certified Nursing Assistant #8 | CNA | Failed to perform hand hygiene during meal assistance |
| Registered Nurse #1 | RN | Unaware of PICC line dressing change policy and IV tubing care |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 7, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's representative about changes to medication and failure to ensure a complete surgical history was obtained and forwarded from the pre-admission screen for Resident #1.
Complaint Details
The complaint investigation focused on failure to notify Resident #1's representative about medication dosage decrease and discontinuation, and failure to document surgical history including the presence of a deep brain stimulator. Interviews with Resident #1's relative, PA-C #4, Licensed Practical Nurse #1, and the Primary Care Physician/Medical Director were conducted. The relative stated they were never informed about medication changes and expressed concern. PA-C #4 confirmed familiarity with the resident and rationale for medication decrease. The PCP was unaware of the deep brain stimulator and medication decrease.
Findings
The facility failed to notify Resident #1's representative of medication changes related to Parkinson's disease and failed to document notification. Additionally, the facility did not ensure a complete surgical history was obtained or forwarded, missing the presence of a deep brain stimulator in Resident #1's records, which could affect medical decision-making.
Deficiencies (2)
Failed to notify Resident #1's representative of changes to medication for Parkinson's disease.
Failed to ensure a complete surgical history was obtained and forwarded from the pre-admission screen for Resident #1, missing documentation of a deep brain stimulator.
Report Facts
Residents sampled: 3
Medication dosage changes: 3
Interview dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PA-C #4 | Certified Physician Assistant | Interviewed and confirmed familiarity with Resident #1 and rationale for medication decrease |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding observation of Resident #1's tremors and awareness of deep brain stimulator |
| Primary Care Physician | Medical Director | Interviewed and confirmed familiarity with Resident #1's condition but unaware of deep brain stimulator and medication decrease |
Inspection Report
Routine
Capacity: 75
Deficiencies: 5
Date: Jun 2, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards including proper management of residents' personal funds, accuracy of resident assessments, development and implementation of care plans, respiratory care, and food service sanitation.
Findings
The facility was found deficient in properly managing residents' personal funds, accurately coding Minimum Data Set (MDS) assessments, developing and implementing complete care plans for oxygen therapy, providing safe and appropriate respiratory care including oxygen administration and CPAP equipment storage, and serving food in a sanitary manner to prevent cross contamination.
Deficiencies (5)
Failed to ensure insurance premiums were paid timely for resident personal funds management.
Failed to ensure Minimum Data Set (MDS) assessments were accurately coded for oxygen therapy and PASARR II for residents with serious mental health diagnoses.
Failed to develop and implement care plans addressing oxygen therapy for residents with physician orders.
Failed to provide oxygen at the physician ordered rate, failed to change oxygen tubing weekly, and failed to properly store CPAP tubing to prevent contamination.
Failed to serve food in a sanitary manner, resulting in potential cross contamination during meal service.
Report Facts
Residents affected: 32
Residents affected: 7
Residents affected: 4
Residents affected: 19
Total census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager (BOM) | Provided information regarding resident personal funds and insurance premium payments | |
| Administrator | Provided facility policies and answered questions about insurance premium payments and MDS assessments | |
| Consultant | Discussed insurance premium adjustments and agreements | |
| MDS Coordinator | Discussed coding of MDS assessments and care plans | |
| Director of Nursing (DON) | Discussed importance of accurate MDS coding, care planning, oxygen administration, and infection control | |
| Licensed Practical Nurse (LPN) #1 | Verified oxygen administration and storage of oxygen and CPAP supplies | |
| Licensed Practical Nurse (LPN) #2 | Provided information about oxygen flow rates and tubing changes | |
| Certified Nursing Assistant (CNA) #1 | Observed serving food in an unsanitary manner | |
| Certified Nursing Assistant (CNA) #2 | Observed serving food in an unsanitary manner and explained importance of sanitary practices |
Inspection Report
Routine
Deficiencies: 12
Date: Mar 18, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, care planning, personal hygiene, safety, medication management, and respiratory care at North Hills Life Care and Rehab.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity, incomplete and untimely care plans, inadequate personal hygiene and grooming, unsafe environmental conditions, improper catheter and respiratory care, and delayed action on medication regimen reviews.
Deficiencies (12)
Failure to ensure resident dignity related to matching shoes, feeding assistance posture, housekeeping during meals, and catheter privacy.
Failure to provide instructions on accessing personal funds after hours for residents who authorized facility management of funds.
Failure to maintain a clean, safe, and sanitary environment including unclean bathrooms, soiled linens, and unaddressed leaks.
Failure to develop and implement complete, person-centered care plans addressing all resident needs with measurable objectives and timetables.
Failure to provide discharge summaries with complete medical information, medication reconciliation, and education.
Failure to provide adequate personal care including bathing, shaving, nail care, and grooming for multiple residents.
Failure to provide appropriate foot care including trimming and cleaning toenails to prevent complications.
Failure to maintain safe environment by leaving a side rail on the floor and using a wheelchair with tattered vinyl and rough edges.
Failure to ensure catheter bag remained below bladder during transfers and was concealed in a privacy bag.
Failure to ensure oxygen tubing was dated and stored properly, oxygen administered at ordered flow rates, and respiratory equipment stored to prevent contamination.
Failure to act timely on pharmacist's recommendations to discontinue unnecessary psychotropic medication.
Failure to ensure psychotropic medications were administered only with documented indications and behaviors were monitored and evaluated.
Report Facts
Residents affected: 1
Residents affected: 32
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in catheter bag dignity and oxygen tubing storage findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including catheter bag privacy, oxygen tubing storage, medication regimen review process |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Named in findings related to resident personal care and hygiene |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Named in catheter bag handling during transfer |
| Business Office Manager | Business Office Manager | Named in findings related to resident personal funds access |
| Nurse Consultant | Nurse Consultant | Named in policy provision and interview regarding care plans and respiratory therapy |
| Treatment Nurse #1 | Treatment Nurse | Named in documentation of resident behaviors and medication monitoring |
| Treatment Nurse #2 | Treatment Nurse | Named in physician communication regarding psychotropic medication |
Viewing
Loading inspection reports...
