Inspection Reports for
Pink Bud Home for the Golden Years
400 So Coker, Greenwood, AR, 72936-2000
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 22, 2025
Visit Reason
The inspection was conducted due to complaints and allegations regarding medication self-administration, abuse and neglect, medication storage, dietary hygiene, and infection control practices at the facility.
Complaint Details
The complaint investigation involved allegations of improper medication self-administration, failure to report and investigate abuse allegations timely and thoroughly, improper medication storage including expired medications, dietary staff hygiene violations, and failure to follow infection control precautions. Immediate Jeopardy was identified related to abuse reporting and investigation, which was removed after the facility implemented a removal plan including staff training and appointing an Abuse and Neglect Coordinator.
Findings
The facility failed to ensure safe self-administration of medication, timely and thorough investigation and reporting of abuse allegations, proper medication storage including removal of expired medications, dietary staff compliance with hand hygiene and glove use, and adherence to Enhanced Barrier Precautions during wound care. Immediate Jeopardy was identified related to abuse reporting and investigation but was removed after corrective actions.
Deficiencies (5)
Failed to ensure one resident self-administered nasal spray only after clinical appropriateness was determined by the interdisciplinary team.
Failed to implement abuse and neglect policies including timely reporting and thorough investigation of abuse allegations for one resident.
Failed to ensure refrigerated narcotic box was permanently affixed and expired anti-angina medication was removed from medication storage.
Dietary staff failed to wash hands and change gloves appropriately before handling food items.
Failed to follow Enhanced Barrier Precautions by not wearing gowns during wound care of a resident with an open stage II moisture associated pressure wound and leaking catheter.
Report Facts
Residents interviewed regarding abuse: 43
Residents unable to verbalize abuse: 11
Employees trained on abuse reporting: 64
Residents affected by abuse reporting deficiency: Many
Residents affected by medication self-administration deficiency: Few
Residents affected by medication storage deficiency: Some
Residents affected by dietary hygiene deficiency: Some
Residents affected by infection control deficiency: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Reported abuse allegation to ADON and reassigned CNA #2 away from Resident #12's room. |
| CNA #2 | Certified Nursing Assistant | Alleged to have been rough with Resident #12. |
| CNA #13 | Certified Nursing Assistant | Alleged to have been rough with Resident #12; reassigned but not removed pending investigation. |
| ADON | Assistant Director of Nursing | Received abuse reports, conducted investigation, reported to Administrator and DON. |
| DON | Director of Nursing | Oversaw abuse investigation and reporting; appointed Abuse and Neglect Coordinator. |
| Administrator | Facility Administrator | Responsible for abuse investigation and reporting; accepted Immediate Jeopardy removal plan. |
| LPN #7 | Licensed Practical Nurse | Observed medication storage deficiencies including unaffixed narcotic box and expired medication. |
| DE #10 | Dietary Employee | Observed failing to change gloves and wash hands when handling food. |
| DE #11 | Dietary Employee | Observed failing to change gloves and wash hands when handling food. |
| ADM | Assistant Dietary Manager | Confirmed dietary staff hand hygiene requirements. |
| DM | Dietary Manager | Confirmed dietary staff hand hygiene requirements. |
| CNA #8 | Certified Nursing Assistant | Observed not wearing gown during wound care of Resident #4. |
| CNA #9 | Certified Nursing Assistant | Observed not wearing gown during wound care of Resident #4. |
| Medical Director | Medical Director | Reviewed wound care expectations and x-ray findings; confirmed infection control expectations. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 3
Date: May 22, 2025
Visit Reason
The inspection was conducted due to allegations of abuse involving Resident #12 by staff members, specifically Certified Nursing Assistants (CNA) #2 and #13, to investigate the facility's compliance with abuse reporting and investigation requirements.
Complaint Details
The complaint involved allegations that CNA #2 and CNA #13 were rough with Resident #12. The facility failed to report these allegations timely and did not conduct a thorough investigation. The complaint was substantiated with findings of noncompliance and immediate jeopardy to resident health and safety.
Findings
The facility failed to immediately report allegations of abuse to the appropriate authorities and did not thoroughly investigate the allegations involving Resident #12. The alleged perpetrators were not removed from resident care during the investigation, and no body audits or nurse assessments were completed. The facility was found to be in immediate jeopardy but implemented a removal plan and conducted staff training to address the deficiencies.
Deficiencies (3)
Failure to timely report suspected abuse to appropriate authorities within two hours as required.
Failure to thoroughly investigate allegations of abuse, including lack of resident statements, accused statements, assessments, bedside staff interviews, and police reports.
Failure to remove alleged perpetrator from resident care during ongoing investigation.
Report Facts
Residents interviewed regarding abuse: 43
Residents unable to verbalize abuse: 11
Employees trained on abuse reporting: 64
Total residents census: 55
Days delay in reporting allegation: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to failure to report abuse allegations and investigation. | |
| Registered Nurse #4 | Registered Nurse | Reported incident to ADON and provided care notes for Resident #12. |
| Assistant Director of Nursing | ADON | Received reports of abuse, failed to complete paperwork or body audit, reported to Administrator and DON. |
| Director of Nursing | DON | Appointed as Abuse and Neglect Coordinator, responsible for monitoring and reporting allegations. |
| Certified Nursing Assistant Supervisor | CNA Supervisor | Removed CNA #13 from working with Resident #12 but did not report incident to supervisor. |
| Certified Nursing Assistant #13 | CNA | Alleged to be rough with Resident #12, was verbally in-serviced and reassigned but not reported to authorities. |
Inspection Report
Routine
Deficiencies: 6
Date: Feb 9, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, focusing on resident care, safety, infection control, and staff competency.
Findings
The facility was found deficient in multiple areas including failure to provide privacy bags for indwelling catheter drainage bags, inadequate privacy during showers, failure to ensure skin injuries were assessed and treated properly, improper catheter care leading to contamination risks, lack of staff competency in resident care, improper sanitary procedures during meal service, and unsafe storage of cleaning chemicals.
Deficiencies (6)
Failure to provide privacy bags for indwelling catheter drainage bags and maintain resident privacy during showers for Residents #5 and #41.
Failure to ensure residents with skin injuries received appropriate assessment, treatment, and notification for Residents #14 and #9.
Failure to provide appropriate catheter care to prevent infection and contamination for Residents #58 and #161.
Failure to ensure licensed staff demonstrated competency in care, treatment, and services for Residents #14, #41, and #56.
Failure to follow sanitary procedures to prevent spread of germs during meal service by Dietary Employee #1.
Failure to store cleaning chemicals safely to prevent resident access.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to catheter care, skin injury reporting, and staff competency |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings related to privacy, catheter care, staff competency, and infection control |
| CNA #5 | Certified Nursing Assistant | Named in findings related to skin injury and shower care |
| Dietary Employee #1 | Dietary Employee | Named in findings related to improper glove use and sanitary procedures during meal service |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in findings related to skin injury and care |
| Infection Control Preventionist | Infection Control Preventionist (ICP) | Named in findings related to infection control and catheter care |
| LPN #3 | Licensed Practical Nurse | Named in catheter care and order entry process |
| LPN #4 | Licensed Practical Nurse | Named in medication and treatment order communication |
| CNA #1 | Certified Nursing Assistant | Named in findings related to shower privacy and dignity |
| CNA #6 | Certified Nursing Assistant | Named in findings related to shower privacy and dignity |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Nov 17, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to accurate resident assessments, care plan development and updates, and ensuring a safe environment free from accident hazards.
Findings
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected tobacco use for one resident, failed to update care plans with interventions after a fall for another resident, and failed to identify and analyze fall hazards leading to a resident's fall. Interviews with staff confirmed these deficiencies.
Deficiencies (3)
Failed to ensure the Minimum Data Set (MDS) accurately reflected tobacco use for Resident #48.
Failed to update the accident/falls care plans with additional interventions after a fall for Resident #54.
Failed to ensure the environment remained free of accident hazards and failed to identify, evaluate, and analyze the fall hazard/risk factor for Resident #54.
Report Facts
Residents reviewed for MDS accuracy: 15
Residents reviewed for falls: 2
BIMS score: 11
BIMS score: 7
Fall risk assessment score: 8
Date of fall incident: May 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | LPN | Stated Resident #48 dipped tobacco several times daily |
| MDS Coordinator #1 | Revealed Resident #48 used smokeless tobacco and expected accurate MDS coding | |
| Director of Nursing | DON | Stated Resident #48 used tobacco daily and expected accurate MDS coding; also stated new interventions should be added to care plan after a fall |
| Administrator | Stated Resident #48 used tobacco daily and expected accurate MDS coding; also expected fall investigations and updated interventions | |
| Licensed Practical Nurse #2 | LPN, Personnel Director | Listed interventions on incident report for Resident #54 fall but did not update care plan or complete fall investigation |
| Certified Nursing Assistant #1 | CNA | Described Resident #54 as pleasantly confused and noted resident did not use call bell |
| Licensed Practical Nurse #3 | LPN | Responded to call bell on evening of Resident #54 fall and completed incident report |
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