Inspection Reports for
Presbyterian Village, Inc.
510 Brookside Drive, Little Rock, AR, 72205
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
83% 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: 2
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to assess compliance with physician orders related to resident care, including the application of compression stockings and infection prevention practices during feeding of dependent residents.
Findings
The facility failed to ensure that compression stockings or leg wraps were applied as ordered for Resident #40, resulting in minimal harm. Additionally, the facility failed to ensure staff performed proper hand hygiene while feeding dependent residents, risking cross contamination and potential infection spread to four residents.
Deficiencies (2)
Failure to follow physician's order for applying compression stockings/leg wraps for Resident #40.
Failure to ensure staff performed hand hygiene while feeding dependent residents, risking infection spread to four residents.
Report Facts
Residents affected: 1
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | CNA | Applied and removed compression stockings for Resident #40; did not document removal |
| Restorative Certified Nursing Assistant #6 | RCNA | Did not apply or ask Resident #40 about compression stockings |
| Licensed Practical Nurse #3 | LPN | Reviewed MAR and stated no order for compression stockings on MAR |
| Licensed Practical Nurse #1 | LPN | Reviewed TAR and physician orders; confirmed stockings should be applied; interviewed Resident #40 |
| Director of Nursing | DON | Acknowledged orders were overlooked and entered as ancillary rather than doctor's orders; provided facility policy |
| Medical Director | MD | Stated stockings should be applied daily and ordered diuretic to reduce edema |
| Certified Nursing Assistant #4 | CNA | Observed feeding dependent residents without performing hand hygiene between residents |
| Certified Nursing Assistant #5 | CNA | Interviewed about hand hygiene practices; had prior experience but no in-service at this facility |
| Infection Preventionist Licensed Practical Nurse #1 | LPN | Provided guidance on hand hygiene requirements |
| Administrator | Administrator | Stated importance of hand hygiene to prevent cross contamination during feeding |
Inspection Report
Routine
Census: 65
Deficiencies: 8
Date: Feb 9, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, infection control, catheter care, food safety, and environmental conditions in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to post contact information for state agencies, unsafe lift equipment, improper transfer techniques, inadequate catheter care, unsanitary kitchen conditions, lack of proper infection prevention practices including hand hygiene, and incomplete implementation of a Legionella water management program.
Deficiencies (8)
Failure to post names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups in an accessible manner to residents.
Lift pads/slings were frayed, ripped, or torn, posing accident hazards to residents requiring mechanical lifts.
Staff failed to use appropriate transfer devices (gait belts) when transferring residents without lifts.
Failure to ensure catheter tubing was secured with a leg strap to prevent injury or trauma.
Indwelling catheter tubing was observed dragging on the floor, risking infection.
Facility kitchen and food storage areas were not maintained in a clean, sanitary manner, including buildup of debris, sticky residues, and dented cans.
Failure to implement effective infection prevention and control program including inadequate hand hygiene and improper reuse of gloves and lift pads.
Failure to implement and document a comprehensive Legionella water management program including flushing of valved off water and water system mapping.
Report Facts
Residents affected: 13
Residents affected: 1
Residents affected: 4
Residents affected: 7
Residents affected: 1
Residents affected: 1
Residents affected: 65
Residents affected: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Spoke about lift pad safety and catheter care; observed transferring Resident #40 without gait belt |
| CNA #3 | Certified Nursing Assistant | Observed performing incontinent care with improper glove use and reuse of lift pad |
| CNA #5 | Certified Nursing Assistant | Observed transferring Resident #40 without gait belt and improper transfer technique |
| Director of Nursing | Director of Nursing (DON) | Provided information on policies, catheter care, transfer techniques, and water management team |
| Dietary #1 | Dietary Staff | Confirmed unsanitary kitchen conditions and food safety policies |
| Maintenance #1 | Maintenance Staff | Discussed water management program and legionella knowledge |
| Infection Preventionist | Infection Preventionist (IP) | Provided infection control policies and water management program details |
| Administrator | Facility Administrator | Provided policies and acknowledged deficiencies |
Inspection Report
Routine
Census: 60
Deficiencies: 5
Date: Nov 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, safety hazards, food handling, arbitration agreements, and quality assurance processes at Presbyterian Village, Inc.
Findings
The facility was found deficient in ensuring resident involvement in care plan development, maintaining laundry dryers free of lint buildup to prevent fire hazards, covering food during transport to prevent foodborne illness, providing neutral arbitration agreements, and implementing effective quality assurance actions to correct repeated deficiencies.
Deficiencies (5)
Failed to ensure resident involvement in care plan development for 1 of 6 sampled residents.
Failed to ensure 2 clothes dryers remained free from lint buildup, creating fire hazard potential affecting all residents.
Failed to cover residents' food during delivery between dining areas, risking foodborne illness for 15 of 16 residents.
Failed to ensure Binding Arbitration Agreements provided for neutral arbitrator selection and convenient venue for 3 residents.
Failed to ensure the Quality Assessment and Assurance Committee developed and implemented effective corrective plans for repeated deficiencies related to accident hazards and food safety.
Report Facts
Residents affected: 1
Residents affected: 60
Residents affected: 15
Residents affected: 3
Residents affected: 60
Total residents: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed about care plan meeting invitations | |
| Resident Services Supervisor | Interviewed about care plan meeting invitations and procedures | |
| Director of Nursing | Interviewed about care plan meetings and food handling policies | |
| Administrator | Interviewed about care plan meetings, food handling, arbitration agreements, and QAA committee | |
| Laundry Staff #1 | Interviewed about dryer lint cleaning practices | |
| Laundry Staff #2 | Interviewed about dryer lint cleaning practices | |
| Certified Nursing Assistant #1 | Interviewed about food tray covering practices | |
| Certified Nursing Assistant #2 | Interviewed about food tray covering practices | |
| Certified Nursing Assistant #3 | Interviewed about food tray covering practices |
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