Inspection Reports for
Quapaw Care and Rehabilitation Center, LLC
138 Brighton Terrace, Hot Springs, AR, 71913
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 5
Date: Jul 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, nutrition, and food safety at Quapaw Care and Rehabilitation Center LLC.
Findings
The facility was found deficient in multiple areas including failure to provide treatment according to care plans for residents with skin concerns and range of motion issues, failure to prepare and serve meals according to planned menus and recipes, and failure to maintain proper food storage, handling, and sanitation practices in the dietary department.
Deficiencies (5)
Failure to ensure resident received treatment in accordance with the Comprehensive Resident Centered Care Plan related to protective sleeve use for skin concerns.
Failure to implement interventions to increase range of motion and prevent further contracture for a resident with right-hand contracture.
Failure to prepare and serve meals according to planned written menus and recipes, including incorrect portion sizes and improper pureeing techniques.
Failure to ensure food items were properly stored, covered, and discarded when expired; failure to maintain proper hand hygiene and food temperatures in dietary services.
Failure to ensure meals were served in a manner that maintained palatability, appearance, nutritive value, and taste, particularly for pureed foods.
Report Facts
Residents requiring mechanical soft diets: 21
Food temperatures: 112
Food temperatures: 115
Food temperatures: 120
Food temperatures: 122
Food temperatures: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Confirmed resident had discoloration and no protective sleeves |
| Director of Nursing | Director of Nursing | Stated protective sleeves were applied late and staff educated |
| Administrator | Administrator | Directed nursing questions to DON and agreed with DON's comments |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Confirmed resident had contracture without device |
| Restorative Nursing Assistant | Restorative Nursing Assistant | Stated resident was never on restorative services |
| Dietary Manager | Dietary Manager | Described appearance of pureed vegetable blend and food safety issues |
| Dietary Staff DC #4 | Dietary Cook | Observed preparing pureed foods incorrectly and contaminating gloves |
Inspection Report
Routine
Deficiencies: 10
Date: May 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, care, infection control, medication storage, food service, and immunization policies at Quapaw Care and Rehabilitation Center LLC.
Findings
The facility was found deficient in multiple areas including unsafe storage of odor eliminators and chemicals, improper use of mechanical lifts, inadequate perineal and catheter care, failure to maintain respiratory equipment, unsecured medication storage, improper food temperature maintenance, unsanitary ice machine conditions, poor infection control practices including hand hygiene, and failure to obtain informed consent for immunizations.
Deficiencies (10)
Odor eliminators were left at the bedside accessible to residents, posing ingestion hazards.
Mechanical lift legs were left in closed position during resident transfers, risking injury.
Housekeeping cart was left unlocked and unattended with chemicals accessible to residents.
Failure to provide timely perineal care and secure catheter tubing to prevent infection and trauma.
Portable nasal cannula tubing was not dated or changed as required, risking respiratory infections.
Medication was left unattended on nurse's cart, risking misappropriation.
Meals were served at improper temperatures and food was not maintained at safe temperatures on steam table.
Ice machine used by residents was found with brownish residue, indicating unsanitary conditions.
Failure to perform proper hand hygiene during perineal care and medication administration.
Failure to obtain informed consent for immunizations prior to administration.
Report Facts
Residents affected: 87
Residents affected: 16
Residents affected: 10
Residents affected: 12
Residents affected: 9
Residents affected: 9
Residents affected: 4
Food temperature: 46
Food temperature: 103
Food temperature: 105.9
Food temperature: 110
Food temperature: 105.8
Food temperature: 108
Cold food temperature: 48
Cold food temperature: 46
Cold food temperature: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in findings related to odor eliminator policy, medication storage, respiratory tubing, and hand hygiene during medication pass |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Named in mechanical lift use and perineal care observations |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Named in mechanical lift use and perineal care observations |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Named in infection control and hand hygiene deficiency during perineal care |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Named in infection control and hand hygiene deficiency during perineal care |
| Director of Nursing | Director of Nursing | Provided policy clarifications and confirmed standard practices related to odor eliminators, mechanical lifts, housekeeping carts, catheter care, respiratory tubing, medication storage, hand hygiene, and immunizations |
| Dietary Supervisor | Dietary Supervisor | Provided food temperature readings and ice machine sanitation information |
| Dietary Employee #1 | Dietary Employee | Provided cold food temperature readings on steam table |
| Business Office Manager | Business Office Manager | Provided vaccination consent documentation |
| Infection Preventionist | Infection Preventionist | Provided vaccination consent information and interview |
| Housekeeping Staff #1 | Housekeeping Staff | Named in housekeeping cart unsecured observation |
Inspection Report
Routine
Census: 102
Deficiencies: 11
Date: May 5, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meal service, failure to provide privacy during hospice care assessments, incomplete care plans, inaccurate resident assessments, improper medication and treatment orders, inadequate infection control practices, unsafe food handling and storage, and failure to maintain proper oxygen therapy protocols.
Deficiencies (11)
Failed to treat residents on the Memory Care Unit with dignity by not providing meals to all residents seated at a table at the same time and failing to provide privacy during hospice care assessments.
Failed to act promptly and provide resolution to a grievance regarding a missing pendant.
Failed to ensure comprehensive assessments were accurately coded for residents and failed to develop and implement complete care plans.
Failed to ensure a Physician's Order was obtained prior to provision of treatment for a resident.
Failed to ensure resident alarm box was attached to sensor pad or found in room to prevent accidents.
Failed to ensure Physician Orders were followed for changing nasal cannulas and humidified water to prevent infection.
Failed to ensure refrigerated narcotic medications were stored in a permanently affixed compartment.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to ensure food items were properly covered and sealed, kitchen appliances cleaned, staff washed hands before handling food, expired food removed, and ice machines maintained clean.
Failed to maintain accurate medical records by inaccurately documenting dates oxygen tubing was changed.
Failed to ensure Enhanced Barrier Precaution signage was posted and PPE used for a resident on transmission-based precautions.
Report Facts
Residents sampled: 19
Residents affected: 7
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 44
Residents affected: 6
Residents affected: 102
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in wound care treatment and medication administration findings |
| LPN #1 | Licensed Practical Nurse | Named in hospice care and oxygen tubing maintenance findings |
| DON | Director of Nursing | Named in multiple findings including care plan, oxygen therapy, and medication storage |
| CNA #6 | Certified Nursing Assistant | Named in meal service and bed alarm findings |
| DE #1 | Dietary Employee | Named in food preparation and hand hygiene findings |
| DE #2 | Dietary Employee | Named in food preparation and hand hygiene findings |
| Infection Preventionist | Named in infection control findings |
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