Inspection Reports for
Ridgecrest Health and Rehabilitation
5504 E Johnson Ave, Jonesboro, AR, 72401
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
18.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
260% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Deficiencies: 2
Date: Oct 29, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with medication administration procedures, specifically regarding timely administration and proper handling of medications for sampled residents.
Findings
The facility failed to administer medications within the recommended time frame for one resident and failed to ensure that the nurse who pulled the medications was the one administering them, posing a risk to medication safety. The deficiencies were noted with minimal harm or potential for actual harm affecting a few residents.
Deficiencies (2)
Failed to administer medications within the recommended time frame for Resident #3.
Failed to ensure that medications pulled by one nurse were administered by the same nurse for Resident #3.
Report Facts
Medication administration time: 1914
Number of residents sampled: 3
BIMS score: 9
Narcotic dosage: 5.325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed pulling and administering medications late; involved in medication administration deficiencies |
| Director of Nurse | Director of Nursing | Provided statements regarding medication administration timing and procedures |
| Medicare Manager | Observed medication administration and confirmed medication correctness |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 2, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, medication administration, and nutritional services.
Findings
The facility was found deficient in providing adequate assistance with activities of daily living, specifically nail care for diabetic residents, ensuring availability and administration of prescribed medications, and preparing meals according to planned recipes to meet residents' nutritional needs. These deficiencies posed minimal harm or potential for actual harm to some residents.
Deficiencies (4)
Failure to ensure residents who required assistance with activities of daily living were regularly provided with necessary assistance to maintain good hygiene and grooming, including failure to keep fingernails clean and trimmed for diabetic residents.
Failure to ensure all pharmaceuticals were available and administered as ordered, resulting in medication errors for residents with chronic conditions.
Failure to ensure medication error rates were maintained below 5 percent, with documented medication errors for two residents during medication pass observations.
Failure to prepare and serve meals according to the planned written quantified recipe and menu, affecting residents receiving pureed and enhanced food diets.
Report Facts
Deficiencies cited: 4
Medication error rate: 5
Number of residents affected: 2
Number of residents observed for medication errors: 3
Number of residents receiving pureed diets: 2
Number of residents receiving enhanced food diets: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #14 | Licensed Practical Nurse | Named in finding related to failure to trim and clean nails of Resident #71. |
| Certified Nursing Assistant #13 | Certified Nursing Assistant | Named in finding related to nail care for residents. |
| Director of Nursing | Director of Nursing | Interviewed regarding nail care responsibilities and medication availability. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Named in observation related to failure to provide foot/toenail care for Resident #22. |
| Assistant Director of Nursing #16 | Assistant Director of Nursing | Interviewed regarding nail care and medication availability. |
| Registered Nurse #25 | Registered Nurse | Named in observation and interview related to medication administration errors. |
| Dietary [NAME] #7 | Dietary Cook | Named in finding related to failure to prepare meals according to recipe. |
Inspection Report
Routine
Deficiencies: 18
Date: Aug 2, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, infection control, medication administration, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during care, inadequate accommodation of resident needs, untimely completion and accuracy of Minimum Data Set (MDS) assessments, incomplete and inaccurate care plans, failure to provide proper wound care and foot care, medication administration errors, failure to follow Registered Dietitian recommendations timely, improper food preparation and serving temperatures, poor infection control practices including improper use of personal protective equipment (PPE), and failure to maintain an effective Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (18)
Failure to ensure dignity was maintained during Activities of Daily Living (ADL) care, including privacy curtain use and handling of soiled items.
Failure to ensure call light was within reach for a resident and timely treatment of skin tear.
Failure to complete admission Minimum Data Set (MDS) in a timely manner.
Failure to complete accurate MDS assessments, including medication and treatment documentation.
Failure to create and implement baseline care plans with interventions for pressure ulcers, enhanced barrier precautions, and PICC lines upon admission.
Failure to develop and implement complete care plans addressing residents' needs, including code status, hearing loss, and elopement risk.
Failure to provide necessary assistance with activities of daily living, including nail care and foot/toenail care for diabetic residents.
Failure to set up wound assessments timely and follow physician orders for wound care treatments.
Failure to follow Registered Dietitian recommendations timely for enteral bolus feeding and failure to provide ordered eye ointment.
Failure to administer enteral water flush per physician orders during medication administration for a resident with PEG tube.
Failure to ensure CPAP usage was documented in care plans and physician orders, and failure to store CPAP masks properly.
Failure to update care plans and implement enhanced barrier precautions, wound care assessments, and infection control measures for residents with wounds, PICC lines, and other conditions.
Failure to ensure all medications were available and administered as ordered, resulting in medication errors.
Failure to prepare and serve meals according to planned recipes and menus, including incorrect portion sizes and improper seasoning.
Failure to serve food and beverages at safe and appetizing temperatures, including cold milk and improperly heated food items.
Failure to ensure dietary staff practiced proper hand hygiene to prevent cross contamination during meal preparation and serving.
Failure to maintain and provide records of the Quality Assurance Performance Improvement (QAPI) program.
Failure to ensure infection prevention and control practices, including proper use of PPE for contact isolation, enhanced barrier precautions, PEG tube care, wound care, and CPAP mask storage.
Report Facts
Weight loss: 8.9
Weight loss percentage: 5.2
Medication error rate: 2
Temperature: 43.7
Temperature: 114.8
Temperature: 45.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #14 | Licensed Practical Nurse | Named in wound care and PICC line medication administration findings |
| ADON #16 | Assistant Director of Nursing | Named in multiple interviews related to wound care, medication administration, and infection control |
| MDS Coordinator #19 | MDS Coordinator | Named in interviews regarding MDS assessments and care plan updates |
| MDS Nurse #20 | MDS Nurse | Named in interviews regarding MDS assessments and care plan updates |
| RN #25 | Registered Nurse | Named in medication administration and medication availability findings |
| DA #7 | Dietary Aide | Named in food preparation and serving findings |
| CNA #12 | Certified Nursing Assistant | Named in food temperature and infection control observations |
| LPN #27 | Licensed Practical Nurse | Named in infection control and medication administration findings |
Inspection Report
Routine
Deficiencies: 4
Date: Jul 3, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident rights, environment, nursing competencies, infection control, and care planning at Ridgecrest Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to respect resident privacy by not knocking before entering rooms, failure to maintain a safe and homelike environment due to damaged walls and unclean conditions, inadequate nursing competencies in care planning and assessment completion, failure to document catheter care and skin/wound evaluations, and poor infection control practices including inadequate hand hygiene and improper wound care.
Deficiencies (4)
Failure to knock on resident doors prior to entering, violating resident privacy and dignity.
Failure to maintain a safe, clean, comfortable, and homelike environment due to damaged walls, unclean floors, and clutter in resident rooms and hallways.
Failure to ensure licensed nurses have appropriate competencies for care planning, including incomplete Minimum Data Set (MDS) assessments, outdated care plans, failure to update physician orders, and failure to document catheter care and skin/wound evaluations.
Failure to implement infection prevention and control practices, including failure to perform hand hygiene before and after resident care, during perineal and wound care, and failure to properly don and change gloves.
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 1
Assessment Reference Date: Jun 15, 2024
Assessment Reference Date: Apr 17, 2024
Brief Interview for Mental Status (BIMS) score: 15
Skin and wound evaluations missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Named in findings related to failure to knock on doors and failure to perform hand hygiene |
| CNA #5 | Certified Nursing Assistant | Named in findings related to failure to knock on doors and failure to perform hand hygiene |
| CNA #6 | Certified Nursing Assistant | Interviewed regarding room conditions and resident care |
| Treatment Nurse | Named in findings related to wound care, care plan updates, and infection control deficiencies | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding policies, care planning, infection control, and staff responsibilities |
| Long-Term Care MDS Coordinator | Interviewed regarding MDS completion and care plan responsibilities | |
| Medicare Manager | Interviewed regarding MDS completion and care plan responsibilities | |
| Administrator | Interviewed regarding staff training and infection control policies | |
| Infection Preventionist | Interviewed regarding hand hygiene and infection control procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 29, 2023
Visit Reason
The inspection was conducted following a complaint related to Resident #2 falling out of bed during incontinent care, resulting in a femur fracture and concerns about the adequacy of care and pain management.
Complaint Details
The investigation was complaint-related concerning Resident #2's fall out of bed during peri-care, delayed fracture diagnosis, inadequate pain management, and failure to notify family. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to provide safe incontinent care to prevent Resident #2 from sliding out of bed, resulting in a femur fracture. The resident was initially treated with Tylenol, but the fracture was not identified until several days later, leading to delayed hospital transfer and inadequate pain management.
Deficiencies (1)
Failure to ensure incontinent care was provided in a safe manner to prevent a resident from sliding out of bed resulting in a femur fracture.
Report Facts
Deficiencies cited: 1
Medication doses: 3
Medication dose: 1
Dates: Nov 14, 2023
Dates: Nov 20, 2023
Dates: Dec 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed fall incident and care details during interview on 12/28/23 |
| Administrator | Administrator | Provided information about fall, x-ray orders, and family notification during interview on 12/28/23 |
| APRN | Advanced Practice Registered Nurse | Ordered x-rays, reviewed results late, and confirmed fracture diagnosis and pain management |
Inspection Report
Deficiencies: 1
Date: Oct 27, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with appropriate pressure ulcer care and prevention, specifically regarding admission assessments and skin audits for residents.
Findings
The facility failed to complete an admission assessment and initial body audit on the day of admission for one resident, resulting in delayed identification and treatment of a deep tissue injury (DTI) on the resident's right heel. Interviews and record reviews confirmed the deficiency and described the facility's policies and procedures related to admission assessments and wound care.
Deficiencies (1)
Failure to complete an admission assessment and initial body audit on the day of admission for Resident #1, leading to delayed identification and treatment of a pressure ulcer (DTI) on the right heel.
Report Facts
Date of first skin audit: Oct 2, 2023
Date wound care orders implemented: Oct 5, 2023
Date of admission: Sep 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Treatment Nurse | Confirmed details about admission assessment and body audit procedures and timing |
| Director of Nursing | Director of Nursing | Confirmed facility policies on admission assessments and body audits, and staffing related to admissions |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 4, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with care standards related to activities of daily living, including timely response to call lights and proper nail care for residents.
Findings
The facility failed to ensure timely response to call lights for Resident #5 and failed to maintain clean and trimmed fingernails for Residents #6, #7, #8, and #9. Care plans were either incomplete or not followed regarding nail care and assistance needs.
Deficiencies (2)
Failure to ensure call light was answered in a timely manner for Resident #5.
Failure to maintain clean and trimmed fingernails for Residents #6, #7, #8, and #9.
Report Facts
Residents sampled: 16
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in relation to nail care for Resident #9 |
| CNA #3 | Certified Nursing Assistant | Described fingernail conditions of Residents #6 and #7 |
Inspection Report
Annual Inspection
Census: 111
Deficiencies: 3
Date: Sep 15, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, environment, and staffing at Ridgecrest Health and Rehabilitation.
Findings
The facility was found deficient in maintaining a clean and homelike environment in multiple resident rooms, providing adequate activities of daily living (ADL) care including nail care for residents, and ensuring sufficient nursing staff to meet resident needs. Several residents had unclean rooms, long and dirty fingernails, and inadequate bathing assistance due to staffing shortages.
Deficiencies (3)
Resident rooms were not maintained in a clean and homelike manner, with dirt, debris, dried substances, and food particles observed in multiple rooms.
Activities of daily living care was not adequately provided for 4 of 13 sampled residents, including failure to properly trim and clean fingernails.
Insufficient nursing staff were available to meet the needs of residents requiring assistance with activities of daily living, affecting all 111 residents.
Report Facts
Residents affected by unclean rooms: 6
Residents sampled for ADL care: 13
Residents affected by inadequate ADL care: 4
Total residents in facility: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Interviewed about sheet changing frequency and bedside table cleanliness |
| RN #2 | Registered Nurse | Interviewed about sheet changing frequency and nail care |
| ADON #1 | Assistant Director of Nursing | Confirmed unclean resident room and potential bloodborne pathogen issue |
| Housekeeper #1 | Housekeeper | Interviewed about room cleaning frequency and process |
| Housekeeper #2 | Housekeeper | Interviewed about cleaning schedules and missed rooms |
| LPN #1 | Licensed Practical Nurse | Confirmed responsibility for nail care and staffing issues |
| RN #1 | Registered Nurse | Confirmed CNA staffing levels on halls |
| Director of Nursing | Director of Nursing | Interviewed about nail care frequency and staffing shortages |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Sep 15, 2023
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements related to resident rights, environment, care, medication administration, staffing, food service, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including residents' access to personal funds, cleanliness and maintenance of resident rooms, timely completion of quarterly assessments, provision of activities of daily living care, medication administration errors, medication storage and security, respiratory care, staffing shortages impacting resident care, food temperature and handling issues, hand hygiene and infection control practices, and ineffective quality assurance processes.
Deficiencies (13)
Failed to ensure residents with trust accounts had access to personal funds after hours and on weekends.
Resident rooms were not maintained in a clean and homelike manner with dirt, debris, dried substances, and unclean surfaces.
Quarterly resident assessments were not completed and submitted within required timeframes for 4 sampled residents.
Failed to provide adequate activities of daily living care including nail care for 4 residents.
Medication administered by family member was not ordered by attending physician for 1 resident.
Medications were left unattended in resident rooms for 2 residents.
Oxygen was administered at incorrect flow rate and nebulizer mouthpiece was not stored properly for 2 residents.
Insufficient nursing staff to meet resident needs, resulting in missed or delayed care such as bathing and showering.
Opened insulin vials were not dated, medication carts were left unlocked, and medications were left unattended on carts.
Meals were served at unacceptable temperatures and food was often cold, affecting palatability.
Dietary staff failed to wash hands before handling clean equipment or food items, risking foodborne illness.
Quality Assurance and Performance Improvement Committee failed to implement effective corrective actions to prevent repeated deficiencies in environment, food service, respiratory care, and safety.
Staff failed to change gloves and perform hand hygiene during wound care, bath tables were cracked, medication administration lacked hand hygiene, and laundry staff did not use appropriate PPE or clean technique.
Report Facts
Residents affected: 2
Resident rooms affected: 6
Resident rooms total: 41
Residents sampled for ADL care: 13
Residents affected by ADL deficiency: 4
Residents sampled for respiratory therapy: 14
Residents affected by respiratory care deficiency: 2
Total residents: 111
Residents affected by staffing deficiency: 111
Breakfast trays temperature readings: 10
Breakfast trays temperature readings: 13
Breakfast trays temperature readings: 24
Breakfast trays temperature readings: 24
Breakfast trays temperature readings: 14
Breakfast trays temperature readings: 10
Breakfast trays temperature readings: 11
Residents affected by wound care deficiency: 31
Residents affected by bath table deficiency: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed staffing shortages and resident care issues |
| RN #1 | Registered Nurse | Observed leaving medication unattended and no hand hygiene during medication pass |
| LPN #2 | Licensed Practical Nurse | Observed failing to perform hand hygiene and glove changes during wound care |
| Director of Nursing | Director of Nursing | Confirmed multiple deficiencies including medication orders, staffing, infection control, and quality assurance |
| CNA #1 | Certified Nursing Assistant | Interviewed about nail care frequency |
| CNA #2 | Certified Nursing Assistant | Reported staffing shortages and care delays |
| Dietary Supervisor #1 | Dietary Supervisor | Provided food temperature data and dietary policy |
| Laundry Aide #1 | Laundry Aide | Interviewed about PPE use during laundry |
| Laundry Aide #2 | Laundry Aide | Observed improper laundry handling |
| LPN #5 | Licensed Practical Nurse | Confirmed insulin vial dating requirements |
| LPN #6 | Licensed Practical Nurse | Authorized family medication administration without physician order |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jul 12, 2023
Visit Reason
The inspection was conducted to evaluate compliance with physician orders and proper care related to enteral feeding for residents, specifically focusing on Resident #1's feeding tube management.
Findings
The facility failed to ensure that the physician's order for enteral feeding was followed for Resident #1. The resident's feeding pump was observed disconnected multiple times during the day, and staff did not verify tube placement prior to feeding. The feeding was off for an extended period, potentially impacting the resident's nutritional intake.
Deficiencies (1)
Failure to follow physician's order for enteral feeding for Resident #1, including prolonged disconnection of feeding pump and lack of tube placement verification before feeding.
Report Facts
Feeding rate: 70
Flush rate: 70
Calories per day: 2415
Calories per day: 1260
Weight loss: 2.6
Weight gain: 14
Feeding hours: 23
Observation times: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Discussed feeding disconnection, applied connector, and admitted failure to check tube placement prior to feeding |
| Director of Nurses | Director of Nurses | Mentioned by LPN #1 as person to assist with changing the feeding pump |
| Nurse Consultant | Nurse Consultant | Provided expert opinion on feeding pump usage and reviewed facility policy |
Inspection Report
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Ridgecrest Health and Rehabilitation, summarizing the findings of a regulatory survey completed on 03/22/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jul 1, 2022
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain a safe, clean, and dignified environment, timely report and investigation of injuries of unknown origin, provision of oral care, restorative services, fall prevention interventions, respiratory care, and food safety practices.
Complaint Details
The visit was complaint-related due to allegations of poor environmental conditions, failure to investigate injuries of unknown origin, inadequate oral care, lack of restorative services, fall prevention failures, improper respiratory care, and food safety violations. The report documents observations, interviews, and record reviews supporting these complaints.
Findings
The facility was found deficient in multiple areas including use of worn and stained linens and improperly attached privacy curtains, failure to timely identify and investigate injuries of unknown origin, inadequate oral care for residents on NPO status, failure to provide restorative services and use of positioning devices, lack of implementation of fall prevention interventions, improper storage of suction supplies, and poor food safety and sanitation practices in the kitchen.
Deficiencies (7)
Use of worn and stained linens on resident beds and privacy curtains unhooked from track and lying on the floor.
Failure to timely identify and investigate injury of unknown origin to rule out abuse or neglect.
Failure to provide oral care to promote good oral hygiene for a resident on NPO status.
Failure to provide restorative services and consistent use of splints, hand rolls, and positioning devices to prevent decline in range of motion.
Failure to ensure planned fall prevention interventions were implemented, including absence of bolsters and skid strips.
Failure to properly store suction supplies when not in use.
Failure to ensure food items stored in refrigerator had use by dates, kitchen equipment was clean, and dishes were clean before storing, risking foodborne illness.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Total residents receiving meals: 111
Total census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aid #1 | Certified Nursing Assistant | Named in findings related to linens, privacy curtains, and injury reporting |
| Director of Nursing | Director of Nursing | Named in findings related to linens, privacy curtains, injury investigation, restorative services, and fall prevention |
| Housekeeping/Laundry Supervisor | Housekeeping/Laundry Supervisor | Named in findings related to linens and laundry practices |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in findings related to injury reporting and fall prevention |
| Assistant Director of Nursing #2 | Assistant Director of Nursing | Named in findings related to injury reporting |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in findings related to oral care and suction supply storage |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in findings related to contracture devices |
| Dietary Employee #1 | Dietary Employee | Named in findings related to food safety and sanitation |
| Dietary Employee #2 | Dietary Employee | Named in findings related to food safety and sanitation |
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