Inspection Reports for
Russellville Nursing and Rehabilitation Center
215 South Portland Avenue, Russellville, AR, 72801
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
17.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 22, 2024
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to provide a safe, clean, and homelike environment, including issues with linen changes, plaster cracking, and cleanliness of the 100 Hall bath, as well as failure to follow grievance policy related to a lost tablet reported by a resident.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to maintain a safe, clean environment and did not follow grievance procedures for a lost tablet reported by Resident #16.
Findings
The facility failed to maintain a safe and clean environment as evidenced by soiled linens, plaster damage in resident bathrooms, and apparent fecal matter in a whirlpool tub. Additionally, the facility did not follow its grievance policy regarding a lost tablet reported by a resident, failing to complete a grievance form or promptly resolve the issue.
Deficiencies (4)
Failure to provide clean linens for Resident #44, with soiled bedding and presence of flies and urine odor.
Cracks and missing plaster between wall and sink in Resident #44 and Resident #15's personal bathrooms.
Presence of apparent fecal matter in the whirlpool tub on 100 Hall used by 43 residents.
Failure to follow grievance policy for Resident #16 regarding a lost tablet, including lack of grievance form completion and prompt resolution.
Report Facts
Residents affected: 43
Residents affected: 2
Residents affected: 1
Residents affected: 1
Expected timeframe for grievance resolution: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding missing tablet grievance for Resident #16 |
| Administrator | Administrator | Interviewed regarding missing tablet grievance for Resident #16 |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Interviewed about linen changes for Resident #44 |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed about cleaning responsibilities for baths |
| Housekeeper #6 | Housekeeper | Interviewed about cleaning schedule for baths |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about plaster damage in resident bathrooms |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Aug 22, 2024
Visit Reason
The inspection was conducted as a comprehensive annual survey of Russellville Nursing and Rehabilitation Center to assess compliance with regulatory requirements related to resident care, safety, grievance policies, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment; failure to follow grievance policies; failure to complete timely Minimum Data Set assessments after significant changes; unsafe use of power strips for medical equipment; inadequate care and monitoring of feeding tubes; improper food handling and storage practices; and failure to implement proper infection prevention and control measures including use of personal protective equipment.
Deficiencies (7)
Failure to provide a safe, clean, homelike environment including soiled linens, plaster cracking, and feces in whirlpool tub affecting multiple residents.
Failure to follow grievance policy including completing grievance forms and prompt resolution for a lost tablet incident.
Failure to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days after a significant change for a resident admitted to hospice care.
Failure to ensure an accepted power source was used for medical equipment, creating potential fire hazards.
Failure to ensure appropriate care for a resident with a feeding tube including checking placement before feeding and flushing.
Failure to procure food from approved sources and to store, prepare, and serve food in a manner to prevent cross contamination and spoilage.
Failure to implement infection prevention and control program including failure to use appropriate PPE during high contact resident care.
Report Facts
Residents affected: 43
Residents affected: 80
Feeding frequency: 2
Power strip outlets: 6
MDS Assessment Reference Date: May 13, 2024
MDS Assessment Reference Date: Jul 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #5 | Interviewed about linen changes for Resident #44 | |
| Maintenance Supervisor | Interviewed about plaster cracks and toilet issues | |
| Certified Nursing Assistant (CNA) #4 | Interviewed about whirlpool tub cleaning and pipe in wall | |
| Housekeeper #6 | Interviewed about cleaning schedule for baths | |
| Assistant Director of Nursing (ADON) | Interviewed about grievance report and missing tablet | |
| Administrator | Interviewed about grievance report and power strip concerns | |
| MDS Coordinator | Interviewed about MDS assessment for Resident #58 | |
| Licensed Practical Nurse (LPN) #3 | Observed and interviewed regarding feeding tube care and PPE use | |
| Director of Nurses (DON) | Interviewed about feeding tube care and infection control | |
| Dietary Employee #1 | Observed with improper hand hygiene and food handling | |
| Dietary Employee #2 | Observed with improper hand hygiene and food handling | |
| Dietary Manager | Interviewed about handwashing and food storage policies |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to resident safety, environment cleanliness, grievance policies, and overall facility conditions at Russellville Nursing and Rehabilitation Center.
Findings
The facility failed to maintain a safe, clean, and homelike environment, including soiled linens, plaster damage in resident bathrooms, and fecal matter in a whirlpool tub. Additionally, the facility did not follow its grievance policy regarding a missing resident tablet, failing to complete a grievance form and promptly resolve the issue.
Deficiencies (2)
Failure to provide a safe, clean, homelike environment including soiled linens and plaster cracking in resident bathrooms and fecal matter in whirlpool tub.
Failure to follow grievance policy including completing grievance form and prompt resolution for missing resident tablet.
Report Facts
Residents affected: 43
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #5 | Interviewed regarding linen changes for Resident #44 | |
| Maintenance Supervisor | Interviewed regarding plaster damage in resident bathrooms | |
| Certified Nursing Assistant (CNA) #4 | Interviewed regarding responsibility for cleaning baths | |
| Housekeeper #6 | Interviewed regarding cleaning of baths | |
| Assistant Director of Nursing (ADON) | Interviewed regarding missing tablet grievance | |
| Administrator | Interviewed regarding missing tablet grievance |
Inspection Report
Routine
Deficiencies: 9
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, grievance policies, assessment procedures, accident prevention, feeding tube care, food safety, and infection control at Russellville Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean environment; failure to follow grievance policies; incomplete Minimum Data Set assessments after significant changes; unsafe use of power strips for medical equipment; unresolved maintenance issues; improper feeding tube care and infection control practices; and food safety violations including expired food and poor hand hygiene.
Deficiencies (9)
Failed to provide a safe, clean, homelike environment including soiled linens, plaster cracking, and feces in whirlpool tub.
Failed to follow grievance policy including completing grievance form and prompt resolution for a lost tablet.
Failed to complete a comprehensive Minimum Data Set assessment within 14 days after significant change for a resident admitted to hospice care.
Failed to ensure accepted power source for medical equipment, with non-medical grade power strip used for oxygen concentrator and pacemaker.
Failed to fix a toilet that moves and creates difficulty for resident use, known for months.
Presence of an uncapped hollow pipe protruding from wall in resident area, posing risk of skin injury.
Failed to ensure placement of PEG feeding tube before feeding and flush; nurse did not check placement before feeding.
Failed to procure food from approved sources and ensure food safety practices including discarding expired food, handwashing, and preventing cross contamination.
Failed to implement infection prevention and control program; staff did not wear gowns or dispose PPE properly during PEG tube feeding.
Report Facts
Residents affected: 43
Residents affected: 80
Use by dates: 3
Feeding frequency: 2
Power strip outlets: 6
MDS assessment timeframe: 14
Grievance resolution timeframe: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Observed administering PEG tube feeding without checking placement and without appropriate PPE |
| Certified Nursing Assistant #5 | CNA | Interviewed about linen changes for Resident #44 |
| Certified Nursing Assistant #4 | CNA | Interviewed about cleaning responsibilities and pipe hazard |
| Housekeeper #6 | Housekeeper | Interviewed about bath cleaning practices |
| Assistant Director of Nursing | ADON | Interviewed about missing tablet grievance |
| Administrator | Administrator | Interviewed about missing tablet grievance and power strip concerns |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about sink plaster damage, toilet issue, and pipe protrusion |
| Director of Nurses | DON | Interviewed about PEG tube feeding procedures and infection control |
| Dietary Employee #1 | Dietary Staff | Observed poor hand hygiene and food handling practices |
| Dietary Employee #2 | Dietary Staff | Observed poor hand hygiene and food handling practices |
| Dietary Manager | Dietary Manager | Interviewed about handwashing and food storage policies |
Inspection Report
Routine
Deficiencies: 8
Date: Oct 13, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care, safety, nutrition, infection control, and medication management.
Findings
The facility was found deficient in several areas including inconsistent documentation of advance directives, inadequate fingernail care for a resident, medications left unattended, improper respiratory care including lack of physician orders and poor equipment storage, failure to prepare and serve meals according to planned menus and nutritional needs, improper food handling and hygiene practices in the kitchen, and failure to post required isolation precaution signage for a resident with MRSA.
Deficiencies (8)
Failed to clearly determine and document the Advanced Directives for 1 resident due to conflicting documents.
Failed to ensure fingernail care was provided to maintain hygiene and prevent injury for 1 resident.
Medications were left unattended in a resident's room, posing a potential safety risk.
Failed to store nebulizer mask and tubing properly, ensure humidifier bottles were filled, and failed to have a physician's order for oxygen administration for certain residents.
Meals were not prepared or served according to the planned menu and nutritional needs, including insufficient portions and missing enhanced food items.
Pureed food items were not blended to a smooth, lump-free consistency, increasing risk of choking.
Food items in the refrigerator were uncovered or unsealed; staff failed to wash hands before handling food or equipment; hot foods were served below required temperatures.
Failed to post contact isolation precaution sign on the door of a resident with MRSA infection.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 64
Residents affected: 1
Residents affected: 3
Residents affected: 24
Residents affected: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding conflicting advance directive documents for Resident #25 | |
| Assistant Director of Nursing (ADON) | Confirmed concerns about conflicting advance directive documents | |
| Medication Assistant - Certified (MA-C) #3 | Medication Assistant - Certified | Interviewed about Resident #42's fingernail care and medication left unattended for Resident #39 |
| LPN #3 | Licensed Practical Nurse | Interviewed about oxygen administration and nebulizer mask storage for Resident #13 |
| Director of Nursing (DON) | Interviewed about humidifier bottle maintenance and oxygen tubing storage | |
| Dietary Employee #1 | Dietary Employee | Observed and interviewed regarding meal preparation and food handling |
| Dietary Employee #2 | Dietary Employee | Observed handling food without washing hands |
| Dietary Employee #3 | Dietary Employee | Observed handling food and equipment without proper hand hygiene |
| Dietary Employee #4 | Dietary Employee | Observed serving meals and preparing pureed foods |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Interviewed about consistency of pureed food items |
| Certified Nursing Assistant (CNA) #3 | Certified Nursing Assistant | Interviewed about lack of isolation precaution signage for Resident #55 |
Inspection Report
Routine
Deficiencies: 8
Date: Oct 13, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of Russellville Nursing and Rehabilitation Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found to have multiple deficiencies including failure to properly document advance directives, inadequate fingernail care, unsafe medication storage, improper respiratory care practices, failure to prepare and serve meals according to planned menus and nutritional standards, poor food handling and hygiene practices, and failure to post required infection control signage.
Deficiencies (8)
Failed to clearly determine and document the Advanced Directives for 1 resident.
Failed to ensure fingernail care was provided to maintain good hygiene and prevent potential injury or infection for 1 resident.
Failed to ensure medications were not left unattended in a resident's room, posing potential risk to 17 residents.
Failed to store nebulizer mask and tubing properly, ensure humidifier bottles were filled, and failed to have physician order for oxygen administration for certain residents.
Failed to ensure meals were prepared and served according to the planned written menu for pureed, alterative, and enhanced food items affecting multiple residents.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to ensure food items stored in the refrigerator were covered or sealed; staff failed to wash hands before handling food or equipment; hot food items were not maintained at or above 135°F.
Failed to post a contact isolation precaution sign to notify staff of appropriate precautions for a resident with MRSA.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 17
Residents affected: 3
Residents affected: 64
Meals observed: 2
Residents affected: 3
Residents affected: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Assistant - Certified #3 | Interviewed regarding fingernail care and medication storage deficiencies | |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding oxygen therapy and nebulizer mask storage |
| Dietary Employee #1 | Observed and interviewed regarding food service and hygiene practices | |
| Dietary Employee #2 | Observed handling food without washing hands | |
| Dietary Employee #3 | Observed handling food and equipment without proper hand hygiene | |
| Dietary Employee #4 | Observed serving meals and food preparation with noted deficiencies | |
| Dietary Supervisor | Interviewed regarding meal preparation and food consistency | |
| Certified Nursing Assistant #1 | Interviewed regarding pureed food consistency | |
| Certified Nursing Assistant (CNA) #3 | Interviewed regarding lack of isolation precaution signage | |
| Administrator | Interviewed regarding advance directive documentation | |
| Assistant Director of Nursing (ADON) | Interviewed regarding advance directive documentation | |
| Director of Nursing (DON) | Interviewed regarding respiratory care and oxygen therapy policies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 10, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the failure of a Medication Assistant-Certified (MA-C) to administer medications according to physician orders for Resident #7.
Complaint Details
The visit was complaint-related concerning missed medication administration for Resident #7. The complaint was substantiated as the facility failed to administer medications as ordered and failed to document or notify appropriate staff.
Findings
The facility failed to ensure that medications were administered as ordered for Resident #7, who missed morning medications on 08/09/2023. There was no documentation of notification to nursing staff or assessment of the resident following the missed medications. Interviews with staff revealed gaps in medication administration protocols and documentation.
Deficiencies (1)
Failure to ensure the Medication Assistant-Certified administered medication according to physician's order for Resident #7.
Report Facts
Residents sampled: 10
Date of missed medication: Aug 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication administration protocols and potential outcomes of missed medications. |
| Director of Nursing | Director of Nursing (DON) | Interviewed about medication administration policies and potential outcomes of missed medications. |
Inspection Report
Deficiencies: 1
Date: Aug 10, 2023
Visit Reason
The inspection was conducted to assess compliance with medication administration protocols, specifically focusing on whether the Medication Assistant-Certified (MA-C) administered medications according to physician orders for sampled residents.
Findings
The facility failed to ensure that the Medication Assistant-Certified administered medications as ordered for one of ten sampled residents, resulting in missed medications without proper notification or assessment. Interviews and record reviews revealed lack of documentation and policy regarding medication administration by MA-Cs and potential risks to residents from missed medications.
Deficiencies (1)
Failure to ensure the Medication Assistant-Certified administered medication according to physician's orders for one resident, including missed medication without notification or assessment.
Report Facts
Residents sampled: 10
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication administration protocols and potential outcomes of missed medications |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration policies and documentation requirements |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jul 29, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident assessments, care planning, respiratory care, psychotropic medication use, vaccination policies, and COVID-19 reporting.
Findings
The facility was found deficient in multiple areas including incomplete resident assessments, inadequate care plans for padded side rails and anticoagulants, improper storage of respiratory equipment, failure to address psychotropic medication orders appropriately, failure to administer pneumonia vaccinations to some residents, and failure to timely notify residents and families of COVID-19 cases.
Deficiencies (6)
Failed to ensure comprehensive, accurate, standardized assessment of residents' functional capacity including documentation of triggered care area assessments for 2 of 16 sampled residents.
Failed to develop and implement a complete care plan addressing padded siderails for 1 resident and anticoagulant use for another resident.
Failed to ensure oxygen tubing, nebulizer mask, and CPAP mask and tubing were properly stored when not in use for 2 residents, risking contamination.
Failed to ensure psychotropic PRN orders were addressed within 14 days and failed to ensure necessary diagnosis and risk vs. benefit documentation for residents on psychotropic drugs.
Failed to ensure pneumonia vaccine was administered or documented for 2 of 17 sampled residents.
Failed to inform residents, representatives, and families of COVID-19 infections within required timeframe.
Report Facts
Residents sampled: 16
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Noted uncovered CPAP mask and acknowledged responsibility to correct |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Mentioned in relation to side rail padding and COVID-19 positive test |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Mentioned regarding availability of side rail padding |
| Director of Nursing | Director of Nursing | Interviewed about care plans, respiratory equipment storage, psychotropic medication orders, and immunization monitoring |
| Minimum Data Set Nurse | MDS Nurse | Interviewed about care plan documentation for padded siderails and anticoagulants |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for monitoring pneumonia vaccinations and interviewed about vaccination issues |
| Administrator | Administrator | Provided COVID-19 positive list and admitted failure to notify residents/families timely |
Inspection Report
Routine
Census: 60
Deficiencies: 6
Date: Jul 29, 2022
Visit Reason
Routine inspection of Russellville Nursing and Rehabilitation Center to assess compliance with regulatory requirements including resident assessments, care planning, respiratory care, psychotropic medication use, immunizations, and COVID-19 reporting.
Findings
The facility was found deficient in multiple areas including incomplete resident assessments, inadequate care plans for padded siderails and anticoagulants, improper storage of respiratory equipment, failure to address psychotropic medication use and PRN orders appropriately, failure to administer pneumonia vaccines to some residents, and failure to timely notify residents and families of COVID-19 infections.
Deficiencies (6)
Failed to ensure comprehensive, accurate, standardized assessment of residents' functional capacity and care area assessments for 2 of 16 sampled residents.
Failed to develop and implement a complete care plan addressing padded siderails and anticoagulant use for 2 of 16 sampled residents.
Failed to ensure proper storage of oxygen tubing, nebulizer mask and tubing, and CPAP mask and tubing for 2 residents, risking respiratory infection for 12 sampled residents.
Failed to ensure psychotropic PRN orders were addressed within 14 days and failed to ensure appropriate use and documentation of psychotropic medications for 1 of 2 sampled residents with PRN orders and 1 of 9 residents with psychotropic drugs.
Failed to ensure pneumonia vaccine was administered or documented for 2 of 17 sampled residents.
Failed to notify residents, their representatives, and families of COVID-19 infections within required timeframe affecting 60 residents.
Report Facts
Residents sampled: 16
Residents affected by respiratory equipment storage deficiency: 12
Residents sampled for psychotropic medication review: 9
Residents sampled for pneumonia vaccine review: 17
Residents affected by COVID-19 notification deficiency: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Mentioned in relation to improper storage of CPAP mask and breathing treatment mask |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan deficiencies, psychotropic medication orders, respiratory equipment storage, and immunization monitoring |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for monitoring pneumonia vaccinations and interviewed about vaccination issues |
| MDS Coordinator | MDS Coordinator | Interviewed about completion of Care Area Assessments |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Mentioned in relation to side rail padding and COVID-19 positive status |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Mentioned in relation to side rail padding availability |
| Administrator | Administrator | Interviewed regarding COVID-19 notification failures |
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