Inspection Reports for
Salem Place Nursing and Rehabilitation Center, Inc.
2401 Christina Lane, Conway, AR, 72034
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
106% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 9
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, infection control, medication management, dietary services, immunizations, and facility policies at Salem Place Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to notify the ombudsman of hospital transfers, incomplete discharge assessments, medication administration and storage issues, dietary service deficiencies including improper meal preparation and food safety, inadequate infection control practices related to laundry delivery, and failure to properly document influenza and pneumococcal immunizations for several residents.
Deficiencies (9)
Failure to notify the ombudsman of a hospital transfer for Resident #95.
Failure to ensure a discharge Minimum Data Set (MDS) assessment accurately reflected Resident #13's discharge status.
Medications left at bedside and missing handrail end-cap creating accident hazards for Resident #64.
Failure to ensure all medications were safely stored, evidenced by antifungal medication left at Resident #15's bedside.
Meals not prepared and served according to planned menu, affecting nutritional needs of residents.
Meals served were not palatable or at safe appetizing temperature, affecting 7 residents.
Dietary staff failed to practice proper hand washing; dairy products thawed; hot foods not maintained at safe temperatures.
Laundry linen delivery cart uncovered during delivery, risking spread of harmful bacteria.
Failure to ensure influenza and pneumococcal immunizations were administered, offered, and documented for 4 of 5 sampled residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 8
Residents affected: 7
Residents affected: 84
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Confirmed Resident #95 was not included in hospital transfer notification list | |
| Administrator | Confirmed hospital transfer notification failure and lack of policy | |
| MDS Coordinator #9 | MDS Coordinator | Responsible for MDS discharge assessments; noted notification system for overdue MDS discharge |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Administered medications but did not observe resident swallowing |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Confirmed medication administration and storage deficiencies; provided Safety Data Sheet for antifungal ointment |
| Maintenance Supervisor | Observed missing handrail end-cap and acknowledged hazard | |
| Dietary [NAME] (DC) #5 | Dietary Cook | Used incorrect scoop sizes and did not follow menu |
| Dietary [NAME] (DC) #7 | Dietary Cook | Used incorrect portion sizes and added excessive water to pureed foods |
| Dietary Aide (DA) #6 | Dietary Aide | Observed thawed ice cream and milk |
| Dietary Aide #8 | Dietary Aide | Checked temperatures of hot food items and found them below safe levels |
| Laundry and Housekeeping Supervisor | Acknowledged lack of policy for laundry delivery and proper cart covering | |
| Laundry Employee #11 | Observed delivering laundry with uncovered cart | |
| Resident #18 | Resident | Did not remember if immunizations were offered or received |
| Resident #60 | Resident | Did not remember if immunizations were offered or received |
| Licensed Practical Nurse (LPN) #10 | Licensed Practical Nurse | Described immunization administration and documentation process |
| Certified Medication Technician (CMT) #1 | Certified Medication Technician | Described immunization administration and documentation process |
| Registered Nurse (RN) #4 | Registered Nurse | Described immunization administration and documentation process |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 27, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding resident care, specifically focusing on the accessibility of call lights for residents.
Findings
The facility failed to ensure that call lights were within reach for 1 of 3 sampled residents, as Resident #1 could not reach the call light due to its placement relative to his position in bed. Both CNA #1 and Registered Nurse #1 confirmed this during interviews.
Deficiencies (1)
Failed to ensure call lights were within reach to enable residents to call for assistance for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in call light placement finding |
| Registered Nurse #1 | Registered Nurse | Named in call light placement finding |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Aug 11, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to maintain wheelchair arm rests and flooring in safe condition, incomplete and untimely resident assessments, inadequate care planning, inaccurate transcription of physician orders, improper respiratory care, medication administration and documentation errors, improper medication storage and labeling, failure to provide routine dental care, unsafe food handling practices, and inadequate infection prevention practices including improper glucometer disinfection and hand hygiene.
Deficiencies (13)
Failed to ensure wheelchair arm rests were free of rips and tears and flooring was free of rips and tears.
Failed to complete and transmit annual comprehensive resident assessments within 14 calendar days for 8 residents.
Failed to complete quarterly resident assessments within required timeframes for 6 residents.
Failed to accurately record Resident Assessment for 1 resident.
Failed to develop and implement complete care plans for 3 residents addressing all needs and medications.
Failed to revise comprehensive care plans quarterly for 4 residents to accurately identify care needs and provide care.
Failed to ensure physician orders were transcribed accurately for 1 resident.
Failed to ensure oxygen was administered at prescribed flow rates and staff were trained on CPAP equipment for 2 residents; nebulizer masks were not stored properly.
Failed to ensure licensed staff accurately documented removal of narcotics at time of administration and ensured periodic reconciliation.
Failed to ensure vials of insulin, nasal sprays, and inhalers were dated and disposed of according to manufacturer instructions; medications were stored improperly including at bedside.
Failed to provide routine dental services for 1 resident requiring oral care.
Failed to ensure food items in freezer were properly sealed to prevent freezer burn; dietary employees used unclean utensils during food preparation.
Failed to disinfect multi-resident use glucometer after each use and failed to perform hand hygiene during medication administration for 3 residents.
Report Facts
Residents with incomplete annual assessments: 8
Residents with incomplete quarterly assessments: 6
Residents with inaccurate assessments: 1
Residents without complete care plans: 3
Residents with incomplete care plan revisions: 4
Residents affected by infection control lapses: 3
Residents affected by food safety issues: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and narcotic documentation deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in infection control and medication administration deficiencies |
| LPN #3 | Licensed Practical Nurse | Named in medication storage and labeling deficiencies |
| LPN #5 | Licensed Practical Nurse | Named in respiratory care and infection control interviews |
| LPN #6 | Licensed Practical Nurse | Named in respiratory care interviews |
| Certified Nursing Assistant #1 | CNA | Interviewed about importance of care plan content |
| Certified Nursing Assistant #2 | CNA | Interviewed about nebulizer mask storage |
| Certified Nursing Assistant #5 | CNA | Interviewed about medication storage |
| Maintenance #1 | Maintenance Staff | Interviewed about work order reporting and repairs |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed about assessment completion and care planning |
| Assistant Director of Nursing | ADON | Interviewed about medication administration, infection control, and dental care policies |
| Administrator | Facility Administrator | Interviewed about policies and dental care |
| Dietary Assistant Manager | Dietary Staff | Interviewed about food storage practices |
| Dietary Employee #1 | Dietary Staff | Observed preparing food with unclean utensils |
| Social Director | Social Services | Interviewed about dental care scheduling |
Inspection Report
Routine
Census: 83
Deficiencies: 9
Date: May 20, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, food service, and medication administration at Salem Place Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to complete timely Minimum Data Set assessments after significant changes, inaccurate coding of anticoagulant therapy, incomplete care plans for residents with urinary catheters and colostomies, inadequate supervision and storage of smoking materials, serving food at unsafe temperatures and poor food quality, improper preparation of pureed diets, failure to maintain food safety and hygiene standards in the kitchen, and lapses in infection prevention practices related to medication administration and equipment cleaning.
Deficiencies (9)
Failure to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days after a significant change in condition for a resident admitted to hospice.
Inaccurate coding of anticoagulant therapy on the Minimum Data Set for a resident receiving anticoagulant medication.
Failure to complete baseline and comprehensive care plans addressing the use of urinary catheter and colostomy for a resident.
Failure to ensure physician orders for hospice care, indwelling urinary catheter, and colostomy were documented.
Failure to ensure residents' smoking materials were securely maintained and smoking assessments completed according to facility policy.
Failure to serve food at safe and appetizing temperatures and maintain food palatability, affecting many residents.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failure to ensure food items in the refrigerator were covered or sealed, proper use of leftovers, and dietary staff hand hygiene to prevent foodborne illness.
Failure to properly clean reusable equipment and handle syringes during medication administration, risking cross-contamination.
Report Facts
Residents affected: 12
Residents affected: 7
Residents affected: 6
Residents affected: 4
Residents affected: 82
Temperature: 46
Temperature: 84
Temperature: 50
Temperature: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding MDS assessments, physician orders, smoking policy, and infection control practices |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed improperly handling medication syringes and interviewed about infection control |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed using stethoscope without cleaning before and after resident use |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about smoking assessment responsibilities and policies |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about smoking assessment responsibilities and policies |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about smoking materials policy and resident supervision |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed food temperature checks and interviewed about food quality |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed food temperature checks and interviewed about food quality |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Observed food temperature checks and interviewed about food quality |
| Dietary Employee #1 | Dietary Employee | Observed preparing pureed food and handling food without proper hygiene |
| Dietary Supervisor | Dietary Supervisor | Provided food temperature data, food quality assessments, and facility policies |
| Social Services Director | Social Services Director | Interviewed about admissions paperwork and smoking policy education |
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