Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 3
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to assess compliance with medication labeling and storage, food thawing and handling practices, and infection prevention and control procedures at the nursing facility.
Findings
The facility was found deficient in properly labeling and discarding medications, specifically inhalers without open or expiration dates; thawing food improperly in unsanitary conditions; and failing to maintain infection control by not using gloves during subcutaneous insulin injections.
Deficiencies (3)
Failed to properly label and discard medication per manufacturer's guidelines, specifically inhalers without open or expiration dates.
Failed to ensure food was thawed properly and in sanitary conditions, specifically thawing fish in a dirty sink at room temperature with no water.
Failed to maintain infection control prevention by not wearing gloves during subcutaneous insulin injections for multiple residents.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 4
Units of insulin administered without gloves: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Observed administering insulin without gloves |
| Licensed Practical Nurse #2 | LPN | Observed retrieving inhaler without proper labeling |
| Director of Nursing | DON | Provided statements on medication labeling and infection control expectations |
| Dietary Manager | DM | Interviewed regarding proper thawing procedures and food safety |
| Administrator | Administrator | Confirmed training and competencies on food handling and infection control |
| Medical Director | Medical Director | Stated expectation for staff to wear appropriate PPE during injections |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to evaluate compliance with medication labeling and storage, food safety and thawing procedures, and infection prevention and control practices at the facility.
Findings
The facility was found deficient in properly labeling and discarding medications per manufacturer guidelines, thawing food in sanitary conditions, and maintaining infection control precautions during subcutaneous insulin injections. These deficiencies posed minimal harm or potential for actual harm to a few or some residents.
Deficiencies (3)
Failed to properly label and discard a medication per the manufacturer's guidelines for 1 medication cart of 3 carts reviewed for medication labeling and storage.
Failed to ensure food was thawed properly and in sanitary conditions, specifically thawing fish in a dirty sink at room temperature with no water.
Failed to maintain infection control prevention for 4 residents during administration of subcutaneous insulin injections without wearing gloves as a standard precaution.
Report Facts
Residents affected: 1
Medication carts reviewed: 3
Residents affected: 4
Residents reviewed for infection control: 5
Residents affected: 4
Units of insulin administered without gloves: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Observed administering insulin without gloves |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding medication labeling and expiration dates |
| Director of Nursing | DON | Interviewed regarding medication labeling and infection control practices |
| Dietary Manager | DM | Interviewed regarding proper thawing procedures |
| Dietary Aide #5 | DA | Interviewed regarding thawing procedures |
| Infection Preventionist | IP | Interviewed regarding PPE use during injections |
| Administrator | Administrator | Interviewed regarding medication labeling, food safety training, and infection control |
| Medical Director | Medical Director | Interviewed regarding expectations for PPE use during injections |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jan 5, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged improper care and injury to Resident #42, including failure to investigate a possible injury and other related care concerns.
Complaint Details
The investigation was triggered by a complaint regarding Resident #42's possible knee injury from improper staff transfer and other care concerns. The complaint was substantiated with findings of delayed investigation and multiple care deficiencies.
Findings
The facility was found to have multiple deficiencies including failure to timely investigate a resident injury, administering medication without physician orders, unsafe use of mechanical lifts, improper care of feeding tubes, lack of oxygen caution signage, failure to ensure hand hygiene among dietary and nursing staff, and inadequate infection control practices during medication administration and meal service.
Deficiencies (7)
Failed to investigate in a timely manner a possible injury to Resident #42 due to improper transfer.
Administered pain-relieving gel without a physician's order affecting 16 residents.
Mechanical lift used with missing clip, risking harm to residents dependent on mechanical lifts.
Failed to aspirate gastric contents prior to administering medications through PEG tube and enteral feeding bags were not properly labeled.
Failed to post oxygen caution signage outside resident rooms where oxygen was in use.
Dietary staff failed to wash hands before serving food, risking cross contamination affecting 72 residents.
Failed to maintain infection control practices during medication administration and meal service, including failure to perform hand hygiene between feeding residents.
Report Facts
Residents affected: 16
Residents affected: 5
Residents affected: 72
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in failure to report Resident #42's knee pain and failure to document incident |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding nursing responsibilities for injury and medication administration |
| Director of Nursing | Director of Nursing | Interviewed regarding policies and procedures for injury investigation, medication administration, and oxygen safety |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding mechanical lift missing clip |
| Dietary Employees #2 and #3 | Dietary Employees | Observed failing to wash hands before serving food |
| Dietary Manager | Dietary Manager | Interviewed regarding hand hygiene requirements for food service |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed and interviewed regarding PEG tube medication administration and hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jan 5, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to investigate a possible injury to Resident #42, medication administration without physician orders, mechanical lift safety, feeding tube care, oxygen safety signage, dietary hand hygiene, and infection control practices.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to investigate a resident injury, medication errors, equipment safety issues, feeding tube care deficiencies, oxygen safety signage absence, dietary hygiene lapses, and infection control failures. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in timely investigation of a resident injury, administering medication without physician orders, mechanical lift safety, feeding tube care and labeling, oxygen caution signage, dietary staff hand hygiene, and infection control during medication administration and meal service. These deficiencies had the potential to affect multiple residents but were assessed as minimal harm or potential for harm.
Deficiencies (7)
Failure to investigate in a timely manner a possible injury to Resident #42 due to improper transfer.
Failure to ensure Resident #42 had a physician's order for medication being administered.
Failure to ensure mechanical lift clips were in place, risking resident safety.
Failure to aspirate gastric contents prior to medication administration via PEG tube and failure to label enteral feeding bags with date, time, and initials.
Failure to place oxygen cautionary signage outside resident rooms where oxygen was in use.
Dietary staff failed to wash hands before serving food, risking cross contamination.
Failure to maintain infection control practices during medication administration and meal service, including inadequate hand hygiene by staff.
Report Facts
Residents affected: 1
Residents affected: 16
Residents affected: 5
Residents affected: 1
Residents affected: 3
Residents affected: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Named in failure to report resident pain and injury |
| Licensed Practical Nurse #1 | LPN | Interviewed about nursing responsibilities for injury and medication administration |
| Director of Nursing | DON | Interviewed about policies and procedures related to injury investigation, medication administration, mechanical lift safety, feeding tube care, oxygen safety, and infection control |
| Certified Nursing Assistant #2 | CNA | Observed passing trays without hand hygiene and feeding resident without hand hygiene |
| Certified Nursing Assistant #3 | CNA | Observed passing trays without hand hygiene and feeding resident without hand hygiene |
| Certified Nursing Assistant #4 | CNA | Observed feeding resident without hand hygiene |
| Dietary Employee #2 | DE | Observed serving food without hand hygiene |
| Dietary Employee #3 | DE | Observed serving food without hand hygiene |
| Dietary Manager | DM | Interviewed about hand hygiene requirements for food service |
Inspection Report
Routine
Census: 69
Deficiencies: 4
Date: Sep 9, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care planning, nutritional services, food preparation, and infection control practices in the dietary department.
Findings
The facility failed to develop a comprehensive care plan for a resident with a colostomy, ensure meals were prepared and served according to the planned menu for residents on pureed diets, provide pureed food with appropriate consistency, and maintain proper hand hygiene and glove use among dietary staff, potentially affecting multiple residents.
Deficiencies (4)
Failed to develop and implement a complete care plan for a resident with a colostomy.
Failed to ensure meals were prepared and served according to the planned written menu for residents on pureed diets.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to ensure dietary staff washed hands and changed gloves before handling food items to prevent cross contamination.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 69
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Employees #1, #2, #3, #4, #5, and #6 mentioned in relation to food preparation and hygiene deficiencies but no full names provided. | ||
| MDS Coordinator | Interviewed regarding care plan for resident with colostomy; no full name provided. | |
| Dietary Supervisor | Provided lists and policy documents related to dietary services; no full name provided. |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 4
Date: Sep 9, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to develop comprehensive care plans for residents, ensure meals were prepared and served according to the planned written menu, provide food in appropriate consistency for residents requiring pureed diets, and maintain proper food handling and hygiene practices in the kitchen.
Complaint Details
The visit was complaint-related, triggered by concerns about care planning for a resident with a colostomy, meal preparation and serving practices for residents on pureed diets, food consistency issues, and improper hand hygiene and glove use by dietary staff. The deficiencies were substantiated with observations, record reviews, and interviews.
Findings
The facility failed to develop a comprehensive care plan for a resident with a colostomy, failed to serve meals according to the planned menu and correct portion sizes for residents on pureed diets, served pureed foods with improper consistency, and failed to ensure dietary staff washed hands and changed gloves properly to prevent cross-contamination. These deficiencies had the potential to affect multiple residents.
Deficiencies (4)
Failed to develop and implement a complete care plan for a resident with a colostomy.
Failed to ensure meals were prepared and served according to the planned written menu for residents on pureed diets.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to ensure dietary staff washed hands and changed gloves before handling food items to prevent cross contamination.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 69
Meals observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding responsibility for care plans and colostomy interventions | |
| Dietary Employee #1 | Observed using incorrect scoop sizes, preparing pureed foods with improper consistency, and failing to wash hands before handling clean equipment | |
| Dietary Employee #2 | Interviewed about serving plain rice instead of Mexican rice | |
| Dietary Employee #3 | Observed placing glasses by rims without washing hands; interviewed about hand hygiene | |
| Dietary Employee #4 | Observed using wrong scoop size for pureed fish sandwich and describing food consistency | |
| Dietary Employees #5 and #6 | Interviewed about consistency of pureed food items served | |
| Dietary Supervisor | Provided list of residents receiving pureed diets and facility hand washing policy |
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