Inspection Reports for
Southridge Village Nursing and Rehab
400 Southridge Parkway, Heber Springs, AR, 72543
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to update and revise the care plan to include restorative nursing services for Resident #81.
Complaint Details
The complaint investigation found that Resident #81 was discharged from therapy services but was not placed on restorative nursing services as required. Interviews with staff confirmed the lack of restorative services and missing documentation. The Medicare Manager and Director of Nursing confirmed procedural failures in adding restorative services to the care plan in a timely manner.
Findings
The facility failed to provide restorative nursing services and failed to update the care plan for Resident #81, who had been discharged from therapy services but was not receiving restorative nursing services as required. Documentation and orders for restorative services were missing, and the restorative program was not properly implemented for this resident.
Deficiencies (2)
Failed to update and revise the care plan to include restorative services for Resident #81.
Failed to provide restorative services to improve or maintain Activities of Daily Living (ADL) functions for Resident #81.
Report Facts
Assessment Reference Date (ARD): May 28, 2024
Brief Interview for Mental Status (BIMS) score: 15
Care Plan Initiation Date: Sep 7, 2023
Restorative Nursing Program Document Date: Jul 11, 2024
Survey Completion Date: Jul 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Occupational Therapist (OT) | Confirmed Resident #81 had a plan for restorative nursing services and provided instructions to the Restorative Nursing Assistant. | |
| Restorative Nursing Assistant (RNA) #2 | Confirmed Resident #81 was not currently receiving restorative nursing services. | |
| Nurse Consultant | Confirmed no restorative documentation was available and that Resident #81 was being added to restorative services. | |
| Medicare Manager | Overseer of restorative program; confirmed procedural failures and described process for adding residents to restorative services. | |
| Director of Nursing (DON) | Confirmed Medicare Manager oversees restorative program and stated care plan updates should occur within 24 hours. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning and restorative nursing service requirements, specifically reviewing the care plan and restorative services provided to Resident #81.
Findings
The facility failed to update and revise the care plan to include restorative nursing services for Resident #81, who had been discharged from therapy but had no restorative nursing orders or documentation. Interviews confirmed delays and gaps in adding restorative services to the care plan, despite existing instructions from therapy staff.
Deficiencies (2)
Failed to update and revise the care plan to include restorative services for Resident #81.
Failed to provide restorative services to improve or maintain Activities of Daily Living (ADL) functions for Resident #81.
Report Facts
Assessment Reference Date: May 28, 2024
Brief Interview for Mental Status (BIMS) score: 15
Care Plan Initiation Date: Sep 7, 2023
Restorative Nursing Program Document Date: Jul 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medicare Manager | Overseer of restorative program, confirmed procedures and delays in adding Resident #81 to restorative services | |
| Director of Nursing | DON | Confirmed Medicare Manager oversees restorative program and timing for care plan updates |
| Occupational Therapist | OT | Confirmed Resident #81 discharged from therapy and restorative nursing instructions |
| Restorative Nursing Assistant #2 | RNA #2 | Confirmed Resident #81 was not currently on restorative nursing case mix and no recent restorative services |
| Nurse Consultant | Confirmed no restorative documentation for Resident #81 at time of survey |
Inspection Report
Routine
Deficiencies: 4
Date: May 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, including foot care, respiratory care, food preparation, and infection control practices.
Findings
The facility was found deficient in providing appropriate foot care, ensuring oxygen was administered at the prescribed flow rate, preparing pureed food to a safe consistency, and maintaining proper hand hygiene and glove use during food preparation. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (4)
Failed to ensure toenails were cut to maintain good hygiene and prevent complications for a resident requiring assistance with activities of daily living.
Failed to ensure oxygen was consistently administered at the flow rate ordered by the Physician to minimize potential respiratory complications.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize choking risk for residents requiring pureed diets.
Failed to ensure staff washed hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items, risking contamination of food served to residents.
Report Facts
Residents sampled for foot care deficiency: 15
Residents affected by foot care deficiency: 1
Residents sampled for oxygen therapy deficiency: 10
Residents affected by oxygen therapy deficiency: 1
Residents affected by pureed food consistency deficiency: 6
Residents affected by food contamination risk due to poor hand hygiene: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | Interviewed regarding Resident #93's toenail care | |
| Licensed Practical Nurse #1 | Interviewed about Resident #93's toenail care and appointments | |
| Registered Nurse #1 | Interviewed about Resident #93's toenail care and refusals | |
| Licensed Practical Nurse #2 | Accompanied Surveyor to Resident #451's room and discussed oxygen flow rate | |
| Director of Nursing | Director of Nursing | Adjusted Resident #451's oxygen flow rate and discussed nurse responsibilities |
| Dietary Employee #1 | Observed preparing pureed food and handling food without proper hand hygiene | |
| Certified Nursing Assistant #1 | Interviewed about consistency of pureed food served | |
| Dietary Supervisor | Provided facility policies on foot care and employee cleanliness | |
| Administrator | Provided facility policies on foot care and oxygen administration |
Inspection Report
Routine
Deficiencies: 4
Date: May 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, including foot care, respiratory care, food preparation, and infection control practices in the facility.
Findings
The facility was found deficient in providing appropriate foot care for one resident, ensuring oxygen was administered at the prescribed flow rate for one resident, preparing pureed food to a smooth consistency for residents requiring such diets, and maintaining proper hand hygiene and glove use among dietary staff to prevent food contamination.
Deficiencies (4)
Failed to ensure toenails were cut to maintain good hygiene and prevent complications for one resident requiring assistance with activities of daily living.
Failed to ensure oxygen was consistently administered at the flow rate ordered by the physician for one resident, risking hypoxia or other respiratory complications.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets, increasing risk of choking.
Failed to ensure staff washed hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items, risking contamination of food served to residents.
Report Facts
Residents sampled: 15
Residents sampled: 10
Residents affected: 6
Residents affected: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | Mentioned in relation to knowledge about Resident #93's toenail care | |
| Licensed Practical Nurse #1 | Mentioned in relation to Resident #93's toenail care and refusals | |
| Registered Nurse #1 | Mentioned in relation to Resident #93's toenail care and refusals | |
| Licensed Practical Nurse #2 | Mentioned in relation to Resident #451's oxygen flow rate | |
| Director of Nursing | Director of Nursing | Mentioned in relation to Resident #451's oxygen flow rate and responsibility for oxygen settings |
| Dietary Employee #1 | Mentioned in relation to food preparation deficiencies and hand hygiene | |
| Certified Nursing Assistant #1 | Mentioned in relation to observation of pureed food consistency |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 7, 2023
Visit Reason
The inspection was conducted to investigate complaints related to infection control practices and medication storage at Southridge Village Nursing and Rehab.
Complaint Details
The visit was complaint-related focusing on infection control and medication storage practices. The deficiencies were substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure nebulizer masks/tubing/mouthpieces and Yankauer suction tips were properly contained when not in use, posing a risk of infection spread for 2 residents. Additionally, medications were not stored securely or labeled properly for 2 residents, risking potential harm to cognitively impaired residents.
Deficiencies (2)
Failure to ensure nebulizer masks/tubing/mouthpieces and Yankauer suction tips were properly contained when not in use to prevent infection spread.
Failure to ensure medications were stored in a secure location and labeled according to accepted standards and state laws.
Report Facts
Residents in sample mix: 6
Residents affected by infection control deficiency: 2
Residents affected by medication storage deficiency: 2
Updraft treatments frequency: 4
Medication liquid volume: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed about proper storage and cleaning of nebulizer equipment and responsibility for medication administration | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about medication powder storage and responsibility for ensuring no unlabeled medicine cups are left out | |
| Director of Nursing (DON) | Interviewed about storage policies, staff responsibilities, and expectations for adherence to CMS guidelines | |
| Administrator | Interviewed about storage policies, staff responsibilities, and expectations for adherence to CMS guidelines |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 7, 2023
Visit Reason
The inspection was conducted to evaluate compliance with safe respiratory care practices and medication storage standards in the nursing home.
Findings
The facility failed to ensure nebulizer masks/tubing/mouthpieces and Yankauer suction tips were properly contained when not in use, posing a risk for infection spread for 2 residents. Additionally, medications were not stored securely or labeled properly, risking resident safety for 2 residents.
Deficiencies (3)
Failed to ensure nebulizer masks/tubing/mouthpieces were properly contained when not in use.
Failed to ensure Yankauer suction tips were properly contained when not in use.
Failed to ensure medications were stored in a secure location and labeled according to accepted standards.
Report Facts
Residents in sample mix: 6
Residents affected: 2
Residents affected: 2
Medication doses: 4
Clear liquid volume: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed about proper storage and cleaning of nebulizer equipment and Yankauer suction tips |
| Licensed Practical Nurse #2 | LPN | Interviewed about medication powder storage and responsibility for medication safety |
| Director of Nursing | DON | Interviewed about storage policies and staff responsibilities for infection control and medication safety |
| Administrator | Administrator | Interviewed about facility policies, staff expectations, and medication storage procedures |
Inspection Report
Routine
Census: 71
Deficiencies: 3
Date: Dec 16, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, safe use of mechanical lifts, and food safety practices in the nursing home.
Findings
The facility failed to complete the admission Minimum Data Set (MDS) timely for a new resident, did not follow manufacturer's instructions for mechanical lift use increasing risk of injury, and failed to maintain proper food safety practices including uncovered food, improper hand hygiene, and inadequate food temperature control.
Deficiencies (3)
Failure to complete admission Minimum Data Set (MDS) within 14 days for a new resident.
Failure to use mechanical lift according to manufacturer's instructions, risking transfer-related injuries.
Failure to ensure food items were covered or sealed, maintain proper food temperatures, and ensure dietary staff hand hygiene, risking potential food borne illness.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 70
Total census: 71
Temperature: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding admission MDS completion timing |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Observed and interviewed regarding mechanical lift use |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed assisting with mechanical lift transfer |
| Dietary Employee #1 | Dietary Employee | Observed handling food and equipment without proper hand hygiene |
| Dietary Employee #2 | Dietary Employee | Observed dropping lid in steam table water and not sanitizing |
| Dietary Supervisor | Dietary Supervisor | Observed improper glove use and food handling practices |
| Director of Nursing | Director of Nursing | Interviewed regarding mechanical lift manufacturer's instructions |
| Administrator | Administrator | Provided mechanical lift user's manual and interviewed on lift use |
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 3
Date: Dec 16, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident assessments, safety, and food service practices at Southridge Village Nursing and Rehab.
Findings
The facility was found deficient in completing admission Minimum Data Set (MDS) assessments timely, improper use of mechanical lifts contrary to manufacturer instructions, and food safety violations including uncovered food items, improper food temperatures, and inadequate hand hygiene among dietary staff.
Deficiencies (3)
Failed to complete admission Minimum Data Set (MDS) within 14 days for a new resident.
Failed to ensure mechanical lift was used according to manufacturer's instructions, risking transfer-related injuries.
Failed to ensure food items were covered or sealed, hot foods heated to proper temperature, and dietary staff practiced proper hand hygiene, risking food borne illness.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 70
Total census: 71
Temperature: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding admission MDS completion timeliness |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Observed and interviewed regarding mechanical lift use |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed assisting with mechanical lift transfer |
| Dietary Employee #1 | Observed handling food and equipment without proper hand hygiene | |
| Dietary Employee #2 | Observed dropping lid in steam table water and not sanitizing | |
| Dietary Supervisor | Dietary Supervisor | Observed and interviewed regarding food safety and hand hygiene practices |
| Director of Nursing | Director of Nursing | Interviewed regarding mechanical lift manufacturer's instructions |
| Administrator | Administrator | Provided mechanical lift user's manual and interviewed on lift use |
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