Deficiencies (last 3 years)
Deficiencies (over 3 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
137% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
106 residents
Based on a July 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Deficiencies: 3
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, focusing on environmental cleanliness and safety concerns.
Findings
The facility failed to maintain a clean and safe environment for three sampled residents, with issues including unclean bathroom grout and tile, damaged walls, and a protruding metal transition strip with sharp edges posing safety hazards.
Deficiencies (3)
Unclean bathroom grout and tile with dark brown substance and rust on door frame in Resident #13's bathroom.
Two large damaged areas with paint missing on the wall in Resident #26's room.
Protruding metal transition strip with sharp edges in Resident #51's bathroom, posing a risk of cuts or falls.
Report Facts
Brief Interview of Mental Status (BIMS) score: 9
Brief Interview of Mental Status (BIMS) score: 14
Assessment Reference Date: Jul 9, 2024
Assessment Reference Date: Jun 28, 2024
Assessment Reference Date: May 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor #12 | Interviewed regarding cleaning and condition of Resident #51's bathroom | |
| Maintenance Director | Interviewed regarding metal transition strip and bathroom repairs for Resident #51 |
Inspection Report
Routine
Deficiencies: 5
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, safety, food handling, infection prevention, and environmental conditions at Springdale Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to ensure staff respected residents' dignity during meal assistance, maintain a clean and safe environment, properly store and handle food to prevent contamination, and implement adequate infection prevention and control practices including hand hygiene, tracheostomy care, and use of personal protective equipment during perineal care.
Deficiencies (5)
Staff failed to avoid standing over residents during meal assistance, violating residents' right to dignity.
Facility failed to maintain a clean and safe environment including unclean bathroom grout, damaged walls, and hazardous metal transition strips.
Open food items in refrigerator were not dated; spoiled fruit was not promptly discarded; expired food was present; and hand hygiene was not followed during food handling.
Staff failed to perform hand hygiene when assisting residents with meals, handled food from the floor, and failed to follow proper tracheostomy care procedures including glove changes and hand hygiene.
Staff failed to use proper personal protective equipment and hand hygiene during perineal care for a resident on enhanced barrier precautions.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 95
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant #1 | Observed standing over residents during meal assistance and improper hand hygiene practices | |
| Certified Nursing Assistant #7 | Observed standing over resident during meal assistance and interviewed about proper assistance techniques | |
| Unit Coordinator/Infection Control #9 | Unit Coordinator/Infection Control | Provided statements on proper meal assistance and infection control procedures |
| Dietary Manager #5 | Dietary Manager | Reported on food safety violations and improper hand hygiene in food handling |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed performing tracheostomy care without proper glove changes and hand hygiene |
| Certified Nursing Assistant #14 | Certified Nursing Assistant | Acknowledged failure to use proper PPE and hand hygiene during perineal care |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 15, 2024
Visit Reason
The inspection was conducted to assess compliance with care planning and provision of activities of daily living (ADL) assistance, including oxygen use and hygiene care, at Springdale Health and Rehabilitation Center.
Findings
The facility failed to ensure individualized comprehensive care plans addressing ADL assistance and oxygen use for certain residents, and residents were not consistently showered or bathed as scheduled, resulting in poor personal hygiene for multiple residents.
Deficiencies (3)
Failed to ensure the comprehensive care plan was individualized to address appropriate care and services for activities of daily living (ADL) for 2 residents.
Failed to revise the care plan to reflect current needs including oxygen use for 1 resident.
Failed to ensure residents were showered/bathed as scheduled to promote good personal hygiene for 5 residents.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 5
Oxygen liters per minute: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed residents #2 and #5 were not care planned for ADL assistance and oxygen order missing from care plan; confirmed residents not showered as scheduled | |
| Certified Nursing Assistant (CNA) #1 | Confirmed residents #2, #3, and #4 had not been showered/bathed according to schedule | |
| Licensed Practical Nurse (LPN) #1 | Confirmed residents are not receiving showers as scheduled |
Inspection Report
Routine
Census: 15
Deficiencies: 1
Date: Jul 28, 2023
Visit Reason
The inspection was conducted to ensure the nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, specifically focusing on the secure unit where personal care items and sharpened pencils were found unsecured.
Findings
The facility failed to ensure that personal care items and sharpened pencils were contained and secured on the secure unit, posing a potential risk to 15 residents. Observations and interviews confirmed that items such as hair spray, toothpaste, body wash, conditioner, and pencils were left unsecured, despite staff acknowledging these should be stored in locked rooms to prevent resident access.
Deficiencies (1)
Failure to ensure personal care items and sharpened pencils were contained and secured on the secure unit.
Report Facts
Residents affected: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding storage of pencils, toothpaste, body wash, and conditioner on the secure unit |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding storage and rationale for securing pencils, toothpaste, body wash, and conditioner on the secure unit |
| Director of Nursing | Director of Nursing | Interviewed regarding unsecured pencils and personal care items on the secure unit |
Inspection Report
Routine
Census: 91
Deficiencies: 9
Date: Jul 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, safety, care, infection control, and food service practices at Springdale Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including residents' access to personal funds after hours, mail delivery on weekends, meal service practices, cleanliness and grooming of residents, skin assessments, safe storage of personal care items on the secure unit, respiratory care equipment containment, food preparation and handling practices, and laundry cross-contamination prevention.
Deficiencies (9)
Failed to ensure residents with trust accounts had access to personal funds after business hours and weekends.
Failed to ensure residents received mail on weekends.
Failed to remove residents' meals from serving trays during meal service and maintain clean bed linens for a resident.
Failed to provide adequate Activities of Daily Living (ADL) care including nail care, shaving, and bathing for sampled residents.
Failed to perform consistent weekly skin assessments for a sampled resident.
Failed to ensure personal care items and sharpened pencils were securely stored on the secure unit to prevent accidents.
Failed to ensure nebulizer mouthpiece and medicine cup were contained after use to prevent contamination.
Failed to prevent cross contamination during food preparation and dining service.
Failed to prevent cross contamination of laundry by improper handling and storage practices.
Report Facts
Residents affected by trust account access issue: 19
Residents affected by mail delivery issue: 91
Residents affected by meal service and linen issues: 12
Residents affected by ADL care deficiencies: 4
Residents affected by secure unit safety issue: 15
Residents affected by respiratory care deficiency: 1
Residents affected by food service deficiencies: 90
Residents affected by laundry cross contamination risk: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Observed improperly handling clothing protectors and food service items. |
| Business Office Manager | BOM | Interviewed regarding residents' access to funds and mail delivery. |
| Financial Assistant | Interviewed regarding trust account cash envelopes and mail handling. | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including meal service, ADL care, skin assessments, and secure unit safety. |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding meal service, nail care, nebulizer equipment storage, and secure unit safety. |
| Licensed Practical Nurse #5 | LPN | Interviewed regarding nebulizer equipment storage. |
| Laundry Staff #1 | Observed and interviewed regarding laundry handling and cross contamination. | |
| Laundry Supervisor | Interviewed regarding laundry cross contamination prevention. | |
| Dietary Manager | Interviewed regarding food preparation and storage practices. | |
| Dietary Aide #1 | Observed improper glove use during food preparation. | |
| Dietary Aide #2 | Observed improper handling of insulated domes. | |
| Certified Nursing Assistant #6 | CNA | Interviewed regarding proper handling of clothing protectors. |
Inspection Report
Routine
Census: 100
Deficiencies: 16
Date: Apr 8, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including use of disposable dinnerware affecting resident dignity, improper use of physical restraints, failure to timely report and investigate abuse allegations, failure to notify residents and representatives of hospital transfers, lack of PASARR screening for mental disorders, incomplete care plans for fall prevention, inadequate discharge summaries, poor nail care, incomplete fall investigations, catheter care deficiencies, oxygen therapy management issues, failure to follow dietary and food safety standards, and lapses in infection prevention and control practices.
Deficiencies (16)
Residents were served meals on disposable styrofoam dinnerware due to staffing shortages, affecting dignity.
Resident placed in a reclined Broda chair constituting a physical restraint without proper assessment or documentation.
Failure to immediately report an allegation of abuse to Administrator and state agencies within required timelines.
Failure to notify resident, representative, and Ombudsman in writing of hospital transfers.
Failure to obtain PASARR screening for resident with mental disorder prior to or on day of admission.
Care plans lacked interventions to prevent falls and incident reports were not consistently completed or reviewed.
No discharge summary or recapitulation of stay was completed for resident discharged home.
Fingernails of residents dependent on staff for nail care were long, dirty, and jagged, increasing risk of infection.
Fall incident was not investigated or care planned to prevent recurrence; lint buildup in laundry dryers posed fire hazard.
Urinary catheter tubing was dragging on floor and not secured properly; improper incontinent care technique used.
Oxygen therapy was administered without physician orders for some residents; BiPAP mask improperly stored; oxygen concentrator malfunctioning.
Laboratory tests were not completed as ordered, delaying physician's ability to make treatment decisions.
Meals served did not meet planned menu portions; residents received less than specified amounts of meat.
Pureed food items were not blended to smooth, lump-free consistency, posing choking risk.
Dietary staff failed to wash hands before handling food and equipment; ice scoop holder and ice machine were dirty.
Staff entered isolation room without PPE and failed to perform hand hygiene, risking transmission of infection.
Report Facts
Residents affected by disposable dinnerware: 100
Staff normally in kitchen: 4
Residents transferred/discharged to hospital: 16
Residents on pureed diets: 11
Residents on mechanical soft diets: 24
Residents receiving meals from kitchen: 100
Residents with PASARR screening missing: 1
Residents with falls reviewed: 9
Residents with catheter care issues: 2
Residents receiving oxygen without orders: 2
Residents with oxygen therapy: 3
Residents with lab orders missed: 1
Residents on isolation with PPE lapses: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Employee #1 | Explained use of disposable dinnerware and food portion sizes | |
| Dietary Supervisor | Discussed disposable dinnerware use, food consistency, and kitchen hygiene | |
| CNA #3 | Discussed use of reclined Broda chair for Resident #34 | |
| DON | Director of Nursing | Provided information on restraint assessments, abuse reporting, fall investigations, oxygen therapy, and lab orders |
| RN #1 | Registered Nurse | Failed to report abuse allegation for Resident #11 |
| LPN #1 | Licensed Practical Nurse | Observed Resident #74's fingernail condition |
| LPN #2 | Licensed Practical Nurse | Checked oxygen concentrator settings and BiPAP mask storage |
| Nurse Consultant | Provided policies and lab report information | |
| Maintenance Director | Observed lint buildup in laundry dryers | |
| CNA #6 | Entered isolation room without PPE | |
| Dietary Employee #3 | Handled food without washing hands | |
| Dietary Employee #4 | Handled food without changing gloves or washing hands |
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