Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 1
Date: May 23, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control protocols, specifically focusing on hand hygiene and the use of personal protective equipment (PPE) for residents on enhanced barrier precautions.
Findings
The facility failed to ensure that staff performed proper hand hygiene and utilized necessary PPE while providing care to Resident #27, who was on enhanced barrier precautions. Observations and interviews confirmed that CNAs did not wear gowns or perform hand hygiene as required, despite training and facility policies outlining these procedures.
Deficiencies (1)
Failure to ensure staff performed hand hygiene and utilized necessary personal protective equipment (PPE) for Resident #27 on enhanced barrier precautions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Named in infection control deficiency for failure to wear gown and perform hand hygiene. |
| CNA #3 | Certified Nursing Assistant | Named in infection control deficiency for failure to wear gown and perform hand hygiene. |
| Lead CNA #4 | Lead Certified Nursing Assistant | Confirmed importance of hand hygiene and PPE use during interview. |
| Director of Nursing | Director of Nursing | Confirmed staff training on hand hygiene and enhanced barrier precautions. |
Inspection Report
Routine
Census: 89
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control practices, specifically related to proper use of Personal Protective Equipment (PPE) during a COVID-19 outbreak.
Findings
The facility failed to ensure that staff wore PPE correctly, with observations of staff wearing masks improperly around residents diagnosed with COVID-19. This failure had the potential to affect 89 residents.
Deficiencies (1)
Failure to ensure staff wore PPE correctly, including masks worn below nose or chin in presence of residents with COVID-19.
Report Facts
Residents affected: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Observed wearing mask improperly and interviewed about mask use |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed wearing mask improperly and interviewed about mask use |
| Director of Nursing | Director of Nursing | Interviewed regarding proper PPE use |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at St Elizabeth's Place nursing home.
Findings
The facility was found deficient in multiple areas including call light accessibility and response, resident personal care and hygiene, skin assessments, catheter care, nursing staff responsiveness, food preparation and safety, and staff training on dementia care. Deficiencies were generally of minimal harm but affected several residents.
Deficiencies (9)
Call lights were not consistently within reach of residents and were not answered in a timely manner.
Residents did not consistently receive assistance with smoking breaks as per their rights and care plans.
Residents' meals were left on serving trays in the dining room, failing to promote a homelike environment.
Fingernails were not regularly trimmed and cleaned, and one resident did not receive a shave as scheduled.
One resident did not receive a thorough head-to-toe skin assessment despite reporting a draining sore.
Catheter securement devices were not used for a resident with an indwelling catheter, risking trauma.
Pureed food items served were not blended to a smooth, lump-free consistency, risking choking hazards.
Food preparation equipment and storage areas were not maintained in a clean and sanitary condition, and dietary staff failed to wash hands appropriately, risking foodborne illness.
Dementia in-service training was not provided to nurse aides in the past year.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 6
Total census: 89
Sample residents: 17
Sample residents: 21
Sample residents: 11
Sample residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #6 | CNA | Named in call light placement deficiency |
| Licensed Practical Nurse #2 | LPN | Named in call light placement and nail care deficiencies |
| Director of Nursing | DON | Confirmed call light issues and nail care deficiencies |
| Certified Nursing Assistant #3 | CNA | Interviewed about smoking break procedures |
| Nurse Consultant #1 | NC | Provided policies on smoking and ADL |
| Certified Nursing Assistant #7 | CNA | Interviewed about nail care |
| Licensed Practical Nurse #3 | LPN | Interviewed about skin assessment procedures |
| Certified Nursing Assistant #5 | CNA | Interviewed about catheter securement |
| Assistant Director of Nursing | ADON | Interviewed about call light response |
| Dietary Employee #1 | DE | Observed preparing pureed food and food safety violations |
| Dietary Employee #2 | DE | Observed handling clean equipment without hand washing |
| Dietary Employee #3 | DE | Observed handling beverage dispenser and glasses without hand washing |
| Dietary Employee #4 | DE | Interviewed about pureed food consistency |
| Dietary Employee #5 | DE | Observed handling clean equipment without hand washing |
| Administrator | Confirmed no dementia in-service training in past year |
Inspection Report
Deficiencies: 1
Date: Aug 22, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards, specifically focusing on the provision of nail care to residents dependent on staff assistance.
Findings
The facility failed to perform nail care on two of six sampled residents who required staff assistance, with observations confirming long, jagged fingernails and toenails. The facility's policy requires daily cleaning and regular trimming, but task sheets showed no specific nail care tasks listed.
Deficiencies (1)
Failure to perform nail care on two residents dependent on staff assistance, resulting in long and jagged nails.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Confirmed condition of Resident #3's toenails and described nail care responsibilities. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to follow the care plan for resident transfers, specifically for Resident #3 who required two-person assistance for transfers but was transferred by only one staff member, resulting in injury.
Complaint Details
The complaint investigation was substantiated. Resident #3 required two-person assistance for transfers but was transferred by one CNA alone, leading to bruising and a fractured femur. Multiple witness statements and medical evaluations confirmed the injury and inappropriate transfer practices.
Findings
The facility failed to ensure staff followed the care plan for Resident #3's transfers, who required two-person assistance. This failure led to an inappropriate transfer causing bruising and a fractured femur. Multiple witness statements and medical documentation confirmed the injury and inadequate supervision during transfers. The facility submitted an action plan to improve staff training and care plan adherence.
Deficiencies (2)
Failure to develop and implement a complete care plan that meets all the resident's needs, specifically regarding transfer assistance requiring two persons.
Failure to ensure adequate supervision and assistance during transfers, resulting in actual harm including bruising and a fractured femur for Resident #3.
Report Facts
Residents affected: 1
Dates of falls: 8
Times inappropriate transfer occurred: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident transfer assistance level and care plan adherence |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Witness statement about transferring Resident #3 alone without reviewing care plan |
| Certified Nursing Assistant #2 | Certified Nursing Assistant (CNA) | Witness statement about transferring Resident #3 with improper technique |
| Certified Nursing Assistant #3 | Certified Nursing Assistant (CNA) | Interviewed about transfer assistance documentation and safety risks |
| Certified Nursing Assistant #4 | Certified Nursing Assistant (CNA) | Interviewed about transfer assistance documentation and safety risks |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Witness statement regarding assessment of bruising and resident condition |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) | Witness statement regarding noticing bruising and reporting |
| Licensed Practical Nurse #3 | Licensed Practical Nurse (LPN) | Witness statement regarding resident assessment and notification of injury |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Witness statement and involved in resident assessment and reporting |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 15, 2022
Visit Reason
The inspection was conducted as a comprehensive annual survey of St Elizabeth's Place nursing home to assess compliance with regulatory requirements including resident care, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including call light accessibility, accurate documentation of residents' code status, timely reporting of injuries of unknown origin, assistance with activities of daily living such as nail care, completion of weekly skin audits, proper respiratory care including oxygen therapy orders and equipment maintenance, antibiotic stewardship, medication administration errors, and timely notification of residents and families regarding COVID-19 positive cases.
Deficiencies (9)
Failed to ensure call light was accessible for 1 of 15 sampled residents.
Failed to ensure accurate documentation of residents' code status for 1 of 23 sampled residents.
Failed to timely report injury of unknown source to administration, physician, and state agency for 1 of 2 residents reviewed for abuse.
Failed to provide nail care assistance to maintain good grooming for 1 of 1 resident reviewed for ADLs.
Failed to ensure weekly skin audits were completed for 1 of 1 resident reviewed for skin audits.
Failed to ensure proper respiratory care including weekly change of humidity bottles and storage bags, presence of physician orders for oxygen therapy, and administration at ordered flow rates for 3 residents.
Failed to ensure residents were not prescribed antibiotics unnecessarily; no documented indication or lab testing for antibiotic use for 1 of 6 residents.
Medication administration errors observed including wrong dosage of calcium carbonate and failure to administer Flonase as ordered.
Failed to notify residents, representatives, and families by 5:00 PM the next calendar day following confirmed positive COVID-19 cases.
Report Facts
Medication error rate: 6.45
Residents affected by call light deficiency: 1
Residents affected by code status documentation deficiency: 1
Residents affected by injury reporting deficiency: 1
Residents affected by nail care deficiency: 1
Residents affected by skin audit deficiency: 1
Residents affected by respiratory care deficiencies: 3
Residents affected by antibiotic stewardship deficiency: 1
Residents affected by COVID-19 notification deficiency: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in call light accessibility and respiratory care findings |
| LPN #7 | Licensed Practical Nurse and Infection Control Nurse | Named in antibiotic stewardship and COVID-19 notification findings |
| ADON #5 | Assistant Director of Nursing | Named in medication administration error findings |
| DON | Director of Nursing | Named in multiple findings including call light, antibiotic stewardship, respiratory care, and medication errors |
| Administrator | Named in COVID-19 notification and medication error findings | |
| APRN #10 | Advanced Practice Registered Nurse | Named in antibiotic stewardship and respiratory care findings |
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