Inspection Reports for
Stella Manor Nursing and Rehabilitation Center

400 North Vancouver Avenue, Russellville, AR, 72801

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

23% better than Arkansas average
Arkansas average: 5.2 deficiencies/year

Deficiencies per year

8 6 4 2 0
2022
2023
2024

Inspection Report

Deficiencies: 1 Date: Nov 7, 2024

Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical service requirements, specifically ensuring that expired over-the-counter and prescribed as needed (PRN) medications were removed from medication storage areas and carts.

Findings
The facility failed to remove expired medications from medication rooms and medication carts, including expired Vitamin B-6 and several PRN medications for multiple residents. Interviews confirmed that some expired medications were missed and that staff in-service training had begun to address the issue.

Deficiencies (1)
Failure to ensure expired over-the-counter and prescribed as needed medications were removed from medication storage rooms and medication carts.
Report Facts
Expired Vitamin B-6 bottles: 3 Expired PRN medication cards: 6 Expired Cyclobenzaprine tablets: 30 Expired Benzonatate capsules: 29 Expired Clonidine Hydrochloride tablets: 24 Expired Tizanidine tablets: 23 Expired Ondansetron tablets: 29

Employees mentioned
NameTitleContext
LPNStated expired medications would be turned in to the Director of Nursing
Director of Nursing (DON)Confirmed Vitamin B-6 should have been removed and that staff in-service had started regarding checking expiration dates

Inspection Report

Annual Inspection
Deficiencies: 6 Date: Oct 12, 2023

Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to medication management, food service, infection control, and overall resident care at Stella Manor Nursing and Rehabilitation Center.

Findings
The facility was found deficient in multiple areas including failure to justify continued use of PRN psychotropic medications beyond 14 days without physician evaluation, improper storage of controlled medications, failure to prepare and serve meals according to planned menus and nutritional needs, inadequate food consistency for pureed diets, unsanitary food handling practices, and failure to maintain a sanitary environment during meal service.

Deficiencies (6)
Failure to ensure PRN psychotropic medications were not continued past 14 days without justification and physician evaluation for 3 residents.
Failure to store controlled medications securely in locked compartments in 3 medication rooms.
Failure to ensure meals were prepared and served according to planned menus and nutritional needs for residents.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency for residents on pureed diets.
Failure to maintain clean and sanitary conditions in the kitchen including expired food items, unclean ice scoop holder, and improper hand hygiene by dietary staff.
Failure to maintain a sanitary environment during lunchtime on the secure unit, including staff stepping inside food carts.
Report Facts
Residents reviewed for unnecessary medication: 6 Residents failed to meet medication criteria: 3 Medication rooms inspected for controlled medication storage: 3 Meals observed: 2 Residents affected by unsanitary environment: 15 Expired food items found: 9

Employees mentioned
NameTitleContext
Director of NursingDirector of Nursing (DON)Confirmed lack of justification and physician evaluation for continued PRN medication use; confirmed controlled medications not stored properly
Dietary Employee #1Dietary EmployeeObserved serving meals not according to menu and poor food consistency; improper hand hygiene
Dietary Employee #2Dietary EmployeeObserved serving meals not according to menu and poor food consistency; improper hand hygiene
Dietary Employee #3Dietary EmployeeObserved improper hand hygiene and food handling
Registered Nurse #1Registered Nurse (RN)Identified medications during medication room tour
Licensed Practical Nurse #1Licensed Practical Nurse (LPN)Identified medications and admitted to unlocked medication container
Licensed Practical Nurse #2Licensed Practical Nurse (LPN)Identified medications during medication room tour
Dietary SupervisorDietary SupervisorProvided explanations regarding meal preparation and food safety
AdministratorFacility AdministratorStated facility had no policy on medication storage
CNA #3Certified Nursing AssistantObserved stepping inside food cart during meal service
CNA #4Certified Nursing AssistantInterviewed about proper procedures for accessing items on food carts

Inspection Report

Annual Inspection
Census: 80 Deficiencies: 5 Date: Jul 14, 2022

Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with federal and state regulations regarding resident care, food service, and facility operations.

Findings
The facility was found deficient in multiple areas including failure to provide accessible survey results to residents, improper meal preparation and serving inconsistent with planned menus, poor food quality and appearance, inadequate food consistency for pureed diets, and unsafe food storage and handling practices. Several food safety and sanitation violations were observed, including expired and improperly stored food items and inadequate hand hygiene among dietary staff.

Deficiencies (5)
Failed to ensure the surveys and plans of correction for the past 3 years were readily accessible to residents and visitors.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs for residents on pureed diets.
Failed to ensure food was prepared by methods that maintained appearance to encourage adequate nutritional intake.
Failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize risk of choking.
Failed to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards, including expired food items, uncovered and undated food, and poor sanitation of equipment and food storage areas.
Report Facts
Residents affected: 10 Residents affected: 45 Residents affected: 79 Total census: 80 Number of servings: 6 Number of servings: 10 Number of residents: 10

Employees mentioned
NameTitleContext
Dietary Employee #1Involved in meal preparation and serving deficiencies including improper portion sizes and food consistency
Dietary Employee #2Observed with improper glove use and hand hygiene violations during food preparation
Dietary SupervisorProvided information on dietary practices, food storage, and food appearance during inspection
Human Resource ManagerCommented on food appearance during meal tray loading
DONDirector of NursingDiscussed responsibility for updating survey results binder

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