Inspection Reports for
The Blossoms at Cumberland Rehab and Nursing Center
1516 Cumberland St, Little Rock, AR, 72202
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
23.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
356% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
57% occupied
Based on a May 2024 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to prevent resident abuse involving two residents at the facility.
Complaint Details
The complaint investigation found that Resident #2 attacked Resident #1 on 02/10/2025 using a wet floor sign, causing serious injuries including brain hemorrhage, fractures, and eye dislocation. Resident #2 was severely cognitively impaired with behavioral disturbances. The incident was witnessed by staff and documented by police and hospital records. Resident #2 was placed on one-to-one observation and transferred to a psychiatric facility.
Findings
The facility failed to prevent resident abuse for 2 of 6 residents reviewed. Resident #2 physically attacked Resident #1 with a wet floor sign causing serious injuries including brain bleeding, fractures, and eye dislocation. The facility had policies on abuse prevention but failed to adequately protect residents. Resident #2 was placed on one-to-one observation after the incident and transferred for psychiatric evaluation.
Deficiencies (1)
Failure to protect residents from abuse, resulting in actual harm to residents.
Report Facts
Residents reviewed for abuse: 6
Residents affected by abuse: 2
BIMS score Resident #1: 7
BIMS score Resident #2: 0
Resident #1 height: 66
Resident #1 weight: 117
Resident #2 height: 67
Resident #2 weight: 184
Incident date: Feb 10, 2025
Number of punches Resident #2 delivered: 4
Number of residents CNA #1 responsible for: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Witnessed the incident and provided care to Resident #1 and Resident #2 during and after the altercation |
| CNA #1 | Certified Nursing Assistant | Witnessed the incident, intervened during the altercation, and provided statements about the event and staffing |
| Administrator | Provided interviews regarding the incident, resident observations, and follow-up actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to prevent resident abuse involving two residents at the facility.
Complaint Details
The complaint investigation was substantiated. Resident #2 physically attacked Resident #1 on 02/10/2025 using a wet floor sign, causing severe injuries. Resident #2 was placed on one-to-one observation and transferred to Geri-Psych for evaluation. Police and EMS were involved. The facility failed to prevent this abuse despite known behavioral issues.
Findings
The facility failed to prevent resident abuse for 2 of 6 residents reviewed, resulting in actual harm. Resident #2 attacked Resident #1 with a wet floor sign causing serious injuries including brain bleeding, fractures, and eye dislocation. The facility had policies on abuse prevention but failed to adequately protect residents from harm.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical abuse resulting in actual harm to residents.
Report Facts
Residents reviewed for abuse: 6
Residents failed to prevent abuse: 2
BIMS score Resident #1: 7
BIMS score Resident #2: 0
Date of incident: Feb 10, 2025
Number of punches Resident #2 inflicted on Resident #1: 4
Resident #1 height in inches: 66
Resident #1 weight in pounds: 117
Resident #2 height in inches: 67
Resident #2 weight in pounds: 184
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Witnessed the incident, provided care to Resident #1 and Resident #2, called 911 |
| CNA #1 | Certified Nursing Assistant | Witnessed the incident, intervened during attack, responsible for 10-12 residents |
| Administrator | Provided information about post-incident actions and staffing |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including treatment administration and pharmaceutical services.
Findings
The facility failed to ensure proper application of prescribed ointment for skin issues and failed to have ordered pain medication available for a resident, resulting in minimal harm or potential for harm to a few residents.
Deficiencies (2)
Failed to ensure staff monitored the skin and applied ointment as ordered for 1 resident with skin issues.
Failed to have medication as ordered for treatment available for 1 resident reviewed for pain control.
Report Facts
Missed ointment application days: 3
Medication delivery delay: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding medication availability and delays |
| Treatment Nurse | Interviewed regarding missed ointment treatments | |
| Administrator | Interviewed regarding residents not receiving treatments and medications as ordered |
Inspection Report
Routine
Deficiencies: 8
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, PASARR screening, activities of daily living assistance, pressure ulcer care, medication administration safety, nutrition and food service standards, infection control, and overall facility safety.
Findings
The facility was found deficient in multiple areas including failure to document residents' advance directives properly, lack of PASARR Level II evaluations, inadequate bathing/showering documentation, failure to provide wound care as ordered, unsafe medication administration practices, failure to follow planned menus, poor food safety and sanitation practices, and lapses in infection prevention hand hygiene during catheter and wound care.
Deficiencies (8)
Failed to ensure residents' advance directive decisions were documented in a prominent part of the clinical record.
Failed to coordinate assessments with PASARR program by obtaining completed Level II PASARR evaluation.
Failed to ensure resident received bath/shower per schedule and proper documentation of bathing.
Failed to provide wound care as per physician's orders for pressure ulcers for sampled residents.
Failed to provide safety during medication administration by leaving medications with residents unsupervised.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs.
Failed to maintain food safety and sanitation standards including handling dented cans, leftover meats, expired foods, and cleanliness of kitchen and equipment.
Failed to ensure staff performed hand hygiene when changing gloves during indwelling urinary catheter care and wound care.
Report Facts
Bath/shower documentation missing days: 9
Wound care dates missing documentation: 15
Wound care dates missing documentation: 8
Medications observed: 13
Menu scoop sizes: 3
Menu scoop sizes: 0.5
Menu scoop sizes: 0.25
Dented cans: 20
Expired food item date: Dec 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding bathing schedule and medication administration process |
| Director of Nursing | Director of Nursing | Interviewed regarding bathing documentation, wound care documentation, medication administration, and infection control |
| Administrator | Administrator | Provided policies, interviewed regarding advance directives, wound care, medication administration, and hand hygiene policies |
| Treatment Nurse | Treatment Nurse | Reviewed wound care records, observed catheter irrigation and wound care, interviewed about hand hygiene |
| Dietary Cook #1 | Dietary Cook | Observed serving meals and interviewed about menu adherence and food handling |
| Dietary Cook #2 | Dietary Cook | Observed food preparation and interviewed about hand hygiene and menu adherence |
| Medication Technician #4 | Medication Technician | Observed medication pass and interviewed about medication administration process |
| Dietary Manager | Dietary Manager | Interviewed about food safety, dented cans, ice machine cleaning, and kitchen sanitation |
Inspection Report
Routine
Deficiencies: 8
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, PASARR screening, activities of daily living assistance, wound care, medication administration, nutrition, food safety, and infection control at The Blossoms at Cumberland Rehab & Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to document residents' advance directives, incomplete PASARR screening documentation, inadequate bathing schedules and documentation, failure to follow wound care orders and document treatments, unsafe medication administration practices, failure to serve meals according to the planned menu, poor food safety and sanitation practices, and lapses in infection prevention hand hygiene during catheter and wound care.
Deficiencies (8)
Failed to ensure residents' advance directive decisions were documented prominently in clinical records.
Failed to coordinate assessments with PASARR program by obtaining completed Level II PASARR evaluation.
Failed to ensure resident received bath/shower per schedule and maintain documentation for 9 missing days.
Failed to provide wound care as per physician orders and document treatments for pressure ulcers and G-tube sites.
Failed to provide safety during medication administration by leaving medications with residents unsupervised.
Failed to ensure meals were prepared and served according to planned menu to meet nutritional needs.
Failed to maintain food safety and sanitation including use of dented cans, leftover meat handling, unclean surfaces, and improper hand hygiene by dietary staff.
Failed to ensure staff performed hand hygiene when changing gloves during indwelling urinary catheter care and wound care.
Report Facts
Missing wound care documentation days: 15
Missing bath/shower documentation days: 9
Medication count: 13
Dented cans: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Interviewed regarding bathing schedule and medication administration process |
| Medication Technician #4 | MT | Observed and interviewed regarding medication pass process |
| Director of Nursing | DON | Interviewed regarding documentation gaps and medication administration policy |
| Treatment Nurse | Reviewed wound care records and observed catheter and wound care hand hygiene | |
| Administrator | AD | Provided policies and interviewed regarding advance directives and hand hygiene |
| Dietary Cook #1 | DC | Observed and interviewed regarding meal preparation and hand hygiene |
| Dietary Cook #2 | DC | Observed and interviewed regarding meal preparation and hand hygiene |
| Dietary Manager | DM | Interviewed regarding food safety practices and dented cans |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide appropriate skin treatment and failure to have ordered pain medication available for a resident.
Complaint Details
The complaint investigation found substantiated issues with missed skin treatment applications and delayed availability of pain medication for Resident #36.
Findings
The facility failed to ensure staff applied prescribed ointment for skin issues and failed to have pain medication available as ordered for one resident. Missed treatments and medication delays were confirmed through record reviews and staff interviews.
Deficiencies (2)
Failure to ensure staff monitored the skin and applied ointment as ordered for Resident #36.
Failure to have medication as ordered for treatment available for Resident #36.
Report Facts
Missed ointment application days: 3
Medication delivery delay: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding medication availability and delays. |
| Treatment Nurse | Interviewed regarding missed ointment treatments; name not provided. | |
| Administrator | Interviewed regarding missed treatments and medication delays; name not provided. |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with physician's orders regarding wound care and nursing staff competencies in completing treatments for residents.
Findings
The facility failed to ensure that wound care treatments were consistently completed per physician's orders for 3 of 4 sampled residents, resulting in missed treatments documented multiple times. Nursing staff orientation and monitoring procedures were found to be insufficient.
Deficiencies (2)
Failed to ensure residents' skin treatments were completed to promote healing per physician's orders for 3 of 4 sampled residents.
Failed to ensure nursing staff were completing treatments per physician's orders for 3 of 4 sampled residents.
Report Facts
Missed treatments for Resident #2: 15
Missed treatments for Resident #3: 40
Missed treatments for Resident #4: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Discussed orientation and monitoring of agency staff; confirmed one-page instruction sheet orientation |
| Administrator | Administrator | Provided information on agency staff orientation and scheduling |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with physician's orders regarding wound care and nursing staff competencies in completing treatments for residents at The Blossoms at Cumberland Rehab & Nursing Center.
Findings
The facility failed to ensure that wound care treatments were consistently completed and documented for 3 of 4 sampled residents, resulting in missed treatments and concerns expressed by residents. The facility's orientation and monitoring of agency staff were also found to be insufficient.
Deficiencies (2)
Failed to ensure residents' skin treatments were completed to promote healing per physician's orders for 3 of 4 sampled residents.
Failed to ensure nursing staff were completing treatments per physician's orders for 3 of 4 sampled residents.
Report Facts
Missed treatments for Resident #2: 15
Missed treatments for Resident #3: 40
Missed treatments for Resident #4: 25
BIMS score for Resident #2: 15
BIMS score for Resident #3: 15
SAMS score for Resident #4: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Discussed orientation and monitoring of agency staff; position held approximately one month |
| Administrator | Administrator | Provided orientation sheets and described agency staff orientation process |
Inspection Report
Routine
Census: 68
Deficiencies: 1
Date: May 1, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, focusing on cleanliness and housekeeping practices.
Findings
The facility failed to provide a clean environment on 5 of 6 resident halls, with observations of dark brown buildup, sticky floors, used bandages on the floor, and strong odors. The Housekeeping Supervisor acknowledged deficiencies in cleaning and lack of a formal cleaning policy.
Deficiencies (1)
Failure to provide a clean environment on multiple resident halls, including buildup of dark brown and black substances, sticky floors, used bandages on the floor, and strong odors.
Report Facts
Residents affected: 68
Number of halls with failed cleaning: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Interviewed regarding cleaning practices and acknowledged deficiencies and lack of cleaning policy | |
| Administrator | Asked Housekeeping Supervisor for cleaning policy and was informed none existed |
Inspection Report
Routine
Census: 68
Deficiencies: 1
Date: May 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.
Findings
The facility failed to provide a clean environment on 5 of 6 resident halls, with observations of dark brown buildup, sticky floors, used bandages on floors, and strong odors in resident rooms. The housekeeping supervisor acknowledged the issues and lack of a formal cleaning policy.
Deficiencies (1)
Failed to provide a clean environment on multiple resident halls, including dirty baseboards, sticky floors, and unsanitary conditions in resident rooms.
Report Facts
Residents affected: 68
Number of halls with failed cleanliness: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Interviewed regarding cleaning practices and acknowledged issues with cleanliness and lack of cleaning policy | |
| Administrator | Asked Housekeeping Supervisor for cleaning policy and was informed none existed |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 2, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care and nursing staff competencies at The Blossoms at Cumberland Rehab & Nursing Center.
Findings
The facility failed to ensure proper treatment orders and care for Resident #66's left wrist wound, and failed to ensure licensed nursing staff demonstrated competency in performing weekly body audits, resulting in Resident #323 developing gangrene and undergoing surgical amputations of toes on the left foot.
Deficiencies (2)
Failure to ensure Resident #66 had an order for treatment to the left wrist and to change the bandage to prevent infection.
Failure to ensure licensed nursing staff demonstrated competency in performing weekly body audits, resulting in Resident #323 developing gangrene and requiring surgical amputations of toes.
Report Facts
Residents affected: 14
Residents affected: 1
Dates with missing weekly skin audits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding bandage care for Resident #66 and body audits for Resident #323 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding bandage care for Resident #66 and body audits for Resident #323 |
| Director of Nursing | Director of Nursing | Interviewed regarding nursing treatment orders and policies |
| Administrator | Administrator | Interviewed regarding investigation of Resident #323's wounds and body audits |
| Administrative Supervisor | Administrative Supervisor | Interviewed regarding policy on body audits |
Inspection Report
Routine
Deficiencies: 12
Date: Feb 2, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey of The Blossoms at Cumberland Rehab & Nursing Center to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, confidentiality of medical records, timely notification to ombudsman on transfers, provision of personal care, appropriate treatment orders, nutritional care, medication administration, controlled substance management, infection control, and food safety practices.
Deficiencies (12)
Failure to ensure residents were provided the opportunity to formulate Advance Directives other than code status for Resident #34.
Failure to keep residents' personal and medical records private by not closing electronic medication administration record on secured unit.
Failure to notify Ombudsman in writing of resident hospital transfer for Resident #323.
Failure to provide facial hair removal care for female residents #23 and #66.
Failure to ensure Resident #66 had an order for treatment and timely bandage changes to prevent infection.
Failure to administer medications and flushes via PEG tube by gravity for Resident #12.
Failure to ensure licensed nursing staff competency in weekly body audits resulting in gangrene and amputation for Resident #323.
Failure to maintain accurate controlled substance counts and proper documentation.
Medication error rate of 21.43% with omitted and improperly administered medications for Residents #33, #62, and #323.
Failure to ensure expired insulin vials were removed, controlled substances properly secured, and medications stored in original packaging.
Failure to ensure food items in freezer had open dates to minimize potential for foodborne illness.
Failure to disinfect multi-resident use glucometer properly after each use to prevent infection spread.
Report Facts
Medication error rate: 21.43
Residents affected: 73
Residents affected: 17
Residents affected: 14
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Mentioned in relation to medication administration errors, confidentiality breach, and facial hair care deficiencies. |
| LPN #2 | Licensed Practical Nurse | Mentioned in relation to medication administration errors and PEG tube medication administration. |
| LPN #3 | Licensed Practical Nurse | Mentioned in relation to treatment bandage and body audits. |
| LPN #5 | Licensed Practical Nurse | Mentioned in relation to controlled substance count discrepancies. |
| Medication Technician #1 | Medication Technician | Mentioned in relation to medication administration errors. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration, confidentiality, treatment orders, and infection control. |
| Administrator | Administrator | Interviewed regarding Ombudsman notification, medication errors, and controlled substance policies. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Mentioned in relation to facial hair care deficiencies. |
| Nurse Consultant #1 | Nurse Consultant | Provided policies and interviewed regarding medication administration and controlled substances. |
| Registered Nurse #1 | Registered Nurse | Mentioned in relation to medication cart observations. |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and open dates. |
| Administrative Supervisor | Administrative Supervisor | Mentioned regarding lack of policy on body audits. |
| Regional Manager | Regional Manager | Interviewed regarding advance directive documentation. |
Inspection Report
Routine
Deficiencies: 13
Date: Feb 2, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, confidentiality breaches of medical records, failure to notify ombudsman of hospital transfers, inadequate personal care related to facial hair removal, lack of physician orders for treatments, failure to maintain nutritional status, improper medication administration via feeding tubes, inadequate competency in performing weekly body audits leading to serious resident harm, inaccurate controlled substance counts, medication errors exceeding acceptable rates, improper medication storage and labeling, failure to date opened food items, and inadequate infection control practices related to glucometer disinfection.
Deficiencies (13)
Failure to ensure residents were provided the opportunity to formulate advance directives other than code status.
Failure to keep residents' personal and medical records private and confidential by not closing electronic medication administration records.
Failure to notify the Ombudsman in writing of resident hospital transfers as required.
Failure to provide facial hair removal care to dependent residents, affecting dignity and personal image.
Failure to ensure physician orders for treatment to a resident's left wrist were present and followed.
Failure to serve physician ordered nutritional diet and timely intervene for weight loss.
Failure to administer medications and flushes via PEG tube by gravity as ordered.
Failure to ensure licensed nursing staff competency in performing weekly body audits, resulting in missed wounds and subsequent amputations.
Failure to maintain accurate controlled substance counts and proper documentation.
Medication error rate of 21.43% due to omitted and improperly administered medications.
Failure to ensure expired insulin vials were removed, controlled substances properly secured, and medications stored in original packaging with expiration dates visible.
Failure to date opened food items in freezer, risking foodborne illness.
Failure to properly disinfect multi-resident use glucometer after each use, risking spread of infection.
Report Facts
Medication error rate: 21.43
Residents affected: 73
Residents affected: 17
Residents affected: 14
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to medication administration errors, confidentiality breach, and glucometer cleaning. |
| LPN #2 | Licensed Practical Nurse | Named in medication administration errors and PEG tube medication administration. |
| LPN #3 | Licensed Practical Nurse | Named in treatment and body audit findings. |
| LPN #5 | Licensed Practical Nurse | Named in controlled substance count discrepancies. |
| Medication Technician #1 | Medication Technician | Named in medication administration errors. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, confidentiality, PEG tube procedures, and glucometer cleaning. |
| Administrator | Administrator | Interviewed regarding advance directives, Ombudsman notification, medication errors, and medication storage. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in facial hair removal care deficiency. |
| Nurse Consultant #1 | Nurse Consultant | Provided policies and interviewed regarding medication administration and controlled substances. |
| Dietary Manager | Dietary Manager | Interviewed regarding undated food items in freezer. |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding insulin vial expiration and medication cart observations. |
| Regional Manager | Regional Manager | Interviewed regarding advance directives. |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 2, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care and nursing staff competencies at The Blossoms at Cumberland Rehab & Nursing Center.
Findings
The facility failed to ensure proper treatment orders and care for Resident #66's left wrist wound, and failed to ensure licensed nursing staff demonstrated competency in performing weekly body audits, resulting in Resident #323 developing gangrene and undergoing surgical amputation of toes.
Deficiencies (2)
Failure to ensure Resident #66 had an order for treatment to the left wrist and to change the bandage to prevent infection.
Failure to ensure licensed nursing staff demonstrated competency in performing weekly body audits, resulting in Resident #323 developing gangrene and requiring surgical amputation of toes.
Report Facts
Residents affected: 14
Residents affected: 1
Weekly skin audit dates with initials: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding bandage care for Resident #66 and body audits for Resident #323 | |
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding bandage care for Resident #66 and body audits for Resident #323 | |
| Director of Nursing (DON) | Interviewed about treatment orders and nursing procedures | |
| Administrator | Interviewed about investigation of Resident #323's wounds | |
| Administrative Supervisor | Interviewed about facility policy on body audits |
Inspection Report
Routine
Census: 66
Deficiencies: 7
Date: Nov 3, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care planning, hygiene, wound care, respiratory care, and medication management.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with privacy bags for Foley catheters, incomplete documentation of advance directives, failure to update care plans after resident falls, inadequate personal hygiene care related to fingernail grooming, failure to change wound dressings as ordered, incorrect oxygen flow rate administration, and failure to implement physician-ordered gradual dose reductions for psychotropic medications.
Deficiencies (7)
Failure to ensure privacy and dignity by providing a privacy bag for a Foley catheter for Resident #269.
Failure to document residents' decisions regarding advance directives prominently in clinical records for Residents #49 and #52.
Failure to review and revise care plans and reassess effectiveness of interventions after resident falls for Resident #2.
Failure to ensure fingernails were clean, groomed, and free of chipped nail polish for Residents #15 and #31.
Failure to change wound dressing as ordered for Resident #63.
Failure to ensure oxygen was administered at the physician-ordered flow rate for Resident #20.
Failure to implement physician-ordered gradual dose reduction of psychotropic medication for Resident #48.
Report Facts
Residents affected: 66
Residents affected: 44
Residents affected: 8
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in oxygen flow rate deficiency and fingernail care findings |
| Administrator | Provided facility policies and explanations related to deficiencies | |
| Director of Nursing | Interim Director of Nursing | Interviewed regarding medication dose reduction and care responsibilities |
Inspection Report
Routine
Census: 66
Deficiencies: 7
Date: Nov 3, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, care planning, advanced directives, personal hygiene, wound care, oxygen therapy, and psychotropic medication management.
Findings
The facility was found deficient in multiple areas including failure to maintain privacy for residents with Foley catheters, incomplete documentation of advance directives, failure to update care plans after resident falls, inadequate personal hygiene care related to fingernail grooming, failure to change wound dressings as ordered, incorrect oxygen flow rates for a resident, and failure to implement physician-ordered gradual dose reduction of psychotropic medication.
Deficiencies (7)
Failed to ensure privacy and dignity by providing a privacy bag for a Foley catheter for 1 resident.
Failed to document residents' decisions regarding advance directives in a prominent part of the clinical record for 2 residents.
Failed to review and revise care plan and reassess effectiveness of interventions after falls for 1 resident.
Failed to ensure fingernails were clean, groomed, and free of chipped nail polish for 2 residents.
Failed to ensure dressing to a wound was changed as ordered for 1 resident.
Failed to ensure oxygen was administered at the flow rate ordered by the physician for 1 resident.
Failed to implement physician's order for antidepressant dose reduction for 1 resident.
Report Facts
Residents affected: 66
Residents affected: 44
Residents affected: 8
Deficiencies cited: 7
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 4
Trazodone dose ordered: 50
Trazodone dose recommended: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in oxygen flow rate deficiency for Resident #20 |
| Administrator | Provided facility policy and information on deficiencies and physician orders | |
| Director of Nursing | Interim Director of Nursing | Discussed importance of following physician orders and dose reductions |
| LPN #2 | Licensed Practical Nurse | Discussed wound care procedures and dressing changes |
| LPN #4 | Licensed Practical Nurse | Discussed wound care procedures and dressing changes |
| LPN #1 | Licensed Practical Nurse | Discussed wound care procedures and dressing changes |
| LPN #3 | Licensed Practical Nurse | Discussed fingernail care and resident assistance |
| CNA #5 | Certified Nursing Assistant | Discussed fingernail care and resident assistance |
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