Inspection Reports for
The Blossoms at Midtown Rehab & Nursing Center
AR, 72205
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
22.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
337% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Deficiencies: 6
Date: Aug 28, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident environment, assessments, accident prevention, food safety, and infection control at The Blossoms at Midtown Rehab & Nursing Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, accurate resident assessments, proper storage and supervision to prevent accidents, food safety and sanitation, and infection prevention practices. Multiple observations and interviews revealed issues such as mold and residue in resident bathrooms, inaccurate Minimum Data Set (MDS) assessments, unsecured chemical storage, improper razor storage, food safety violations including expired and improperly stored food, and failure of housekeeping staff to follow isolation protocols.
Deficiencies (6)
Failure to maintain a safe, clean, and homelike environment in resident rooms, including mold and residue in bathrooms and damaged furnishings.
Failure to accurately assess and complete the Minimum Data Set (MDS) for residents, leading to incorrect coding of care needs.
Failure to ensure chemicals were properly stored away from residents to prevent accidents and injuries; unsecured soiled room door with hazardous chemicals accessible.
Failure to ensure razors were properly stored to prevent accidents and injury; razor left accessible in resident room.
Failure to maintain food safety standards including dirty ice scoop holder, improperly stored and expired food, failure to wash hands between handling dirty and clean equipment, and inadequate hot food temperatures.
Failure to ensure isolation practices were followed by housekeeping staff, including failure to change gloves or perform hand hygiene when cleaning isolation rooms.
Report Facts
Residents potentially affected by unsecured chemical storage: 55
Ambulatory residents using vending machine near unsecured soiled room: 50
Brief Interview for Mental Status score: 12
Brief Interview for Mental Status score: 10
Food temperature: 115
Food temperature: 130
Food temperature: 103
Food temperature: 130
Food temperature: 120
Food temperature: 120
Expired food item date: May 6, 2025
Expired food item date: Aug 11, 2025
Expired food item date: Jul 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #31 | Reported ongoing bathroom cleanliness issues and odor. | |
| Housekeeping Supervisor | Described cleaning schedule and mold spray use. | |
| Maintenance Director | Commented on mold and cleaning responsibilities. | |
| Assistant Director of Nursing | ADON | Expressed concern about bathroom cleanliness and infection risk. |
| Administrator | Acknowledged facility deficiencies and lack of housekeeping policy. | |
| MDS Nurse | Reported on MDS assessment errors and lack of policy. | |
| Unit Manager/Assistant Director of Nursing/Registered Nurse | UM/ADON/RN | Described concerns about unsecured chemical storage and biohazard risks. |
| Housekeeper #1 | Admitted to leaving keys in unlocked soiled room door. | |
| RN #8 | Registered Nurse | Discussed razor safety and resident supervision. |
| Dietary Manager | DM | Confirmed food safety violations and improper food storage. |
| Housekeeper #9 | Observed failing to follow isolation protocols during cleaning. | |
| Licensed Practical Nurse #5 | LPN | Discussed responsibility for cleaning refrigerators. |
| ADON #6 | Assistant Director of Nursing | Discussed assignment of refrigerator cleaning duties. |
| Dietary [NAME] #4 | DC #4 | Observed failing to wash hands before handling clean equipment and improper food temperature maintenance. |
Inspection Report
Routine
Deficiencies: 5
Date: Aug 28, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident environment, accurate resident assessments, accident prevention, food safety, infection control, and overall facility safety.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, accurate Minimum Data Set (MDS) assessments, proper storage and supervision to prevent accidents, food safety and sanitation practices, and infection control protocols, particularly isolation practices by housekeeping staff.
Deficiencies (5)
Failure to ensure a comfortable homelike environment with clean bathrooms and proper maintenance in resident rooms.
Failure to accurately assess and complete the Minimum Data Set (MDS) for residents, leading to incorrect coding of care needs.
Failure to ensure chemicals were properly stored away from residents and razors were properly stored to prevent accidents and injury.
Failure to maintain food safety standards including unsanitary ice scoop holder, improperly stored and expired food, inadequate hand hygiene by dietary staff, and improper hot food temperatures.
Failure to ensure isolation practices were followed by housekeeping staff, risking spread of infectious disease.
Report Facts
Residents potentially affected by unsecured chemical storage: 50
Residents affected by chemical storage and razor safety deficiencies: 1
Residents reviewed for MDS assessment accuracy: 2
Residents affected by environmental deficiencies: 3
Food temperature readings below required level: 103
Food temperature readings below required level: 115
Food temperature readings below required level: 130
Food temperature readings below required level: 120
Expired food item date: May 6, 2025
Expired food item date: Aug 11, 2025
Expired food item date: Jul 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #31 | Reported ongoing bathroom cleanliness issues. | |
| Housekeeping Supervisor | Described cleaning schedule and mold spray use. | |
| Maintenance Director | Commented on mold and cleaning supplies. | |
| Assistant Director of Nursing | ADON | Expressed concern about bathroom cleanliness and infection risk. |
| Administrator | Acknowledged facility deficiencies and committed to corrections. | |
| MDS Nurse | Discussed MDS assessment inaccuracies and lack of policy. | |
| Unit Manager/Assistant Director of Nursing/Registered Nurse | UM/ADON/RN | Discussed chemical storage and safety concerns. |
| Housekeeper #1 | Admitted to leaving keys in unlocked chemical storage door. | |
| Housekeeper #9 | Observed failing to follow isolation protocols during cleaning. | |
| RN #8 | Discussed razor safety and resident supervision. | |
| Dietary Manager | DM | Confirmed food safety violations and improper food storage. |
| Dietary [NAME] #4 | DC #4 | Observed not washing hands between dirty and clean tasks. |
| Licensed Practical Nurse #5 | LPN #5 | Discussed refrigerator cleaning responsibilities. |
| Assistant Director of Nursing #6 | ADON #6 | Discussed refrigerator cleaning assignment. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 11, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to administer medications as ordered to residents, specifically focusing on medication administration errors for Residents #2 and #4.
Complaint Details
The complaint investigation found substantiated medication administration failures for Residents #2 and #4. Resident #2 was hospitalized after missing multiple doses of antipsychotic medication due to pharmacy delays and lack of required lab results. Resident #4 missed antibiotic doses due to medication unavailability and PICC line issues. Interviews with nursing staff and a Regional Nurse Consultant confirmed these findings.
Findings
The facility failed to ensure medications were administered as ordered by the physician for Residents #2 and #4. Resident #2 missed several doses of antipsychotic and antimanic medications due to pharmacy delays and medication unavailability, resulting in hospitalization. Resident #4 missed multiple doses of intravenous antibiotic medication due to medication unavailability and PICC line issues.
Deficiencies (2)
Failure to administer antipsychotic and antimanic medications as ordered to Resident #2, resulting in missed doses and hospitalization.
Failure to administer intravenous antibiotic medication as ordered to Resident #4 on multiple dates due to medication unavailability and PICC line malfunction.
Report Facts
Missed medication doses for Resident #2: 8
Missed medication doses for Resident #4: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Confirmed no intravenous antibiotic was administered on 02/10/2025 and searched for medication | |
| Licensed Practical Nurse (LPN) #2 | Confirmed medication was searched for with LPN #1 and was unable to be located | |
| Regional Nurse Consultant | Reviewed documentation and confirmed medication administration failures and explained importance of medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 11, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to administer medications as ordered by the physician for certain residents, specifically Residents #2 and #4.
Complaint Details
The complaint investigation found substantiated issues with medication administration for Residents #2 and #4, including missed doses due to pharmacy delays, medication unavailability, and PICC line malfunction. The Regional Nurse Consultant confirmed these findings and emphasized the risks of exacerbation of chronic conditions due to missed medications.
Findings
The facility failed to ensure medications were administered as ordered, resulting in missed doses of antipsychotic and antibiotic medications for Residents #2 and #4. This included delays due to pharmacy issues, medication unavailability, and PICC line malfunction, leading to potential harm such as Resident #2's hospitalization and Resident #4 not receiving antibiotics on multiple days.
Deficiencies (2)
Failure to administer antipsychotic medication as ordered for Resident #2, resulting in missed doses and hospitalization.
Failure to administer antibiotic medication as ordered for Resident #4 on multiple dates due to medication unavailability and PICC line issues.
Report Facts
Missed medication doses for Resident #2: 8
Missed medication doses for Resident #4: 4
Medication dosage: 100
Medication dosage: 300
Medication dosage: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed no intravenous antibiotic was administered on 02/10/2025 and searched for medication |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed medication was searched for but unable to be located |
| Regional Nurse Consultant | Regional Nurse Consultant | Reviewed documentation and confirmed missed medication doses and explained importance of medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 28, 2024
Visit Reason
The inspection was conducted due to allegations of misappropriation of property and controlled substances at the facility, specifically concerning missing narcotics and failure to report alleged misappropriations.
Complaint Details
The complaint investigation revealed 693 discontinued narcotics were unaccounted for and not surrendered to the Pharmacy Division. The Chief Nursing Officer confirmed the missing narcotics and the failure to transmit the faxed report to the Pharmacy Division. The facility failed to report alleged misappropriations for 15 residents to the State Agency, with 3 residents still having current medication orders for the missing drugs.
Findings
The facility failed to ensure residents were free from misappropriation of property involving controlled substances for 4 of 15 residents reviewed. Additionally, the facility failed to timely report allegations of misappropriation of property to the State Agency for 15 residents, with 3 residents still on medications. A total of 693 discontinued narcotics were unaccounted for and not surrendered to the Pharmacy Division as required.
Deficiencies (2)
Failed to ensure residents were free from misappropriation of property involving controlled substances for 4 residents.
Failed to timely report allegations of misappropriation of property to the State Agency for 15 residents, with 3 residents still on medications.
Report Facts
Residents reviewed for misappropriation: 15
Residents affected by misappropriation: 4
Discontinued narcotics unaccounted for: 693
Residents affected by missing narcotics: 15
Missing oxycodone tablets for Resident #3: 26
Missing hydrocodone/acetaminophen tablets for Resident #5: 1
Missing hydrocodone/acetaminophen tablets for Resident #4: 42
Missing clonazepam tablets for Resident #7: 14
Missing tramadol tablets for Resident #7: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chief Nursing Officer | CNO | Confirmed missing narcotics and failure to report to Pharmacy Division and State Agency |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 28, 2024
Visit Reason
The inspection was conducted due to allegations of misappropriation of property and controlled substances at The Blossoms at Midtown Rehab & Nursing Center, involving 15 residents with missing or unaccounted medications.
Complaint Details
The complaint investigation revealed 693 discontinued narcotic drugs were unaccounted for and not surrendered to the state Pharmacy Division as required. The Chief Nursing Officer confirmed the missing drugs and the failure to transmit the faxed report initially. The facility failed to report alleged misappropriations of medications for residents #4, #5, and #7 who still had current medication orders.
Findings
The facility failed to ensure residents were free from misappropriation of property and failed to timely report allegations of misappropriation to the State Agency. Specifically, 693 discontinued narcotic drugs were unaccounted for and not surrendered to Pharmacy Services, affecting 15 residents. Several residents had missing quantities of opioid and anti-anxiety medications. The facility also failed to report alleged misappropriations of medications for three residents still on medications.
Deficiencies (2)
Failed to ensure residents were free from misappropriation of property for 4 of 15 residents reviewed.
Failed to timely report allegations of misappropriation of property to the State Agency for 15 residents, with 3 residents still on medications.
Report Facts
Discontinued narcotic drugs unaccounted for: 693
Residents affected: 15
Missing oxycodone quantity: 26
Missing hydrocodone/acetaminophen quantity: 1
Missing hydrocodone/acetaminophen quantity: 42
Missing clonazepam quantity: 14
Missing tramadol quantity: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chief Nursing Officer | CNO | Confirmed missing narcotics and failure to transmit faxed report; signed Arkansas Department of Health Report of Loss of Controlled Substances form. |
Inspection Report
Routine
Deficiencies: 9
Date: May 8, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, nutrition, and facility operations at The Blossoms at Midtown Rehab & Nursing Center.
Findings
The facility was found deficient in multiple areas including accurate resident assessments, care plan updates for oxygen therapy, wound care administration, safe storage of hazardous items, proper oxygen administration, meal preparation and serving according to menus, food safety and sanitation practices, and adherence to infection prevention protocols including Enhanced Barrier Precautions.
Deficiencies (9)
Failed to complete an accurate discharge Minimum Data Set (MDS) assessment reflecting resident discharge status.
Failed to review and revise care plan to include oxygen therapy use for a resident.
Failed to ensure wound care was administered as ordered to prevent infection and promote healing.
Failed to ensure potentially hazardous items were stored securely to prevent accidents.
Failed to ensure oxygen was administered at the physician ordered flow rate to prevent respiratory complications.
Failed to prepare and serve meals according to the planned menu to meet residents' nutritional needs.
Failed to ensure food was palatable, attractive, and served at safe and appetizing temperatures.
Failed to maintain food storage, preparation, and serving areas in sanitary condition to prevent contamination.
Failed to ensure staff followed Enhanced Barrier Precautions (EBP) between resident rooms to prevent cross contamination.
Report Facts
Residents potentially affected by inaccurate discharge MDS: 76
Residents potentially affected by failure to update care plan for oxygen therapy: 55
Residents potentially affected by failure to provide wound care as ordered: 8
Residents potentially affected by failure to administer oxygen at ordered flow rate: 57
Residents potentially affected by failure to prepare and serve meals according to menu: 74
Residents potentially affected by food safety and sanitation deficiencies: 89
Total census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Spoke about oxygen settings for Resident #71 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Verified oxygen orders for Resident #71 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed administering medication without proper PPE to Resident #33 |
| Director of Nursing | Director of Nursing | Provided policies and interviews regarding oxygen administration and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed assisting with medication administration without proper PPE |
| Dietary Employee #2 | Dietary Employee | Observed food preparation and sanitation deficiencies |
| Dietary Employee #3 | Dietary Employee | Observed serving incorrect portion sizes and food temperatures |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed failing to follow proper hand hygiene with Enhanced Barrier Precautions |
Inspection Report
Deficiencies: 2
Date: May 8, 2024
Visit Reason
The inspection was conducted to evaluate compliance with care standards including wound care and nutritional services at The Blossoms at Midtown Rehab & Nursing Center.
Findings
The facility failed to provide appropriate pressure ulcer care for one resident as ordered by the physician, potentially affecting eight residents. Additionally, the facility did not ensure meals were prepared and served according to the planned menu, affecting nutritional needs of 87 residents receiving regular and mechanical soft diets.
Deficiencies (2)
Failure to provide wound care as ordered for Resident #199, missing documentation of second application of Povidone-iodine on multiple dates.
Failure to prepare and serve meals according to the planned menu, including insufficient portion sizes and missing cheese in scrambled eggs.
Report Facts
Residents affected by wound care deficiency: 8
Residents affected by meal preparation deficiency: 74
Residents affected by meal preparation deficiency: 13
Number of residents served insufficient fried chicken portions: 19
Number of servings prepared for mechanical soft diets: 11
Portion size served for oatmeal: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Observed serving insufficient portions of fried chicken during lunch meal service | |
| Dietary Employee #2 | Weighed chicken portions and explained servings prepared for mechanical soft diets | |
| Dietary Employee #3 | Served oatmeal with incorrect portion size and did not follow menu portion size | |
| Dietary Employee #4 | Served oatmeal with incorrect portion size and did not follow menu portion size | |
| Dietary Employee #5 | Served oatmeal with incorrect portion size and did not follow menu portion size |
Inspection Report
Routine
Deficiencies: 2
Date: May 8, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to wound care and nutritional services at The Blossoms at Midtown Rehab & Nursing Center.
Findings
The facility failed to provide appropriate pressure ulcer care for one resident as ordered by the physician, potentially affecting eight residents. Additionally, the facility failed to prepare and serve meals according to the planned written menu, affecting 74 residents on regular diets and 13 on mechanical soft diets.
Deficiencies (2)
Failed to ensure Resident #199 received wound care as ordered to prevent wound infection and promote healing.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs for 2 of 2 meals observed.
Report Facts
Residents affected by wound care deficiency: 8
Residents affected by meal preparation deficiency: 74
Residents affected by meal preparation deficiency: 13
Number of residents served one fried chicken leg on 200 Hall: 12
Number of residents served one fried chicken leg on 400 Hall: 7
Servings of chicken prepared for mechanical soft diets: 11
Inspection Report
Routine
Deficiencies: 9
Date: May 8, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, nutrition, and facility operations at The Blossoms at Midtown Rehab & Nursing Center.
Findings
The facility was found deficient in multiple areas including accurate resident assessments, care plan updates for oxygen therapy, wound care administration, safe storage of hazardous items, proper oxygen administration, meal preparation and serving according to menus, food safety and sanitation practices, and infection prevention protocols related to Enhanced Barrier Precautions.
Deficiencies (9)
Failed to complete a discharge Minimum Data Set (MDS) assessment accurately reflecting resident discharge status.
Failed to review and revise care plan to include oxygen therapy for a resident with physician's orders.
Failed to provide appropriate pressure ulcer care as ordered to prevent infection and promote healing.
Failed to ensure potentially hazardous items were stored securely to prevent accidents.
Failed to ensure oxygen was administered at the flow rate ordered by the physician to prevent respiratory complications.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs.
Failed to ensure food was palatable, attractive, and served at safe and appetizing temperatures.
Failed to ensure foods were stored covered and sealed, ice machine and scoop holder were clean, and dietary employees practiced proper hand hygiene to prevent foodborne illness.
Failed to ensure staff followed Enhanced Barrier Precautions between resident rooms to prevent cross contamination.
Report Facts
Residents potentially affected by inaccurate discharge MDS: 76
Residents potentially affected by failure to update care plan for oxygen therapy: 55
Residents potentially affected by failure to provide wound care as ordered: 8
Residents potentially affected by failure to administer oxygen at ordered flow rate: 57
Residents potentially affected by failure to prepare and serve meals according to menu: 74
Residents potentially affected by food safety and sanitation deficiencies: 89
Residents potentially affected by failure to follow Enhanced Barrier Precautions: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Observed administering medication without wearing isolation gown in Enhanced Barrier Precautions room |
| Licensed Practical Nurse #2 | LPN | Spoke about oxygen settings for Resident #71 |
| Licensed Practical Nurse #3 | LPN | Spoke about oxygen orders for Resident #71 |
| Licensed Practical Nurse #4 | LPN | Described dirty ice scoop holder and acknowledged it was in use |
| Licensed Practical Nurse #6 | LPN | Verified oxygen order for Resident #248 |
| Director of Nursing | DON | Provided policies and confirmed practices related to oxygen administration and infection control |
| Assistant Director of Nursing | ADON | Observed administering medication without PPE and explained proper PPE use for Enhanced Barrier Precautions |
| Dietary Employee #1 | DE | Observed handling clean utensils without washing hands after touching dirty items |
| Dietary Employee #2 | DE | Observed preparing food with unclean equipment and improper sanitation |
| Dietary Employee #3 | DE | Observed serving incorrect portion sizes and food temperatures |
| Dietary Employee #4 | DE | Observed serving incorrect portion sizes |
| Dietary Employee #5 | DE | Observed serving incorrect portion sizes |
| Certified Nursing Assistant #1 | CNA | Described cleaning practices for ice chests and scoop holders |
| Certified Nursing Assistant #2 | CNA | Described cleaning practices for ice chests and scoop holders |
Inspection Report
Routine
Deficiencies: 4
Date: Nov 22, 2023
Visit Reason
The inspection was conducted to assess the maintenance and cleanliness of resident rooms and HVAC units in the nursing home, ensuring the facility is safe, clean, and comfortable for residents, staff, and the public.
Findings
The facility failed to maintain four resident rooms and HVAC units in a clean and sanitary manner, with observed damage to walls in multiple rooms and dark brown and black spots resembling mold or mildew inside HVAC vents on multiple floors. The facility lacked policies on HVAC maintenance and building upkeep.
Deficiencies (4)
Damage to walls behind beds in rooms including gouges and unfinished plaster repairs.
Dark brown and black circular-shaped spots with a slightly furry appearance inside HVAC vents on multiple floors.
Water damage observed in ten ceiling tiles in the hallway on the second floor.
Facility lacked policies on maintenance of HVAC system and upkeep and repair of the building.
Report Facts
Number of resident rooms with damage: 4
Number of ceiling tiles with water damage: 10
Number of HVAC vents with dark spots: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Observed dark spots in HVAC units and commented on damage and lack of policies | |
| Administrator | Observed dark spots in HVAC units, commented on damage and lack of policies |
Inspection Report
Routine
Deficiencies: 5
Date: Nov 22, 2023
Visit Reason
The inspection was conducted to assess the condition and maintenance of resident rooms and HVAC units in the nursing home to ensure the environment is safe, clean, and comfortable for residents, staff, and the public.
Findings
The facility failed to maintain resident rooms in good repair, with damage observed in four rooms and HVAC units and vents on multiple floors found to have dark brown and black spots with a slightly furry appearance, indicating possible mold or mildew. Additionally, the facility lacked policies on HVAC maintenance and building upkeep.
Deficiencies (5)
Damage to walls behind beds in rooms 202, 301, 304, and 406 including gouges and unfinished plaster repairs.
Dark brown and black circular-shaped spots with a slightly furry appearance observed inside HVAC vents on the second, third, and fourth floors.
Water damage observed in ten ceiling tiles in the hallway on the second floor.
Facility lacked a policy on maintenance of the HVAC system.
Facility lacked a policy on upkeep and repair of the building.
Report Facts
Number of damaged rooms: 4
Number of ceiling tiles with water damage: 10
Number of HVAC vents with spots on fourth floor: 3
Number of HVAC vents with spots on third floor: 4
Number of HVAC vents with spots on second floor: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Observed HVAC spots and wall damage, commented on mold and repairs | |
| Administrator | Observed HVAC spots, commented on cleaning and lack of HVAC maintenance policy |
Inspection Report
Routine
Census: 81
Deficiencies: 8
Date: May 11, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility standards including resident care, medication management, dietary services, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and clean environment, inadequate care for residents with contractures, improper medication management including unnecessary drug use and unsecured medications, failure to prepare and serve meals according to planned menus and nutritional needs, poor food handling and hygiene practices by dietary staff, and inconsistent meal service times.
Deficiencies (8)
Failed to clean tube feeding pumps, poles, fall mats, and floors in multiple resident rooms, compromising a safe and homelike environment.
Failed to ensure devices were put in residents' hands to prevent contracture decline for 1 resident with contractures.
Failed to ensure a resident's drug regimen was free from unnecessary drugs, specifically antipsychotic and anti-epileptic medications without adequate indications.
Failed to secure medication properly by leaving it on a bedside table for a resident, risking medication safety.
Failed to prepare and serve meals according to the planned written menu, including omission of pureed dessert and bread, and serving incorrect entrees.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency, risking choking hazards.
Failed to serve meals consistently at scheduled times, with lunch service delayed by almost 2 hours.
Failed to ensure dietary staff washed hands and changed gloves before handling food, and hot food items were not maintained at safe temperatures on the steam table.
Report Facts
Residents affected: 81
Residents affected: 35
Residents affected: 5
Residents affected: 10
Meal service delay: 118
Food temperature: 104
Food temperature: 124
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Informed about dried substances on feeding pumps and medication regimen issues |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding care for residents with contractures |
| MDS Coordinator | MDS Coordinator | Interviewed about care plans and medication use for Resident #82 |
| Dietary Supervisor | Dietary Supervisor | Interviewed about meal service delays, food preparation, and hygiene practices |
| Dietary Employee #1 | Dietary Employee | Observed handling food without proper hand hygiene |
| Dietary Employee #2 | Dietary Employee | Observed preparing pureed foods with improper consistency and handling food without hand hygiene |
| Dietary Employee #3 | Dietary Employee | Observed contaminating gloves and handling food |
| Dietary Employee #4 | Dietary Employee | Interviewed about meal preparation errors and food consistency |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Interviewed about meal serving times |
| Certified Nursing Assistant #2 | Certified Nursing Assistant (CNA) | Interviewed about meal serving times |
| Certified Nursing Assistant #3 | Certified Nursing Assistant (CNA) | Interviewed about consistency of pureed food items |
Inspection Report
Routine
Census: 81
Deficiencies: 1
Date: May 11, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with meal service schedules and ensure meals and snacks are served at times in accordance with residents' needs, preferences, and requests.
Findings
The facility failed to ensure residents' meals were consistently served at regularly scheduled times and did not provide a dependable eating schedule for one of one meal service observed. Lunch service was delayed by almost two hours due to staffing shortages in the kitchen, potentially affecting all 81 residents.
Deficiencies (1)
Failed to ensure residents' meals were served at regularly scheduled times and provide a dependable eating schedule.
Report Facts
Residents affected: 81
Meal service delay: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Explained the reason for delayed lunch service due to staffing shortage | |
| Certified Nursing Assistant (CNA) #1 | Provided information about usual meal serving times | |
| Certified Nursing Assistant (CNA) #2 | Provided information about variability in meal serving times | |
| Director of Nursing (DON) | Confirmed usual meal serving times and acknowledged late meal service |
Inspection Report
Routine
Census: 81
Deficiencies: 1
Date: May 11, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with meal service schedules and ensure meals and snacks are served according to residents' needs, preferences, and requests.
Findings
The facility failed to ensure residents' meals were consistently served at regularly scheduled times and did not provide a dependable eating schedule for one of the meal services observed. This issue potentially affected all 81 residents receiving meals from the kitchen.
Deficiencies (1)
Failed to ensure meals were served at regularly scheduled times and provide a dependable eating schedule for residents.
Report Facts
Residents affected: 81
Meal service delay duration: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided information about meal times and acknowledged late meal service |
| Dietary Supervisor | Dietary Supervisor | Explained delay in meal service due to staffing shortage |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: May 11, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and ensure the facility provides a safe, clean, and homelike environment, appropriate care, medication management, nutritional services, and food safety.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and clean environment, inadequate care for residents with contractures, improper medication management including unnecessary psychotropic drug use, unsecured medications, failure to prepare and serve meals according to planned menus and nutritional needs, poor food consistency for pureed diets, inconsistent meal service times, and inadequate food safety practices including poor hand hygiene and improper food temperature maintenance.
Deficiencies (8)
Failed to clean tube feeding pumps, poles, fall mats, and floors in resident rooms, compromising a safe and homelike environment.
Failed to ensure devices were placed in residents' hands to prevent contracture and decline in range of motion.
Failed to ensure a resident's drug regimen was free from unnecessary drugs, specifically psychotropic and anti-epileptic medications without adequate indications.
Failed to secure medication properly, leaving medication on a bedside table without documented approval for self-administration.
Failed to prepare and serve meals according to the planned written menu, affecting residents on pureed and mechanical soft diets.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency, increasing risk of choking.
Failed to serve meals consistently at regularly scheduled times, resulting in delayed meal service.
Failed to ensure dietary staff washed hands and changed gloves before handling food, and failed to maintain hot food items at or above 135°F on the steam table.
Report Facts
Residents affected: 81
Residents affected: 35
Residents affected: 5
Residents affected: 10
Meal service delay: 118
Food temperature: 104
Food temperature: 124
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Informed of dried substances on feeding pumps and poles; interviewed regarding psychotropic medication use and meal service times |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed about care for residents with contractures |
| MDS Coordinator | MDS Coordinator | Interviewed about care plans and psychotropic medication use for Resident #82 |
| Dietary Supervisor | Dietary Supervisor | Interviewed about meal service delays, ice machine cleaning, and food safety practices |
| Dietary Employee #1 | Dietary Employee | Observed handling food without proper hand hygiene and glove changes |
| Dietary Employee #2 | Dietary Employee | Observed preparing pureed food with improper consistency and handling food without proper hygiene |
| Dietary Employee #3 | Dietary Employee | Observed contaminating gloves and handling food |
| Dietary Employee #4 | Dietary Employee | Interviewed about meal preparation and food consistency |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Interviewed about meal service times |
| Certified Nursing Assistant #2 | Certified Nursing Assistant (CNA) | Interviewed about meal service times |
| Certified Nursing Assistant #3 | Certified Nursing Assistant (CNA) | Interviewed about consistency of pureed food items |
Viewing
Loading inspection reports...
