Deficiencies (last 3 years)
Deficiencies (over 3 years)
17.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
240% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 8
Date: Sep 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, dietary services, infection control, and facility operations.
Findings
The facility was found deficient in ensuring accurate Minimum Data Set (MDS) assessments, comprehensive and timely care plans including resident representative involvement, proper dietary services including provision of physician-ordered therapeutic diets and fortified foods, infection prevention practices including hand hygiene and equipment maintenance, and maintaining Legionella surveillance and sanitary conditions in resident unit refrigerators.
Deficiencies (8)
Failed to ensure accurate MDS assessment for Resident #72 regarding current diagnoses.
Failed to develop and implement a complete care plan meeting all resident needs for Resident #50.
Failed to include cognitively impaired resident's representative in care plan meetings for Resident #5.
Failed to renew laboratory waiver (CLIA Certificate of Waiver) timely, resulting in expired certificate.
Failed to provide diet based on nutritional needs and weight loss orders for 6 residents, including failure to provide enhanced/fortified diets as ordered.
Failed to ensure physician ordered therapeutic diets were provided for Residents #4, #14, and #27.
Failed to ensure proper hand hygiene and glove use by dietary staff and used equipment with cracks posing contamination risk.
Failed to maintain Legionella surveillance and sanitary conditions in resident unit refrigerator, including storing staff and resident foods together and breast pumps with substances in the same refrigerator.
Report Facts
Residents reviewed for MDS assessment accuracy: 27
Residents reviewed for comprehensive care plan: 27
Residents reviewed for development of comprehensive care plans: 28
Residents reviewed for nutritional dietary needs and weight loss: 37
Weight loss percentage: 11.9
Weight loss percentage: 4.13
Weight loss percentage: 19.16
Weight loss percentage: 4.87
Weight loss percentage: 5
Weight loss percentage: 10
CLIA fee payment: 268
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Discussed dietary practices, lack of fortified recipes, and meal preparation deficiencies | |
| Registered Dietician | Provided input on menu approval and nutritional requirements | |
| Director of Nursing | Provided statements regarding care plan and dietary expectations | |
| Minimum Data Set Coordinator/Care Plan Coordinator | Provided information on MDS and care plan completion processes | |
| Social Services Director | Discussed care plan meeting notification process | |
| Maintenance Supervisor | Discussed water temperature monitoring and Legionella surveillance | |
| Consultant #2 | Provided information on infection control and policy issues | |
| Licensed Practical Nurse #8 | LPN | Identified meal tray items and discussed dietary issues |
| Licensed Practical Nurse #3 | LPN | Discussed refrigerator use and infection control concerns |
| Certified Nursing Assistant #5 | CNA | Discussed refrigerator use and labeling |
| Certified Nursing Assistant #4 | CNA | Discussed breast pump storage in refrigerator |
| Dietary Aid #9 | Observed handling dishes without hand washing and wearing artificial nails | |
| Dietary #10 | Observed improper glove use and use of damaged blender |
Inspection Report
Routine
Deficiencies: 9
Date: Sep 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, dietary services, infection control, and laboratory certification at The Springs of MT Vista nursing home.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, failure to include resident representatives in care planning, expired laboratory waiver, failure to provide ordered therapeutic diets, improper food handling and preparation practices, inadequate infection control including Legionella surveillance, and improper storage of resident and staff foods and breast pumps.
Deficiencies (9)
Failed to ensure a Minimum Data Set (MDS) assessment was accurately completed for Resident #72, specifically regarding current diagnoses.
Failed to develop and implement a complete care plan that meets all the resident's needs for Resident #50.
Failed to include a cognitively impaired resident's representative in the care plan meetings for Resident #5.
Failed to ensure the laboratory waiver was renewed; the CLIA Certificate of Waiver was expired.
Failed to provide diets based on nutritional needs for 6 residents, including failure to provide enhanced/fortified diets as ordered.
Failed to ensure physician ordered therapeutic diets were provided for Residents #4, #14, and #27.
Failed to ensure proper hand washing and glove use by dietary staff and used equipment with cracks that could harbor contaminants.
Failed to maintain Legionella surveillance and water management plan; hot water heaters were set below recommended temperatures and no water flow diagram was available.
Failed to maintain sanitary conditions in resident unit refrigerator; staff and resident foods and breast pumps with substances were stored together without labeling.
Report Facts
Residents reviewed for MDS assessment accuracy: 27
Residents reviewed for comprehensive care plan: 27
Residents reviewed for development of comprehensive care plans: 28
Residents reviewed for nutritional dietary needs and weight loss: 37
Weight loss percentage: 11.9
Weight loss percentage: 4.13
Weight loss percentage: 19.16
Weight loss percentage: 4.87
Hot water heater temperature setting: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Discussed dietary practices, lack of fortified recipes, and food preparation deficiencies | |
| MDS/CP Coordinator | Provided information on MDS assessment and care plan completion processes | |
| Director of Nursing | Provided statements on assessment responsibilities and care plan accuracy | |
| Administrator | Provided statements on care plan and MDS completion timing | |
| Consultant #2 | Discussed MDS policy and Legionella surveillance | |
| Registered Dietician | Discussed menu approval and dietary concerns | |
| Maintenance Supervisor | Discussed water temperature monitoring and water management knowledge | |
| Certified Nursing Assistant #5 | Provided information on refrigerator use and storage | |
| Licensed Practical Nurse #3 | Provided statements on refrigerator storage and breast pump contamination risk | |
| Licensed Practical Nurse #6 | Provided statements on refrigerator use | |
| Dietary Aid #9 | Observed with improper hand hygiene and artificial nails | |
| Dietary [NAME] #10 | Observed with improper glove use and use of damaged blender | |
| Activity Director | Provided statements on refrigerator cleaning and storage practices |
Inspection Report
Deficiencies: 1
Date: Jul 21, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care and treatment standards, specifically regarding the management of a Peripherally Inserted Central Catheter (PICC) for a sampled resident.
Findings
The facility failed to ensure appropriate care and treatment for the management of a PICC line for Resident #57, including lack of physician orders for dressing changes, flushes, and infection monitoring, inconsistent dressing management by nursing staff, and unclear policies on dressing change frequency and responsibility.
Deficiencies (1)
Failure to provide necessary care and treatment for management of a PICC line, including lack of orders for dressing changes, flushes, and infection monitoring for Resident #57.
Report Facts
Days antibiotic treatment ordered: 14
Date of survey completion: Jul 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Discussed dressing change orders and antibiotic administration for Resident #57's PICC line |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Discussed dressing reinforcement and antibiotic administration responsibilities |
| Director of Nursing | Director of Nursing | Provided information on dressing change frequency and physician order requirements |
Inspection Report
Routine
Capacity: 154
Deficiencies: 9
Date: Jul 21, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident fund management, care planning, medication storage, respiratory care, food safety, staffing qualifications, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to promptly refund resident trust funds after discharge or death, incomplete care plans for residents, inadequate management of PICC line care, unsecured tobacco products, lack of No Smoking/Oxygen in Use signs and improper oxygen administration, unsecured medication storage, improper food storage and labeling, lack of a qualified full-time social worker, and inaccurate documentation of dryer lint trap cleaning.
Deficiencies (9)
Failure to ensure resident funds were refunded promptly within 30 days after discharge or death for 9 sampled residents.
Failure to develop and implement comprehensive person-centered care plans for 2 sampled residents.
Failure to provide appropriate treatment and care for management of a PICC line for 1 sampled resident.
Failure to secure tobacco products and ignition devices for 1 resident identified as a smoker.
Failure to post No Smoking/Oxygen in Use signs and improper oxygen flow rate administration for residents requiring oxygen therapy; improper storage of BiPAP mask and tubing.
Failure to store medications in a secure manner with unlocked medication room and medications left unsecured.
Failure to ensure food stored in refrigerator, freezer, and dry storage were dated, sealed, and discarded appropriately.
Failure to employ a qualified full-time social worker as required for a facility licensed for more than 120 residents.
Failure to ensure accurate documentation of dryer lint trap cleaning to prevent fire hazard.
Report Facts
Residents licensed capacity: 154
Residents affected by resident funds refund deficiency: 51
Residents sampled with resident funds refund deficiency: 9
Residents sampled with incomplete care plans: 2
Residents sampled with PICC line care deficiency: 1
Residents sampled with tobacco product security deficiency: 1
Residents sampled with oxygen therapy deficiencies: 12
Residents sampled with oxygen sign deficiency: 3
Residents sampled with medication storage deficiency: 4
Residents affected by food storage deficiency: 71
Residents licensed capacity requiring qualified social worker: 154
Lint trap cleaning log signatures: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laundry Aide #1 | Named in inaccurate dryer lint trap cleaning documentation | |
| Director of Nursing | DON | Interviewed regarding oxygen administration, medication storage, and tobacco product security |
| Social Services Director | SSD | Interviewed regarding qualifications and employment status |
| Administrator | Interviewed regarding facility capacity, social worker employment, and medication storage | |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding PICC line care and medication storage |
| Registered Nurse #2 | RN | Interviewed regarding oxygen administration and signage |
| Dietary Manager | DM | Interviewed regarding food storage and dryer lint trap cleaning |
Inspection Report
Routine
Capacity: 154
Deficiencies: 9
Date: Jul 21, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident fund management, care planning, treatment and care, safety, medication storage, food safety, staffing qualifications, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to promptly refund resident trust funds, incomplete care plans, inadequate management of PICC line care, unsecured tobacco products, lack of No Smoking/Oxygen signs and improper oxygen administration, unsecured medication storage, improper food storage and labeling, lack of a qualified full-time social worker, and inaccurate documentation of dryer lint trap cleaning.
Deficiencies (9)
Failed to ensure resident funds were refunded promptly within 30 days after discharge or death for 9 sampled residents.
Failed to develop and implement a comprehensive person-centered care plan for 2 sampled residents.
Failed to ensure necessary care and treatment for management of a PICC line for 1 sampled resident.
Failed to ensure tobacco products and ignition devices were secured for 1 sampled resident.
Failed to ensure No Smoking/Oxygen in Use signs were posted and oxygen flow rates were administered per orders for residents requiring oxygen therapy; BiPAP masks and tubing were improperly stored.
Failed to store medications in a secure manner; medication room door was unlocked with medications accessible.
Failed to ensure food stored in refrigerator, freezer, and dry storage were dated, sealed, and discarded appropriately.
Failed to employ a qualified full-time social worker as required for a facility licensed for more than 120 residents.
Failed to ensure staff documented dryer lint trap cleaning accurately to prevent fire risk.
Report Facts
Residents with resident trust fund balance not refunded timely: 9
Residents affected by resident trust fund issue: 51
Facility licensed capacity: 154
Residents requiring oxygen therapy sampled: 12
Residents identified as smokers sampled: 4
Residents affected by food safety deficiencies: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed about resident trust fund refund policies and balances | |
| Administrator | Interviewed about resident trust fund refund policies and facility staffing | |
| MDS Coordinator | Interviewed regarding care plan documentation for residents | |
| Licensed Practical Nurse #1 | LPN | Interviewed about PICC line dressing changes and medication administration |
| Licensed Practical Nurse #2 | LPN | Interviewed about PICC line care and antibiotic administration |
| Director of Nursing | DON | Interviewed about PICC line care, tobacco product policies, oxygen administration, and medication storage |
| Registered Nurse #1 | RN | Interviewed about oxygen administration and BiPAP mask storage |
| Registered Nurse #2 | RN | Interviewed about oxygen administration and No Smoking/Oxygen signs |
| Dietary Manager | DM | Interviewed about food storage and kitchen practices |
| Social Services Director | SSD | Interviewed about qualifications and social worker staffing |
| Laundry Aide #1 | Interviewed about dryer lint trap cleaning and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 21, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide necessary care and treatment for management of a Peripherally Inserted Central Catheter (PICC) for Resident #57.
Complaint Details
The investigation was complaint-related, focusing on the failure to provide necessary care for Resident #57's PICC line. The complaint was substantiated with findings of inadequate care and unclear staff responsibilities.
Findings
The facility failed to ensure proper care and treatment for Resident #57's PICC line, including lack of physician orders for dressing changes, flushes, and infection monitoring. Staff were unclear about dressing change protocols, and the facility policy requires dressing changes at least every seven days or when compromised. The Director of Nursing confirmed the need for physician orders for dressing changes and acknowledged uncertainty about the last dressing change date upon admission.
Deficiencies (1)
Failure to provide appropriate treatment and care for management of a PICC line for Resident #57, including lack of orders and documentation for dressing changes, flushes, and infection monitoring.
Report Facts
Days antibiotic treatment: 14
Date of admission: Jul 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about dressing change orders for Resident #57's PICC line |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about dressing change and antibiotic administration for Resident #57 |
| Director of Nursing | Director of Nursing | Interviewed about dressing change frequency and physician orders |
Inspection Report
Annual Inspection
Census: 73
Capacity: 154
Deficiencies: 8
Date: Apr 22, 2022
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and to evaluate the facility's care and safety practices.
Findings
The facility was found deficient in multiple areas including failure to revise care plans for residents with central lines and code status changes, inadequate nail care for dependent residents, unsecured smoking materials, improper storage and maintenance of oxygen and nebulizer equipment, unsanitary kitchen conditions with expired and unlabeled food, lack of a qualified social worker despite licensed bed capacity, failure to implement effective quality assurance and infection control plans, and improper handling of linens and trash for residents on transmission-based precautions.
Deficiencies (8)
Failure to revise care plan to address central line care and update code status for residents.
Failure to ensure fingernails were trimmed, clean, and free of jagged edges for dependent residents.
Failure to secure smoking materials in locked boxes when not in use for residents who smoke.
Failure to properly store oxygen tubing and nebulizer equipment to prevent cross contamination.
Unsanitary kitchen conditions including unclean equipment, unlabeled and expired food items, and structural damage.
Failure to employ a qualified full-time social worker as required for licensed bed capacity.
Failure to implement an effective Quality Assurance and Performance Improvement (QAPI) plan to monitor and correct infection control deficiencies.
Failure to properly handle linens and trash from residents on transmission-based precautions, including inconsistent use of yellow bags and PPE.
Report Facts
Residents affected: 73
Licensed bed capacity: 154
Residents sampled for nail care: 21
Residents affected by nail care deficiency: 44
Residents affected by smoking materials deficiency: 10
Residents with oxygen therapy: 20
Residents on Airborne Quarantine: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan revisions, smoking materials storage, oxygen tubing procedures, and infection control practices | |
| Director of Nursing (DON) | Interviewed about central line care, code status updates, smoking materials, oxygen tubing, infection control, and quarantine procedures | |
| Dietary Manager | Interviewed regarding kitchen sanitation, food labeling, and storage practices | |
| Administrator | Interviewed about social worker qualifications, maintenance issues, quality assurance activities, and infection control policies | |
| Housekeeper (HSK) #1 and #2 | Interviewed about laundry handling and infection control procedures | |
| Certified Nursing Assistants (CNA) #1, #2, #3 | Interviewed about laundry handling, PPE use, and quarantine procedures | |
| Licensed Practical Nurse (LPN) #1 and #2 | Interviewed about laundry handling and PPE use in quarantine rooms | |
| Infection Control Preventionist (ICP) | Interviewed about quarantine and isolation linen handling | |
| Maintenance Supervisor | Interviewed about kitchen ceiling and ventilation repairs |
Inspection Report
Annual Inspection
Census: 73
Capacity: 154
Deficiencies: 8
Date: Apr 22, 2022
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements including care planning, resident hygiene, smoking safety, respiratory care, food safety, social work staffing, quality assurance, and infection control.
Findings
The facility was found deficient in multiple areas including failure to update care plans for dialysis and code status changes, inadequate nail care for residents, unsecured smoking materials, improper storage and cleaning of respiratory equipment, unsanitary kitchen conditions with expired and unlabeled food, lack of qualified social worker for licensed bed capacity, ineffective quality assurance monitoring of infection control, and improper handling of quarantine and isolation linens and trash.
Deficiencies (8)
Failure to revise care plan to address central line care for resident on dialysis and update code status to Do Not Resuscitate for hospice resident.
Failure to ensure fingernails were trimmed, clean, and free of jagged edges for dependent residents.
Failure to secure smoking materials in locked boxes when not in use for residents allowed to keep smoking materials in their rooms.
Failure to properly store oxygen tubing and nebulizer equipment to prevent cross contamination and respiratory infection.
Failure to maintain kitchen equipment, refrigerators, and food storage areas in a clean and sanitary condition; failure to label and date food items; presence of expired food; and failure to maintain kitchen ceiling and ventilation.
Failure to employ a qualified full-time social worker despite licensed capacity exceeding 120 beds.
Failure to implement an effective quality assurance plan to monitor and correct infection control deficiencies cited in prior surveys.
Failure to properly handle and transport linens and trash from quarantine and isolation rooms according to infection control protocols, including inconsistent use of yellow bags and PPE.
Report Facts
Residents affected: 73
Licensed capacity: 154
Residents sampled for nail care: 21
Residents affected by nail care deficiency: 44
Residents sampled for smoking materials: 4
Residents affected by smoking materials deficiency: 10
Residents sampled for oxygen therapy: 9
Residents affected by oxygen therapy deficiency: 20
Residents affected by kitchen sanitation deficiency: 72
Residents affected by social worker deficiency: 73
Residents affected by infection control deficiency: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding dialysis care plan, smoking materials storage, oxygen therapy procedures, and infection control practices. |
| Dietary Manager | Dietary Manager | Provided information on kitchen sanitation, food storage, and labeling practices. |
| Administrator | Administrator | Provided information on facility licensing, social worker staffing, quality assurance activities, and infection control policies. |
| Housekeeper #1 | Housekeeper | Provided information on laundry handling for quarantine and isolation rooms. |
| Housekeeper #2 | Housekeeper | Provided information on laundry handling and isolation/quarantine linen transport. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Provided information on handling of trash and laundry for transmission-based precautions residents. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Provided information on laundry handling for transmission-based precautions residents. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Provided information on laundry handling and use of yellow bags for quarantine and isolation. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed entering airborne quarantine room without gown. |
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