Deficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
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
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
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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