Deficiencies (last 3 years)
Deficiencies (over 3 years)
16.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
221% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Deficiencies: 1
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to assess compliance with nutritional and meal service requirements in the facility, specifically to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of residents.
Findings
The facility failed to ensure meals were prepared and served according to the planned written menu for 1 of 1 meal observed, including incorrect portion sizes, missing gravy for pureed diets, and substitution of yellow cake for chocolate cake without proper documentation or justification.
Deficiencies (1)
Meals were not prepared and served according to the planned written menu, including incorrect sausage patty portions, insufficient pureed hashbrown portions, missing gravy for pureed diets, and substitution of yellow cake for chocolate cake.
Report Facts
Residents served incorrect portions: 41
Residents served large portion diets: 10
Meal observed: 1
Inspection Report
Routine
Deficiencies: 6
Date: Feb 27, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident safety, medication management, nutrition services, infection control, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to provide smoking aprons to residents who smoked on the secured unit, expired medications present on medication carts, meals not prepared or served according to the planned menu and nutritional standards, pureed foods not blended to smooth consistency, improper food storage and handling practices, and failure to properly implement contact isolation precautions for a resident with VRE infection.
Deficiencies (6)
Failure to provide smoking aprons for 3 of 4 residents on the secured unit who smoked.
Expired or undated over-the-counter medications found in medication cart #1.
Meals were not prepared and served according to the planned written menu, including incorrect portion sizes and substitutions.
Pureed food items served were lumpy, thick, and not smooth, posing risk of choking.
Food storage areas had expired items, improperly sealed bags, and ceiling tiles with stains and damage; cold food items were not maintained at proper temperatures; dietary staff failed to wash hands before handling food.
Failure to post appropriate contact isolation signage for a resident with VRE infection, resulting in staff not wearing required PPE.
Report Facts
Residents requiring smoking aprons not provided: 3
Expired medications found: 16
Residents served incorrect sausage patties: 41
Residents served correct sausage patties: 10
Temperature of pureed beets: 78
Temperature of regular beets: 67
Expired vinegar: 1
Expired flour: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #18 | Observed assisting residents during smoking breaks and interviewed about smoking apron procedures. | |
| Licensed Practical Nurse (LPN) #19 | Observed unlocking courtyard door for smoking breaks and interviewed about smoking apron procedures. | |
| Director of Nursing (DON) | Interviewed regarding smoking apron procedures and contact isolation signage. | |
| Licensed Practical Nurse (LPN) #16 | Observed medication cart and interviewed about expired medications. | |
| Assistant Director of Nursing (ADON) | Interviewed about medication destruction process. | |
| Administrator | Interviewed about expired medication disposal. | |
| Dietary Manager #1 | Interviewed about food storage, food preparation, and menu compliance. | |
| Dietary Aide (DA) #4 | Observed handling food and interviewed about hand hygiene. | |
| Dietary Aide (DA) #6 | Interviewed about meal substitutions. | |
| Licensed Practical Nurse (LPN) #7 | Interviewed about pureed food consistency and contact isolation signage. | |
| Certified Nursing Assistant (CNA) #12 | Observed entering isolation room without PPE and interviewed about contact isolation. | |
| Registered Nurse (RN) #13 | Interviewed about resident isolation status. | |
| Certified Nursing Assistant (CNA) #8 | Interviewed about pureed food consistency. | |
| Certified Nursing Assistant (CNA) #9 | Interviewed about pureed food consistency. | |
| Licensed Practical Nurse (LPN) #10 | Interviewed about pureed food and oatmeal consistency. | |
| Dietary Manager #2 | Interviewed about food temperature. |
Inspection Report
Routine
Deficiencies: 6
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident safety, medication management, food and nutrition services, infection control, and overall facility conditions.
Findings
The facility was found deficient in multiple areas including failure to provide smoking aprons to residents who smoked on the secured unit, expired medications present on medication carts, improper food preparation and serving inconsistent with menus and dietary standards, poor food storage and hygiene practices, and inadequate infection control signage for a resident on contact isolation precautions.
Deficiencies (6)
Failure to provide smoking aprons for 3 of 4 residents on the secured unit who smoked.
Expired or undated over-the-counter medications found in medication cart #1.
Meals were not prepared and served according to the planned written menu, including incorrect portions and substitutions.
Pureed food items served were not blended to a smooth, lump-free consistency as required.
Food storage areas had unsealed food items, expired food, and ceiling tiles with stains and damage; cold food items were not maintained at proper temperatures; dietary staff failed to wash hands before handling food.
A resident on contact isolation for VRE did not have appropriate contact isolation signage on the door, and staff were unaware of the isolation status.
Report Facts
Expired medications: 16
Residents served incorrect portions: 41
Residents served incorrect portions: 10
Temperature of pureed beets: 78
Temperature of regular beets: 67
Expired vinegar: 1
Expired flour: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #19 | Licensed Practical Nurse | Observed unlocking courtyard door and interviewed about smoking apron procedures. |
| Certified Nursing Assistant #18 | Certified Nursing Assistant | Observed assisting residents during smoking break and interviewed about smoking apron awareness. |
| Director of Nursing | Director of Nursing | Interviewed regarding smoking apron procedures and infection control signage. |
| Licensed Practical Nurse #16 | Licensed Practical Nurse | Observed medication cart and interviewed about expired medications. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about medication destruction process. |
| Dietary Manager #1 | Dietary Manager | Interviewed about food preparation, storage, and hand hygiene policies. |
| Dietary Aide #6 | Dietary Aide | Interviewed about meal substitutions. |
| Certified Nursing Assistant #12 | Certified Nursing Assistant | Observed entering isolation room without gown and interviewed about isolation awareness. |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Interviewed about isolation signage requirements. |
| Registered Nurse #13 | Registered Nurse | Interviewed about resident isolation status. |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to assess compliance with nutritional standards and ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of residents.
Findings
The facility failed to ensure meals were prepared and served according to the planned menu for 1 of 1 meal observed, including incorrect portion sizes, missing gravy for pureed diets, and substitution of yellow cake for chocolate cake. Facility policies require menus to be followed and reviewed by dietitians, but these were not consistently adhered to.
Deficiencies (2)
Meals were not prepared and served according to the planned written menu, including incorrect sausage portions and missing gravy for pureed diets.
Residents on pureed diets were served yellow cake instead of the planned pureed chocolate cake.
Report Facts
Residents served incorrect sausage portions: 41
Residents served large portion diets: 10
Residents served incorrect sausage portions: 41
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 22, 2024
Visit Reason
The inspection was conducted to investigate complaints related to elopement risks and supervision failures at The Springs of Avalon nursing home.
Complaint Details
The complaint investigation found that Resident #1 was able to leave the secure unit and was found approximately one mile from the facility. The resident was unaccounted for 30 to 45 minutes. The facility conducted a root cause analysis and implemented interventions after the incident.
Findings
The facility failed to initiate a care plan for a resident at high risk of elopement and failed to provide adequate supervision to prevent elopement for another resident, who was found approximately one mile from the facility after leaving the secure unit.
Deficiencies (2)
Failed to initiate a care plan for elopement risk for Resident #3.
Failed to ensure adequate supervision to prevent elopement for Resident #1.
Report Facts
Elopement risk score: 8
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 8
Unaccounted time: 30
Unaccounted time: 45
Distance from facility: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Confirmed picking up Resident #1 approximately 1 mile from the facility and contacting the Administrator. |
| Director of Nursing | Director of Nursing | Confirmed criteria for placement on secure unit and details about Resident #1's elopement. |
| Administrator | Administrator | Confirmed Resident #1 was found 1 mile from the facility, conducted root cause analysis, and verified unaccounted time. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 22, 2024
Visit Reason
The inspection was conducted to investigate complaints related to elopement risks and supervision failures at The Springs of Avalon nursing home.
Complaint Details
The complaint investigation found substantiated issues regarding elopement risk and supervision failures. Resident #1 was unaccounted for approximately 30 to 45 minutes and was found about one mile from the facility. Resident #3 was identified as high risk for elopement but did not have an appropriate care plan.
Findings
The facility failed to initiate a care plan for a resident at high risk of elopement and failed to provide adequate supervision to prevent elopement for another resident, who was found approximately one mile from the facility after leaving the secure unit.
Deficiencies (2)
Failed to initiate a care plan for elopement risk for Resident #3.
Failed to ensure adequate supervision to prevent elopement for Resident #1.
Report Facts
Elopement risk score: 8
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 8
Unaccounted time: 30
Unaccounted time: 45
Distance from facility: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Confirmed picking up Resident #1 approximately 1 mile from the facility and contacting the Administrator |
| Director of Nursing | Director of Nursing | Confirmed criteria for secure unit placement and Resident #1's elopement incident |
| Administrator | Administrator | Confirmed Resident #1 was found 1 mile from the facility, conducted root cause analysis, and verified unaccounted time |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 2, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident rights, safety, care, environment, and food service at The Springs of Avalon nursing home.
Findings
The facility was found deficient in multiple areas including failure to post required contact information in the secure unit, missing advance directives for some residents, unsafe and unsecured environmental hazards such as loose sinks, broken window coverings, unsecured hygiene products, exposed electrical wiring, unsecured toilets, unsecured handrails, and unsafe food storage and sanitation practices. Several residents did not receive adequate personal care such as shaving and nail care, and some residents lacked access to fresh fluids. The facility policies and maintenance programs were either lacking or not fully implemented.
Deficiencies (7)
Failed to post contact information for State agencies and advocacy groups in the secure unit accessible to residents.
Failed to ensure advance directives were in the electronic record and readily available for sampled residents.
Failed to maintain building in good repair including loose bathroom sinks, damaged window coverings, detached molding, missing ceiling tiles with exposed fiberglass insulation.
Failed to provide adequate personal care including shaving and nail care for residents dependent on staff.
Failed to ensure resident environment was free from accident hazards including missing call light pull cords, exposed electrical wiring, unsecured hygiene products, unsecured toilets, broken windows covered with plywood blocking exits, unsecured janitor closet door, and unsecured handrails in the secure unit hallway.
Failed to provide enough fresh fluids to maintain residents' health; water pitchers were dirty and contained brown particles, some residents had no fluids available.
Failed to procure, store, prepare, and serve food in accordance with professional standards including uncovered, unsealed, undated food items, expired food not removed, dirty kitchen environment, uncontained ice scoop with thick dark matter, and improper hand hygiene by dietary staff.
Report Facts
Residents affected: 20
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 13
Residents affected: 4
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aid #3 | Certified Nurse Assistant | Named in relation to nail care deficiencies for Resident #31. |
| Certified Nurse Aid #4 | Certified Nurse Assistant | Named in relation to nail care deficiencies for Resident #47. |
| Certified Nurse Aid #5 | Certified Nurse Assistant | Named in relation to nail care deficiencies for Resident #31. |
| Director of Nursing | Director of Nursing | Confirmed requirements for posting contact information and provided Resident Hydration and Prevention of Dehydration policy. |
| Administrator | Administrator | Confirmed multiple environmental hazards and policy deficiencies. |
| Maintenance Supervisor | Maintenance Supervisor | Confirmed environmental hazards including unsecured handrails and exposed wiring. |
| Dietary Employee #1 | Dietary Employee | Observed contaminating hands during dishwashing and improper handling of clean dishes. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Described ice scoop storage and condition. |
Inspection Report
Routine
Deficiencies: 8
Date: Feb 2, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, safety, care, environment, and food service standards.
Findings
The facility was found deficient in multiple areas including failure to post required contact information in the secure unit, missing advance directives for residents, unsafe and unsecured environmental conditions such as loose sinks, broken windows, unsecured hygiene products, exposed wiring, unsecured toilets, unsecured handrails, and unsafe food storage and handling practices. Several residents lacked adequate personal care such as shaving and nail care, and some residents did not have access to fresh water. The facility also failed to maintain a sanitary kitchen environment.
Deficiencies (8)
Failed to post contact information for State agencies and advocacy groups in the secure unit accessible to residents.
Failed to ensure advance directives were in the electronic record and readily available for sampled residents.
Failed to maintain building in good repair including loose bathroom sinks, damaged window coverings, detached molding, missing ceiling tiles with exposed fiberglass insulation.
Failed to provide adequate personal care including shaving and nail care for residents dependent on staff.
Failed to ensure resident environment was free from accident hazards including missing call light pull cords, exposed wiring, unsecured hygiene products, unsecured toilets, broken windows covered with plywood blocking exits, unsecured janitor closet door, and unsecured handrails.
Failed to provide fresh water to residents; water pitchers contained brown particles and were not cleaned regularly.
Failed to ensure food safety and sanitation in the kitchen including uncovered, undated, expired food items, dirty kitchen floors and equipment, uncontained ice scoop with thick dark matter, and improper hand hygiene by dietary staff.
Failed to ensure handrails in the secure unit hallway were firmly secured to prevent falls.
Report Facts
Residents affected: 20
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 13
Residents affected: 4
Handrails insecure: 7
Tiles missing: 4
Tiles loose: 3
Expired food items: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aid #3 | Certified Nurse Aid | Interviewed about nail care frequency for Resident #31 |
| Certified Nurse Aid #4 | Certified Nurse Aid | Interviewed about nail care frequency for Resident #47 |
| Certified Nurse Aid #5 | Certified Nurse Aid | Interviewed about shaving and nail care for Resident #31 |
| Director of Nursing | Director of Nursing | Confirmed requirements for posting contact information and provided Resident Hydration policy |
| Administrator | Administrator | Confirmed multiple environmental hazards and policy absence |
| Maintenance Supervisor | Maintenance Supervisor | Confirmed environmental hazards including exposed wiring and insecure handrails |
| Dietary Staff #1 | Dietary Employee | Observed handling dishes with contaminated hands |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about ice scoop storage and use |
Inspection Report
Deficiencies: 1
Date: Feb 2, 2024
Visit Reason
The inspection was conducted to review the facility's compliance with care standards following an unwitnessed fall involving Resident #264 and to assess whether appropriate neurological assessments were performed post-fall.
Findings
The facility failed to perform neurological assessments after unwitnessed falls for Resident #264 on 9/9/2023 and 12/3/2023, as confirmed by the Director of Nursing and based on record reviews and interviews.
Deficiencies (1)
Failure to perform a neurological assessment after an unwitnessed fall for Resident #264.
Report Facts
Residents reviewed for falls: 6
Assessment Reference Date: Dec 28, 2023
Brief Interview of Mental Status (BIMS) score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed inability to locate neurological assessments for Resident #264 | |
| Certified Nursing Assistant (CNA) | Reported hearing fall and finding Resident #264 on the floor |
Inspection Report
Deficiencies: 1
Date: Feb 2, 2024
Visit Reason
The inspection was conducted to review the facility's compliance with care standards following reports of unwitnessed falls among residents, specifically to assess neurological assessments performed after such incidents.
Findings
The facility failed to perform neurological assessments after unwitnessed falls for one resident (Resident #264) out of six reviewed. The Director of Nursing confirmed the absence of neurological assessments for falls occurring on 9/9/2023 and 12/3/2023.
Deficiencies (1)
Failure to perform neurological assessment after an unwitnessed fall for Resident #264.
Report Facts
Residents reviewed for falls: 6
Residents with unwitnessed falls: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed absence of neurological assessments for Resident #264 | |
| Certified Nursing Assistant (CNA) | Reported hearing fall and finding Resident #264 on the floor |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 28, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care standards including personal hygiene, wound care, nutrition, food safety, and meal service quality.
Findings
The facility failed to ensure residents received adequate personal hygiene care including nail care, bathing, and shaving; failed to properly label wound dressings; did not consistently provide nutritional supplements or proper meal setups; served meals at unacceptable temperatures; failed to prepare pureed foods to a smooth consistency; and had food safety issues including improper food storage and unclean ice machine.
Deficiencies (7)
Failed to ensure residents' fingernails were cleaned and personal hygiene was maintained including showers and shaving.
Failed to ensure dressing for a non-pressure-related skin condition was properly labeled with date and initials.
Failed to maintain acceptable nutritional status and provide ordered nutritional supplements to residents with weight loss.
Failed to ensure meals were prepared and served according to the planned menu and nutritional needs.
Failed to serve meals at acceptable temperatures to improve palatability and encourage nutritional intake.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to ensure food items were properly stored, dietary staff washed hands before handling food, hot foods maintained at safe temperatures, and ice machine was clean.
Report Facts
Weight loss: 6.6
Weight loss: 8.52
Weight loss: 16.75
Temperature: 95.4
Temperature: 97
Temperature: 103
Temperature: 104
Temperature: 106
Temperature: 109
Temperature: 110
Temperature: 111.5
Temperature: 113.6
Temperature: 117
Temperature: 120
Temperature: 40
Weight: 0.75
Residents affected: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in nail care and personal hygiene findings. |
| RN #1 | Registered Nurse | Named in shower and shaving responsibility findings. |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including nail care, showering, shaving, wound care, nutrition, and food safety. |
| Treatment Nurse | Treatment Nurse | Named in wound care dressing labeling findings. |
| Dietary Manager | Dietary Manager | Named in nutrition and meal service findings. |
| Dietary Employee #2 | Dietary Employee | Named in meal preparation and food substitution findings. |
| Dietary Employee #3 | Dietary Employee | Named in pureed food consistency findings. |
| Dietary Employee #5 | Dietary Employee | Named in nutritional supplement findings. |
| CNA #3 | Certified Nursing Assistant | Named in showering and bathing findings. |
| CNA #4 | Certified Nursing Assistant | Named in nail care findings. |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations related to personal hygiene, wound care, nutrition, food safety, and meal service in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' personal hygiene (nail care, bathing, shaving), improper labeling of wound dressings, inadequate nutritional care and meal service (missing supplements, improper meal set-up, weight loss), serving meals at unsafe temperatures, poor food preparation consistency for pureed diets, and food safety violations such as uncovered food items and unclean ice machine.
Deficiencies (7)
Failure to ensure residents' fingernails were cleaned and residents received showers and/or baths and were shaved regularly to maintain good personal hygiene.
Failure to ensure a dressing for a non-pressure-related skin condition was properly labeled with date and initials.
Failure to maintain acceptable nutritional status and provide ordered nutritional interventions to minimize weight loss.
Failure to prepare and serve meals in accordance with the planned, written menu to meet nutritional needs.
Failure to serve meals at acceptable temperatures to improve palatability and encourage nutritional intake.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency to minimize choking risk.
Failure to ensure food items stored in refrigerator/freezer were covered and sealed; dietary staff washed hands before handling food; hot foods maintained at or above 135°F; and ice machine was clean to prevent contamination.
Report Facts
Weight loss: 6.6
Weight loss: 16.75
Temperature: 95.4
Temperature: 97
Temperature: 103
Temperature: 106
Temperature: 110
Temperature: 113.6
Temperature: 117
Temperature: 104
Temperature: 40
Number of residents affected: 69
Number of residents affected: 53
Number of residents affected: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in nail care deficiency and interview about nail care responsibilities |
| RN #1 | Registered Nurse | Interviewed about showering and shaving responsibilities |
| DON | Director of Nursing | Interviewed about nail care, showering, shaving, wound care, and dietary processes |
| Treatment Nurse | Interviewed about wound care and dressing labeling | |
| CNA #3 | Certified Nursing Assistant | Interviewed about shower schedule and responsibilities |
| CNA #4 | Certified Nursing Assistant | Interviewed about nail care schedule and responsibilities |
| LPN #1 | Licensed Practical Nurse | Interviewed about meal set-up and dietary procedures |
| Dietary Employee #2 | Observed and interviewed about meal preparation and substitutions | |
| Dietary Employee #3 | Interviewed about pureed food consistency | |
| Dietary Manager | Interviewed about dietary tray cards and meal orders |
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