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
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 1
Date: May 8, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and nutritional standards, specifically to ensure that hot foods were served hot and cold foods/beverages were served cold to maintain palatability and encourage adequate nutritional intake.
Findings
The facility failed to maintain proper food temperatures during meal service, with multiple observations showing hot foods served below the required temperature and cold foods not kept sufficiently cold. Several residents reported that their food was often cold, and staff interviews confirmed improper handling of food carts leading to temperature drops.
Deficiencies (1)
Failure to ensure hot foods were served hot and cold foods/beverages were served cold to maintain palatability and encourage adequate nutritional intake.
Report Facts
Food tray count: 16
Food tray count: 14
Food tray count: 14
Food tray count: 13
Food temperature: 59
Food temperature: 113
Food temperature: 105.2
Food temperature: 98
Food temperature: 103.8
Food temperature: 44
Food temperature: 114
Food temperature: 111
Food temperature: 107
Food temperature: 55.9
Food temperature: 94.8
Food temperature: 102.8
Food temperature: 107.7
Food temperature: 45
Food temperature: 113
Food temperature: 43.7
Food temperature: 104.7
Food temperature: 113.6
Food temperature: 100.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Placed first lunch meal tray on shelf inside food cart |
| CNA #2 | Certified Nursing Assistant | Delivered lunch trays and checked food temperatures |
| CNA #3 | Certified Nursing Assistant | Delivered lunch trays and checked food temperatures |
| District Dietary Manager | District Dietary Manager | Stated hall-trays food temperatures should be 120 degrees Fahrenheit and explained impact of food cart handling |
| LPN #7 | Licensed Practical Nurse | Loaded breakfast trays into unheated food cart with door open |
| CNA #4 | Certified Nursing Assistant | Delivered food cart and checked food temperatures |
| CNA #5 | Certified Nursing Assistant | Delivered breakfast trays and checked food temperatures |
| CNA #8 | Certified Nursing Assistant | Checked food temperatures after meal delivery |
| Dietary Manager | Dietary Manager | Informed LPN #7 about proper food cart door handling to maintain temperature |
Inspection Report
Routine
Deficiencies: 4
Date: May 8, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident financial management, comprehensive assessments, food service safety and quality, and food storage and sanitation practices at The Springs of Camden nursing home.
Findings
The facility was found deficient in honoring residents' financial rights by failing to pay interest on a resident trust account and improperly handling resident funds. The comprehensive assessments for one resident did not accurately reflect PASRR status. Food temperatures during meal service were often below safe levels, and food storage and handling practices were inadequate, including uncovered foods, expired items, poor hand hygiene, and an unclean ice machine.
Deficiencies (4)
Failed to ensure interest was paid on a resident trust account and mishandled resident funds by withdrawing money and not depositing it in an interest-bearing account.
Failed to ensure comprehensive assessments accurately reflected PASRR status for a resident.
Failed to ensure hot foods were served hot and cold foods/beverages were served cold to maintain palatability and encourage adequate nutritional intake.
Failed to ensure foods stored in dry storage were covered and sealed; expired food items were promptly removed; dietary staff washed hands properly; and ice machine was maintained clean.
Report Facts
Resident trust account balance: 2025.36
Resident trust account balance: 1141.17
Withdrawal amount: 1025
BIMS score: 15
Food temperature: 59
Food temperature: 44
Food temperature: 55.9
Food temperature: 43.7
Expired food item date: 2023
Expired food item date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding resident trust account and fund withdrawal |
| Administrator | Administrator | Interviewed regarding resident trust account funds and safe access |
| MDS Coordinator | MDS Coordinator | Interviewed regarding inaccurate comprehensive assessments |
| Director of Nursing | Director of Nursing | Interviewed regarding inaccurate comprehensive assessments |
| District Dietary Manager | District Dietary Manager | Interviewed regarding food temperature standards and observations |
| Dietary [NAME] | Dietary Cook | Observed washing hands improperly and handling food |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding ice machine cleaning and condition |
| LPN #7 | Licensed Practical Nurse | Interviewed regarding food cart door practices |
| CNA #2 | Certified Nursing Assistant | Observed checking food temperatures |
| CNA #3 | Certified Nursing Assistant | Observed checking food temperatures |
| CNA #4 | Certified Nursing Assistant | Observed checking food temperatures and commenting on reheating |
| CNA #5 | Certified Nursing Assistant | Observed checking food temperatures and commenting on reheating |
| DC #6 | Dietary Cook | Observed washing hands improperly and handling food |
Inspection Report
Routine
Deficiencies: 1
Date: May 8, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and nutritional standards, specifically to ensure that hot foods were served hot and cold foods/beverages were served cold to maintain palatability and encourage adequate nutritional intake.
Findings
The facility failed to maintain proper food temperatures during meal services on multiple occasions, with hot foods served below the recommended temperature and cold foods not kept sufficiently cold. Observations and interviews confirmed that food trays were placed in unheated carts with doors left open, resulting in temperature drops. Residents reported receiving cold food sometimes, and staff acknowledged lack of knowledge about keeping food cart doors closed.
Deficiencies (1)
Failure to ensure hot foods were served hot and cold foods/beverages were served cold to maintain palatability and encourage adequate nutritional intake.
Report Facts
Food temperature: 59
Food temperature: 113
Food temperature: 105.2
Food temperature: 98
Food temperature: 103.8
Food temperature: 44
Food temperature: 114
Food temperature: 111
Food temperature: 107
Food temperature: 45
Food temperature: 43.7
Food temperature: 94.8
Food temperature: 102.8
Food temperature: 102.2
Food temperature: 100.4
Food temperature: 113.6
Food temperature: 113
Food temperature: 107.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | License Practical Nurse | Placed first lunch meal tray on shelf inside food cart |
| CNA #2 | Certified Nursing Assistant | Delivered lunch trays and checked food temperatures |
| CNA #3 | Certified Nursing Assistant | Delivered lunch trays and checked food temperatures |
| District Dietary Manager | District Dietary Manager (DDM) | Stated hall-trays food temperatures should be 120 degrees Fahrenheit and plates should be warm |
| LPN #7 | License Practical Nurse | Placed breakfast meal trays on shelf in unheated food cart with door open |
| CNA #4 | Certified Nursing Assistant | Delivered food cart and checked food temperatures, stated food should have been reheated |
| CNA #5 | Certified Nursing Assistant | Delivered breakfast meals and checked food temperatures, stated food should have been reheated |
| CNA #8 | Certified Nursing Assistant | Checked food temperatures after meal delivery |
| Dietary Manager | Dietary Manager (DM) | Informed LPN #7 that food cart door should remain closed to retain temperature |
Inspection Report
Deficiencies: 4
Date: May 8, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident financial management, comprehensive assessments, food service safety and quality, and food procurement and storage practices at The Springs of Camden nursing home.
Findings
The facility was found deficient in multiple areas including failure to pay interest on a resident trust account, inaccurate comprehensive assessments for PASRR status, serving food at improper temperatures, and inadequate food storage and hygiene practices in the dietary department.
Deficiencies (4)
Failed to ensure that interest was paid on a resident trust account for Resident #3.
Failed to ensure the comprehensive assessment accurately reflected the PASRR status for Resident #4.
Failed to ensure hot foods were served hot and cold foods/beverages were served cold to maintain palatability and encourage adequate nutritional intake.
Failed to ensure foods stored in the dry storage area were covered and sealed; expired food items were promptly removed; dietary staff washed hands appropriately; and the ice machine was maintained in a clean sanitary condition.
Report Facts
Resident trust account balance: 2025.36
Resident trust account balance: 1141.17
Withdrawal amount: 1025
BIMS score: 15
Food temperature: 59
Food temperature: 113
Food temperature: 105.2
Food temperature: 98
Food temperature: 103.8
Food temperature: 44
Food temperature: 114
Food temperature: 111
Food temperature: 55.9
Food temperature: 94.8
Food temperature: 102.8
Food temperature: 107.7
Food temperature: 45
Food temperature: 113
Food temperature: 43.7
Food expiration date: Apr 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding Resident #3 trust account and withdrawal |
| Administrator | Administrator | Interviewed regarding Resident #3 trust account and knowledge of money in safe |
| MDS Coordinator | MDS Coordinator | Interviewed regarding inaccurate comprehensive assessments for Resident #4 |
| Director of Nursing | Director of Nursing | Interviewed regarding inaccurate comprehensive assessments for Resident #4 |
| License Practical Nurse #1 | LPN | Observed placing meal trays on food cart |
| Certified Nursing Assistant #2 | CNA | Observed checking food temperatures on 05/05/2025 |
| Certified Nursing Assistant #3 | CNA | Observed checking food temperatures on 05/05/2025 and 05/06/2025 |
| District Dietary Manager | District Dietary Manager | Interviewed regarding food temperature standards |
| License Practical Nurse #7 | LPN | Interviewed regarding food cart door policy |
| Certified Nursing Assistant #4 | CNA | Observed checking food temperatures on 05/06/2025 |
| Certified Nursing Assistant #5 | CNA | Observed checking food temperatures on 05/06/2025 |
| Dietary [NAME] #6 | Dietary Cook | Observed food handling and handwashing practices |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding ice machine cleaning |
| Dietary Manager | Dietary Manager | Interviewed and observed cleaning ice machine and food storage practices |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 15, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with proper care standards, specifically focusing on incontinence care for residents dependent on staff.
Findings
The facility failed to ensure proper incontinence care was provided to one sampled resident, which had the potential to affect nine residents dependent on staff for incontinence care, potentially causing skin breakdown, poor hygiene, and infection.
Deficiencies (1)
Failure to provide proper incontinence care to Resident #64, including not repeating care after a wet incontinence pad was observed.
Report Facts
Residents sampled: 4
Residents potentially affected: 9
Inspection Report
Routine
Deficiencies: 9
Date: Mar 15, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal and state regulations related to resident care, medication management, infection control, food safety, and facility operations at The Springs of Camden nursing home.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meal service, improper medication storage and handling, inadequate privacy protections, incomplete care planning meetings, unsafe mechanical lift equipment, improper incontinence care, failure to maintain safe food temperatures, lack of refrigerator/freezer temperature monitoring, and inadequate infection prevention practices including improper use of PPE and incomplete Legionella water management.
Deficiencies (9)
Failed to ensure residents were treated with respect and dignity during meal service for 4 of 5 sampled residents requiring assistance.
Failed to protect privacy by leaving medication cards face up and unattended on medication cart affecting 1 resident with potential to affect 74 residents.
Failed to conduct care plan meetings and notify family representatives for 1 resident.
Mechanical lift machine missing a clip, risking injury to 1 resident and potentially affecting 17 residents.
Failed to provide proper incontinence care to 1 resident dependent on staff, risking skin breakdown and infection.
Medications were stored at bedside and on medication carts unattended, risking misappropriation affecting 4 sampled residents and potentially 15 others.
Meals served at unsafe and unappetizing temperatures to 1 resident.
Failed to monitor refrigerator and freezer temperatures and allowed use of dented cans, risking foodborne illness affecting 70 residents.
Failed to ensure proper infection prevention and control including PPE use in COVID isolation rooms, food/beverage contamination risk in laundry room, and incomplete Legionella water management program affecting all residents.
Report Facts
Residents affected by privacy deficiency: 74
Residents affected by mechanical lift deficiency: 17
Residents affected by medication storage deficiency: 15
Residents affected by food safety deficiency: 70
Sampled residents with dignity deficiency: 4
Sampled residents with medication storage deficiency: 4
Sampled residents with incontinence care deficiency: 1
Sampled residents with care plan meeting deficiency: 1
Sampled residents with dignity deficiency sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication storage and privacy deficiency findings. |
| LPN #1 | Licensed Practical Nurse | Named in medication storage deficiency and meal service observations. |
| LPN #2 | Licensed Practical Nurse | Named in meal service dignity deficiency observations. |
| CNA #1 | Certified Nursing Assistant | Named in meal service dignity and incontinence care deficiencies. |
| CNA #2 | Certified Nursing Assistant | Named in meal service dignity and incontinence care deficiencies. |
| CNA #3 | Certified Nursing Assistant | Named in mechanical lift deficiency observation. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including privacy, mechanical lift, medication storage, infection control, and care planning. |
| Social Worker | Social Worker | Interviewed regarding care plan meeting notifications. |
| Housekeeping #1 | Housekeeping Staff | Named in infection control PPE deficiency. |
| Housekeeping #2 | Housekeeping Staff | Named in infection control and contamination risk in laundry room. |
| Administrator | Administrator | Interviewed regarding medication self-administration, Legionella program, and infection control. |
| Dietary #1 | Dietary Staff | Interviewed regarding food temperature and food safety. |
| Dietary #2 | Dietary Staff | Interviewed regarding food temperature, food safety, and refrigerator/freezer monitoring. |
| RN #1 | Registered Nurse | Named in infection control PPE deficiency observations. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 15, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with care standards, specifically focusing on appropriate care for residents who are continent or incontinent of bowel/bladder, catheter care, and prevention of urinary tract infections.
Findings
The facility failed to ensure proper incontinence care was provided to one resident (Resident #64) dependent on staff for incontinence care, which had the potential to affect nine residents and cause skin breakdown, poor hygiene, and/or infection. Observations and interviews revealed staff did not repeat incontinence care when a wet pad was noted before applying a clean brief.
Deficiencies (1)
Failure to ensure proper incontinence care was provided to Resident #64, including not repeating care after a wet incontinence pad was observed.
Report Facts
Residents affected: 9
Sampled residents: 4
Resident #64 incontinent status: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | CNA #1 and CNA #2 observed providing incontinence care to Resident #64 | |
| Director of Nursing | DON interviewed regarding proper incontinence care procedures |
Inspection Report
Annual Inspection
Capacity: 74
Deficiencies: 9
Date: Mar 11, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations regarding resident rights, privacy, care planning, safety, medication management, food safety, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meal service, protect resident privacy, conduct care plan meetings with family involvement, maintain mechanical lift equipment safely, provide proper incontinence care, secure medications properly, serve food at safe temperatures, monitor food storage temperatures, and implement infection prevention protocols including proper PPE use and Legionella water management.
Deficiencies (9)
Failed to ensure residents were treated with respect and dignity during meal service for 4 of 5 sampled residents requiring assistance.
Failed to protect the privacy of 1 resident by leaving medication cards face up and unattended on medication cart.
Failed to conduct care plan meetings and notify family representatives for 1 resident.
Failed to maintain mechanical lift in safe, operational condition for 1 resident with potential to affect 17 residents.
Failed to provide proper incontinence care for 1 resident dependent on staff.
Failed to ensure medications were not stored at bedside or on top of medication carts, risking misappropriation.
Failed to serve meals at palatable, attractive, and safe appetizing temperatures to 1 resident.
Failed to monitor refrigerator and freezer temperatures and allowed use of dented cans, risking foodborne illness for many residents.
Failed to ensure droplet precautions and appropriate PPE use in COVID isolation rooms and failed to prevent cross contamination in laundry room; also failed to follow Legionella Water Management Program.
Report Facts
Residents affected: 74
Residents affected: 17
Residents affected: 9
Residents affected: 15
Residents affected: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication storage deficiency and interview about medication policies |
| LPN #1 | Licensed Practical Nurse | Observed assisting residents and interviewed about medication storage |
| LPN #2 | Licensed Practical Nurse | Observed assisting residents during meal service and interviewed about positioning |
| CNA #1 | Certified Nursing Assistant | Observed assisting residents during meal service and interviewed about positioning |
| CNA #2 | Certified Nursing Assistant | Observed assisting residents during meal service and interviewed about positioning |
| CNA #3 | Certified Nursing Assistant | Interviewed about mechanical lift use |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy, medication policies, mechanical lift, infection control, and care planning |
| Social Worker | Social Worker | Interviewed about care plan meetings and family notification |
| Housekeeping #1 | Housekeeping Staff | Observed and interviewed about PPE use in COVID isolation room |
| Housekeeping #2 | Housekeeping Staff | Interviewed about sanitation practices in laundry room |
| Administrator | Facility Administrator | Interviewed about Legionella prevention and medication self-administration policy |
| Dietary #1 | Dietary Staff | Interviewed about food temperatures |
| Dietary #2 | Dietary Staff | Interviewed about food temperatures, dented cans, and refrigerator/freezer monitoring |
| Dietary Employee #3 | Dietary Staff | Interviewed about pantry practices and dented cans |
| RN #1 | Registered Nurse | Observed and interviewed about PPE and medication storage |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Jan 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged injury caused by an improper transfer performed by a staff member on Resident #40, as well as other quality of care concerns including inaccurate assessments, inadequate care planning, insufficient activities of daily living assistance, catheter care deficiencies, oxygen therapy issues, food safety concerns, quality assurance process failures, and staff COVID-19 vaccination compliance.
Complaint Details
The complaint investigation was triggered by an alleged injury to Resident #40 caused by an improper transfer by a Certified Nursing Assistant (CNA #7) on 1/5/23, which resulted in a skin tear. The facility failed to timely investigate the injury and other possible injuries. The investigation included interviews, record reviews, and observations. Additional complaints involved inaccurate MDS assessments, inadequate care planning, insufficient ADL care, catheter care deficiencies, oxygen therapy issues, food safety concerns, ineffective QAA activities, and staff COVID-19 vaccination noncompliance.
Findings
The facility failed to investigate an injury in a timely manner, ensure accurate Minimum Data Set (MDS) assessments, provide adequate pain management care plans, deliver proper activities of daily living assistance, maintain catheter care and documentation, set oxygen flow rates per physician orders, maintain sanitary food preparation and equipment, conduct effective Quality Assessment and Assurance (QAA) activities, and ensure all staff were fully vaccinated against COVID-19. Additionally, the kitchen freezer was not properly maintained, risking food contamination.
Deficiencies (10)
Failed to investigate an injury in a timely manner and investigate for other possible injuries to Resident #40 due to improper transfer by staff.
Failed to ensure Minimum Data Sets (MDS) were accurately encoded for oxygen and anticoagulants for selected residents.
Failed to include pain management and pain medication side effect care areas and interventions in the Individualized Care Plan for Resident #40.
Failed to provide adequate Activities of Daily Living (ADL) care including hygiene, shaving, and cleaning contractured hands for Resident #41.
Failed to ensure catheter bags were maintained to minimize contamination risk and failed to complete and document catheter care and output per physician orders for Resident #40 and Resident #50.
Failed to ensure oxygen was set at the physician ordered flow rate for Resident #41.
Failed to ensure food was prepared under sanitary conditions; food and equipment were stored improperly; and resident trays were chipped and cracked, risking foodborne illness.
Failed to ensure the Quality Assessment and Assurance (QAA) Committee effectively corrected, monitored, and reassessed quality deficiencies related to respiratory care and ADL care.
Failed to ensure all staff were fully vaccinated against COVID-19 or had approved exemptions or delays as required by CMS regulations.
Failed to maintain kitchen freezer properly, resulting in water streaming from condenser, ice buildup, and potential food cross contamination.
Report Facts
Skin tear measurement: 3.3
Skin tear measurement: 0.8
Number of residents affected by food safety issues: 64
Number of trays in kitchen: 46
Number of trays damaged: 6
Hours worked by CNA #1: 2745.45
Hours worked by CNA #2: 1280.56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Assistant | Named in improper transfer causing injury to Resident #40 |
| LPN #5 | Licensed Practical Nurse | Mentioned in relation to reporting and investigation of Resident #40's injury |
| LPN #1 | Licensed Practical Nurse | Measured skin tear and involved in investigation of Resident #40 |
| CNA #6 | Certified Nursing Assistant | Interviewed about pain recognition for Resident #40 |
| ADON/ICP | Assistant Director of Nursing/Infection Control Professional | Conducted retraining, provided policies, and involved in multiple findings |
| Consultant #2 | Consultant | Provided policies and statements regarding skin tear, catheter care, oxygen therapy |
| Administrator | Facility Administrator | Provided documentation, interviewed about QAA and freezer issues |
| Dietary Manager | Dietary Manager | Interviewed about kitchen conditions and tray availability |
| CNA #1 | Certified Nursing Assistant | Mentioned in COVID-19 vaccination noncompliance |
| CNA #2 | Certified Nursing Assistant | Mentioned in COVID-19 vaccination noncompliance |
| HR Employee | Human Resources Employee | Mentioned in COVID-19 vaccination exemption and compliance |
| LPN #4 | Licensed Practical Nurse | Involved in oxygen flow rate adjustment for Resident #41 |
| LPN #3 | Licensed Practical Nurse | Interviewed about catheter care procedures |
| Consultant #1 | Consultant | Interviewed about vaccination compliance and ADL care |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jan 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including investigation of an injury incident, accuracy of resident assessments, care planning, activities of daily living assistance, catheter care, respiratory care, food safety, quality assurance processes, and staff COVID-19 vaccination status.
Findings
The facility was found deficient in timely investigation of an injury due to improper transfer, inaccurate resident assessments, incomplete care plans for pain management, inadequate assistance with activities of daily living, improper catheter care and documentation, failure to maintain oxygen flow rates per physician orders, unsanitary food preparation and storage conditions, ineffective quality assurance monitoring, incomplete staff COVID-19 vaccination compliance, and malfunctioning kitchen freezer equipment.
Deficiencies (10)
Failed to investigate an injury in a timely manner and investigate for other possible injuries to Resident #40 after an improper transfer by staff.
Failed to ensure Minimum Data Sets (MDS) were accurately encoded for oxygen and anticoagulants for selected residents.
Failed to include pain management and pain medication side effect care areas and interventions in the Individualized Care Plan for Resident #40.
Failed to provide adequate Activities of Daily Living (ADL) care including hygiene and shaving for Resident #41.
Failed to ensure catheter bags were maintained properly and catheter care and output were documented per physician orders for residents with catheters.
Failed to ensure oxygen was set at the physician ordered flow rate for Resident #41.
Failed to ensure food was prepared under sanitary conditions; food and equipment were stored in a manner that did not promote foodborne illness; and resident trays were free of chips and cracks.
Failed to ensure the Quality Assessment and Assurance (QAA) Committee effectively monitored and reassessed quality deficiencies related to respiratory care and ADL care.
Failed to ensure all staff were fully vaccinated for COVID-19 or had approved exemptions or temporary delays as required by CMS regulations.
Failed to ensure kitchen freezer operated safely and minimized possibility of food cross contamination due to ongoing maintenance issues.
Report Facts
Skin tear measurement: 3.3
Skin tear measurement: 0.8
Number of residents affected by food safety deficiency: 64
Number of trays in kitchen: 46
Number of trays damaged: 6
Hours worked by CNA #1: 2745.45
Hours worked by CNA #2: 1280.56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in investigation of skin tear and injury to Resident #40 |
| CNA #7 | Certified Nursing Assistant | Named in injury incident involving improper transfer of Resident #40 |
| ADON/ICP | Assistant Director of Nursing/Infection Control Professional | Provided retraining, infection control education, and policy information |
| Administrator | Facility Administrator | Responded to surveyor inquiries and provided documentation |
| Consultant #1 | Provided policy information and payroll documentation | |
| Consultant #2 | Provided policy information and assisted with surveyor questions | |
| Dietary Manager | Provided information on kitchen conditions and tray availability | |
| LPN #4 | Licensed Practical Nurse | Identified oxygen flow rate discrepancy for Resident #41 |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding ADL care for Resident #41 |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding catheter bag placement and care |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding catheter care procedures |
| HR Employee | Human Resources Employee | Involved in COVID-19 vaccination exemption documentation |
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