Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 11, 2025
Visit Reason
The inspection was conducted in response to a complaint against the facility regarding quality of care and treatment related to infection prevention and control practices.
Complaint Details
The complaint investigation found that staff did not wear gowns as required by Enhanced Barrier Precautions policy while providing care to Resident #7, who required enteral tube feeding and was cognitively impaired. Interviews with CNA #1, LPN #3, and the Director of Nursing confirmed non-compliance with PPE protocols.
Findings
The facility failed to ensure staff donned proper Personal Protective Equipment (PPE) while providing care to Resident #7 on Enhanced Barrier Precautions. Multiple observations and interviews confirmed staff did not wear gowns during high-contact care activities, contrary to facility policy.
Deficiencies (1)
Failure to ensure staff donned proper Personal Protective Equipment (PPE) while providing care to Resident #7 on Enhanced Barrier Precautions.
Report Facts
Resident BIMS score: 0
Assessment Reference Date: Jan 15, 2025
Plan of Care revision date: Oct 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed not wearing gown while providing care to Resident #7 and interviewed about PPE use. |
| CNA #1 | Certified Nursing Assistant | Observed not wearing gown during care and transfers of Resident #7 and interviewed about PPE knowledge. |
| CNA #2 | Certified Nursing Assistant | Observed not wearing gown during transfers of Resident #7. |
| Director of Nursing | Director of Nursing | Interviewed regarding PPE policy and staff compliance for residents on Enhanced Barrier Precautions. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to quality of care and treatment concerning infection prevention and control practices for Resident #7.
Complaint Details
The complaint was related to quality of care/treatment. The deficiency was substantiated based on observations, record review, interviews, and facility policy review.
Findings
The facility failed to ensure staff donned proper Personal Protective Equipment (PPE) while providing care to Resident #7 on Enhanced Barrier Precautions. Multiple observations and interviews confirmed staff did not wear gowns during high-contact care activities, posing a risk of infection transmission.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program ensuring staff wore proper PPE for Resident #7 on Enhanced Barrier Precautions.
Report Facts
Residents sampled for complaint: 3
Assessment Reference Date: Jan 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed not wearing gown while providing care to Resident #7 and interviewed about PPE use |
| CNA #1 | Certified Nursing Assistant | Observed not wearing gown during care and interviewed about familiarity with Enhanced Barrier Precautions |
| CNA #2 | Certified Nursing Assistant | Observed not wearing gown during care of Resident #7 |
| Director of Nursing | Director of Nursing | Interviewed regarding PPE policy and staff responsibilities for residents on Enhanced Barrier Precautions |
Inspection Report
Deficiencies: 1
Date: Dec 4, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically to determine if a baseline care plan was developed and implemented to meet a resident's immediate needs upon admission.
Findings
The facility failed to ensure a baseline care plan was developed and implemented for Resident #4, who required respiratory/tracheostomy care. The baseline care plan did not address the resident's trach, despite physician orders and nursing staff awareness of the resident's condition and care needs.
Deficiencies (1)
Failure to create and implement a baseline care plan addressing the resident's tracheostomy care within 48 hours of admission.
Report Facts
Residents affected: 1
Assessment reference date: Sep 22, 2024
Timeframe for baseline care plan: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Confirmed familiarity with Resident #4 and the need for baseline care plan addressing trach | |
| Director of Nursing | Confirmed baseline care plan should have addressed presence and care of trach | |
| Treatment Nurse | Confirmed following physician orders for trach site care |
Inspection Report
Deficiencies: 1
Date: Dec 4, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements regarding the development and implementation of baseline care plans for residents, specifically focusing on respiratory/tracheostomy care for Resident #4.
Findings
The facility failed to ensure a baseline care plan was developed and implemented to meet the needs of Resident #4 with a tracheostomy. The baseline care plan did not address the presence of the trach or related care instructions, despite physician orders and staff awareness.
Deficiencies (1)
Failure to create and implement a baseline care plan addressing the resident's tracheostomy and related care needs within 48 hours of admission.
Report Facts
Residents reviewed for Respiratory/Tracheostomy care: 3
Residents affected: 1
Assessment reference date: Sep 22, 2024
Timeframe for baseline care plan development: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Confirmed familiarity with Resident #4 and acknowledged baseline care plan should include trach care | |
| Director of Nursing | Confirmed baseline care plan should address presence and care of trach | |
| Treatment Nurse | Confirmed following physician orders for trach site care |
Inspection Report
Routine
Deficiencies: 4
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, Medicare/Medicaid notifications, nutritional services, food safety, and hand hygiene practices at The Springs of Chenal nursing home.
Findings
The facility was found deficient in documenting residents' advanced directives, providing required Advanced Beneficiary Notices (ABN) for Medicare coverage changes, following prescribed fortified food recipes, maintaining proper food storage and labeling, and enforcing adequate hand hygiene and food handling practices. Multiple minimal harm deficiencies were identified affecting a few to many residents.
Deficiencies (4)
Failed to document residents' decisions regarding advanced directives prominently in clinical records for 1 resident.
Failed to provide Advanced Beneficiary Notice (ABN) to resident and/or representative regarding Medicare coverage and financial liability for 1 resident.
Failed to prepare and serve meals according to planned written recipes for fortified foods for 2 meals observed.
Failed to ensure foods in freezer and storage were covered, sealed, dated, and expired foods removed; poor hand hygiene and food handling practices observed.
Report Facts
Residents affected: 1
Residents affected: 1
Meals observed: 2
Residents affected: 2
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Unable to locate advanced directive information for Resident #154 |
| Social Director | Social Director | Responsible for sending Advanced Beneficiary Notice (ABN); did not send ABN for Resident #3 |
| Dietary [NAME] #1 | Dietary Staff | Prepared fortified cereal incorrectly and demonstrated poor hand hygiene and food handling |
| Food Supervisor #2 | Food Supervisor | Confirmed recipe not followed and observed food safety violations |
| District Dietary Manager | District Dietary Manager | Interviewed regarding meal preparation and hand hygiene policy; provided revised hand washing policy |
| Dietary [NAME] #4 | Dietary Staff | Interviewed about fortified foods and observed handling cake without changing gloves |
| Licensed Practical Nurse (LPN) #5 | Licensed Practical Nurse | Confirmed food items in medication room refrigerator belonged to residents |
| Dietary Aid #3 | Dietary Aid | Observed handling clean plates without washing hands |
Inspection Report
Routine
Deficiencies: 4
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, Medicare/Medicaid notifications, nutritional services, food safety, and infection control practices at the nursing facility.
Findings
The facility was found deficient in documenting residents' advanced directives, providing required Medicare notices, following nutritional menus and recipes, and maintaining food safety and hygiene standards. Multiple minimal harm deficiencies were cited related to these issues.
Deficiencies (4)
Failed to ensure residents' advanced directive decisions were documented prominently in clinical records.
Failed to provide Advanced Beneficiary Notice (ABN) to resident and/or representative regarding Medicare coverage and financial liability.
Failed to ensure meals were prepared and served according to planned written recipes and menus to meet nutritional needs.
Failed to ensure foods in freezer and storage were covered, sealed, dated, and expired foods removed; poor hand hygiene and food handling practices observed.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Unable to locate advanced directive information for Resident #154; discussed importance of obtaining advance directives on admission. |
| Social Director | Social Director (SD) | Responsible for sending Advanced Beneficiary Notice (ABN); did not send ABN to Resident #3 or representative. |
| Dietary [NAME] #1 | Dietary staff | Prepared fortified cereal incorrectly; poor hand hygiene and food handling practices observed. |
| Food Supervisor #2 | Food Supervisor | Confirmed recipe deviations and food safety issues; involved in interviews and policy revisions. |
| District Dietary Manager | District Dietary Manager | Interviewed regarding meal preparation and hand hygiene policy; provided revised hand washing policy. |
| Dietary [NAME] #4 | Dietary staff | Interviewed about fortified foods not provided; observed handling food with gloves improperly. |
| Dietary Aid #3 | Dietary Aid | Observed handling clean plates without washing hands. |
| Licensed Practical Nurse #5 | Licensed Practical Nurse (LPN) | Stated that food items in medication room refrigerator belonged to residents. |
Inspection Report
Routine
Census: 40
Deficiencies: 9
Date: Jul 20, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and hygiene standards, specifically focusing on food procurement, storage, preparation, and serving practices to prevent food borne illness.
Findings
The facility failed to ensure expired food items were removed, dietary staff did not consistently wash hands before handling clean food items, and hot food items on the steam table were not maintained at the required temperature. These deficiencies had the potential to affect 40 residents.
Deficiencies (9)
Expired can of cocoa found on shelf with expiration date 03/20/22.
Dietary Employee #1 contaminated hands by scratching head and handled clean dishes without washing hands.
Dietary Employee #1 handled clean plates after lifting plate warmer lid without washing hands.
Dietary Employee #2 contaminated hands by turning off faucet with bare hands and handled clean blender blade without washing hands.
Dietary Employee #2 handled clean blender blade without washing hands after sanitizing blender bowl.
Dietary Employee #1 handled glasses by rims without washing hands before pouring punch.
Dietary Employee #2 handled clean blender blade without washing hands after sanitizing for grounding meat products.
Milk at 50 degrees Fahrenheit used on dinner rolls for pureeing instead of properly heated milk.
Food items on steam table (pureed broccoli at 127°F and pureed rolls with milk at 89°F) were not reheated before serving.
Report Facts
Temperature: 135
Temperature: 127
Temperature: 89
Temperature: 50
Census: 40
Inspection Report
Routine
Census: 40
Deficiencies: 3
Date: Jul 20, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and hygiene standards, specifically focusing on food procurement, storage, preparation, and service practices in the kitchen.
Findings
The facility failed to ensure expired food items were removed, staff did not consistently wash hands before handling food or clean equipment, and hot food items on the steam table were not maintained at proper temperatures, posing potential foodborne illness risks to residents.
Deficiencies (3)
Expired beverage/food items were not promptly removed from stock.
Dietary staff failed to wash hands and changed gloves before handling food items, risking cross contamination.
Hot food items on the steam table were not maintained at or above 135 degrees Fahrenheit.
Report Facts
Residents affected: 40
Census: 40
Food temperature: 127
Food temperature: 89
Expired food date: Mar 20, 2022
Inspection Report
Annual Inspection
Deficiencies: 9
Date: May 6, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and to evaluate the facility's adherence to care standards, including resident transfer notifications, care planning, medication administration, infection control, respiratory care, nutrition, and food safety.
Findings
The facility was found deficient in multiple areas including failure to provide timely and written notification to resident representatives regarding hospital transfers, incomplete care plans for respiratory treatments and oxygen use, improper medication administration including failure to administer Clonidine as ordered, inadequate incontinent care, improper feeding tube care and labeling, failure to maintain oxygen therapy orders and equipment properly, unsafe medication storage and labeling, failure to prepare and serve meals according to the planned menu, and food safety violations including improper food temperature maintenance and poor hand hygiene among dietary staff.
Deficiencies (9)
Failure to provide timely written notification to resident representatives regarding hospital transfers for multiple residents.
Failure to update and implement care plans for residents receiving updraft nebulizer treatments and oxygen therapy.
Failure to administer Clonidine medication according to physician orders for high blood pressure.
Inadequate incontinent care resulting in residents not being thoroughly cleansed.
Failure to properly label and maintain feeding tube formula bags and improper administration technique risking infection.
Failure to order and administer oxygen therapy at prescribed flow rates and failure to maintain nebulizer masks in a sanitary manner.
Failure to ensure medications and biologicals were properly labeled and stored securely to prevent administration errors.
Failure to prepare and serve meals according to the planned menu, including serving incorrect portion sizes and food preparation methods.
Failure to maintain hot food temperatures at or above 135°F and failure of dietary staff to follow proper hand hygiene and food safety practices.
Report Facts
Residents affected: 3
Residents affected: 10
Residents affected: 6
Residents affected: 9
Residents affected: 40
Temperature: 120
Temperature: 110
Portion size: 2.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Observed improper feeding tube medication administration and failure to label medications |
| Director of Nursing | DON | Interviewed regarding care plan deficiencies, medication administration, oxygen therapy, and notification failures |
| Dietary Employee #2 | Observed improper hand hygiene and food safety practices in kitchen | |
| Dietary Employee #3 | Prepared incorrect food items not matching menu specifications |
Inspection Report
Routine
Deficiencies: 8
Date: May 6, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, feeding tube management, respiratory care, medication storage, and dietary services at The Springs of Chenal nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification to resident representatives for hospital transfers, incomplete care plans for respiratory treatments and oxygen use, improper medication administration including failure to administer Clonidine as ordered, inadequate incontinent care, improper feeding tube care and labeling, failure to maintain oxygen equipment properly, medication storage and labeling issues, and dietary service deficiencies including failure to serve meals as per the planned menu and improper food handling and storage.
Deficiencies (8)
Failure to provide timely written notification to resident representatives for hospital transfers for multiple residents.
Failure to develop and implement complete care plans for residents with respiratory treatments and oxygen use.
Failure to administer Clonidine according to physician orders for a resident with hypertension.
Failure to provide thorough incontinent care resulting in inadequate cleansing of a resident.
Failure to properly label and manage feeding tube formula bags and improper medication administration via feeding tubes.
Failure to ensure oxygen was ordered and administered properly, and nebulizer masks were stored to prevent cross contamination.
Failure to ensure medications were labeled and stored properly to prevent administration errors.
Failure to prepare and serve meals according to the planned menu and failure to maintain proper food temperatures and hygiene practices in the kitchen.
Report Facts
Residents affected: 3
Residents affected: 10
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 9
Residents affected: 5
Residents affected: 40
Temperature: 120
Temperature: 110
Weight: 2.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Observed improper feeding tube medication administration and unlabeled feeding tube bags |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including medication administration, oxygen therapy, feeding tube care, and notification procedures |
| Dietary Employee #2 | Observed improper glove use and food handling in kitchen | |
| Dietary Employee #3 | Prepared boiled chicken instead of fried chicken as per menu |
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