Deficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
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
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
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
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
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 |
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