Deficiencies (last 3 years)
Deficiencies (over 3 years)
22.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
329% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
59% occupied
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 82
Deficiencies: 6
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, nutrition, food safety, infection control, and overall care practices at The Springs of Greers Ferry nursing home.
Findings
The facility was found deficient in maintaining resident dignity during meal assistance, following menu and dietary orders, ensuring proper food preparation and sanitation in the kitchen, and implementing infection control measures during tracheostomy care. Several residents experienced minimal harm or potential for harm due to these deficiencies.
Deficiencies (6)
Failed to ensure dignity was maintained during lunch service as staff did not sit with residents while assisting with meals.
Failed to reasonably accommodate the needs and preferences of Resident #61 by not following the menu card instructions.
Failed to ensure meals were prepared and served according to the planned written menu, resulting in smaller portion sizes than prescribed.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to maintain a sanitary kitchen environment including unclean ceiling tiles, rusty vent panels, greasy deep fryer, expired food items, improper hand hygiene, and contaminated food handling.
Failed to implement proper infection control measures during tracheostomy care, contaminating sterile field and not changing gloves as required.
Report Facts
Residents affected: 82
Residents affected: 8
Residents affected: 1
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #9 | LPN | Named in infection control deficiency during tracheostomy care |
| Certified Nursing Assistant #5 | CNA | Observed assisting residents during lunch but standing instead of sitting |
| Certified Nursing Assistant #6 | CNA | Observed assisting residents during lunch but standing instead of sitting |
| Certified Nursing Assistant #7 | CNA | Confirmed menu card instructions for Resident #61 |
| Dietary Manager | Interviewed regarding food preparation, sanitation, and menu compliance | |
| Dietary [NAME] (DC) #1 | Dietary Cook | Observed preparing meals and noted for improper food preparation and hygiene |
| Dietary Aide #2 | Dietary Aide | Observed contaminating gloves and improper hand hygiene during food handling |
| Director of Nursing | DON | Interviewed regarding feeding practices and infection control |
| Speech Therapist | Interviewed regarding feeding accommodations for Resident #61 | |
| Administrator | Interviewed regarding importance of following menu orders |
Inspection Report
Routine
Census: 82
Deficiencies: 6
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, nutritional needs, food safety, infection control, and overall care practices at The Springs of Greers Ferry nursing home.
Findings
The facility was found deficient in maintaining resident dignity during meal service, following menu orders for special diets, preparing pureed foods to proper consistency, ensuring adequate food portions, maintaining kitchen sanitation and food safety, and implementing proper infection control during tracheostomy care. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (6)
Failed to ensure dignity was maintained during lunch service as staff did not sit with residents while assisting with eating.
Failed to reasonably accommodate the needs and preferences of a resident by not following the menu card for food presentation.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs, including serving inadequate portions of ham.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to maintain kitchen sanitation including dirty ceiling tiles, dusty vents, greasy deep fryer, expired food items, improper hand hygiene, and unclean ice machine.
Failed to implement infection control measures during tracheostomy care, contaminating sterile field and not changing gloves appropriately.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 8
Total census: 82
Portion size: 1.5
Ham prepared: 10
Menu servings: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #9 | LPN | Named in infection control deficiency during tracheostomy care |
| Certified Nursing Assistant #5 | CNA | Observed not sitting with residents during lunch service |
| Certified Nursing Assistant #6 | CNA | Observed not sitting with residents during lunch service |
| Certified Nursing Assistant #7 | CNA | Confirmed menu card instructions for Resident #61 |
| Dietary Manager | Interviewed regarding food portion sizes, kitchen sanitation, and food safety | |
| Director of Nursing | DON | Interviewed regarding feeding practices and infection control |
| Speech Therapist | Interviewed regarding food presentation for Resident #61 | |
| Dietary [NAME] (DC) #1 | Dietary Cook/Aide | Observed preparing food inconsistently with recipes and poor hygiene practices |
| Dietary Aide #2 | DA | Observed contaminating gloves and improper hand hygiene |
| Certified Nursing Assistant #3 | CNA | Interviewed about consistency of pureed foods |
Inspection Report
Routine
Census: 67
Deficiencies: 2
Date: Jul 6, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards including personal grooming, nursing staff sufficiency, and overall resident care in the facility.
Findings
The facility failed to ensure proper grooming for some residents dependent on staff, including regular shaving and nail care, and failed to maintain sufficient qualified nursing staff at all times to meet residents' needs safely, particularly on weekends.
Deficiencies (2)
Failure to ensure facial hair was removed regularly to maintain good grooming for 1 of 20 sampled residents dependent on staff for shaving and failure to ensure fingernails were regularly trimmed for 2 of 30 sampled residents dependent on staff for nail care.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Report Facts
Residents affected: 67
Residents sampled for grooming deficiency: 20
Residents sampled for nail care deficiency: 30
Staff leaving: 25
Typical staff count: 8
Typical staff count: 4
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about residents' fingernail conditions and staffing |
| Restorative Aide #1 | Restorative Aide | Observed providing care and interviewed about resident refusal of care |
| Director of Nursing | Director of Nursing | Provided statements about staffing levels and nursing staff log |
Inspection Report
Routine
Census: 67
Deficiencies: 8
Date: Jul 6, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with catheter privacy bags, incomplete care plans for chronic conditions, inadequate grooming and nail care, fire hazard risks due to lint buildup in dryers, insufficient nursing staff especially on weekends, improper meal preparation and portioning, food safety violations including improper food storage and cross-contamination risks, and failure to document resident vaccinations properly.
Deficiencies (8)
Failure to ensure indwelling urinary catheter drainage bags were concealed in privacy bags to maintain resident dignity.
Failure to develop and implement a care plan for Chronic Viral Hepatitis C for a resident.
Failure to ensure regular grooming including shaving and fingernail trimming for dependent residents.
Failure to keep clothes dryers free of lint buildup, creating a fire hazard.
Failure to provide sufficient qualified nursing staff to meet residents' needs safely.
Failure to prepare and serve meals according to the planned menu and portion sizes for residents on special diets.
Failure to ensure foods stored in the kitchen were covered, sealed, and dated; expired food was not removed; and dietary staff did not follow proper hand hygiene and glove use.
Failure to document resident pneumococcal and influenza vaccinations or refusals in medical records.
Report Facts
Residents affected: 6
Residents affected: 1
Residents affected: 20
Residents affected: 67
Staffing rating: 1
Expired food items: 20
Residents affected: 4
Residents affected: 12
Staff members left: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about resident grooming and staffing issues |
| Director of Nursing | Director of Nursing | Provided information on catheter privacy bag policy, staffing, and vaccination documentation |
| Dietary Employee #1 | Dietary Employee | Observed preparing and serving meals with improper portions and poor hygiene practices |
| Dietary Employee #2 | Dietary Employee | Observed handling food with poor hygiene practices |
| Administrator | Administrator | Provided policies and grievance logs, and answered questions about dryer lint and staffing |
Inspection Report
Routine
Census: 67
Deficiencies: 3
Date: Jul 6, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards including personal grooming, nursing staff sufficiency, and overall resident care at The Springs of Greers Ferry nursing home.
Findings
The facility failed to ensure proper grooming for some residents dependent on staff, including regular shaving and nail care. Additionally, the facility did not maintain sufficient qualified nursing staff at all times, particularly on weekends, which affected timely resident care and response to call lights.
Deficiencies (3)
Failure to ensure facial hair was removed regularly to maintain good grooming for dependent residents.
Failure to ensure fingernails were regularly trimmed when needed to maintain good grooming for dependent residents.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Report Facts
Residents affected: 67
Census: 67
Staff members left: 25
Payroll Based Journal Staffing Data Report: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about residents' fingernail conditions and staffing |
| Restorative Aide #1 | Restorative Aide | Observed providing care and interviewed about resident refusal of care |
| Director of Nursing | Director of Nursing | Provided staffing information and nursing staff log |
| CNA #1 | Certified Nursing Assistant | Interviewed about staffing and resident care |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 8
Date: Jul 6, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the facility's care and services.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with catheter care, incomplete care plans for chronic conditions, inadequate grooming assistance, fire hazards due to lint buildup in dryers, insufficient nursing staff especially on weekends, improper meal preparation and portioning, unsafe food handling practices, and lack of documentation for resident vaccinations.
Deficiencies (8)
Failed to ensure indwelling urinary catheter drainage bag was concealed in a privacy bag to promote dignity and privacy.
Failed to develop and implement a care plan for Chronic Viral Hepatitis C for a resident.
Failed to ensure facial hair was removed regularly and fingernails were trimmed to maintain good grooming for dependent residents.
Failed to ensure clothes dryers remained free of lint build-up to decrease fire potential.
Failed to ensure sufficient qualified nursing staff were available at all times to meet residents' needs safely.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs.
Failed to ensure foods stored in freezer and refrigerator were covered, sealed, and dated; expired food was not promptly removed; and dietary staff did not follow proper hand hygiene and glove use.
Failed to develop and implement procedures to ensure resident medical records included documentation of pneumococcal and influenza vaccinations or refusals.
Report Facts
Residents affected: 6
Residents affected: 1
Residents affected: 20
Residents affected: 30
Residents affected: 67
Staff leaving: 25
Expired food items: 20
Residents on mechanical soft diets: 13
Residents on pureed diets: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about fingernail care and grooming deficiencies |
| Restorative Aide #1 | Restorative Aide | Observed providing care and interviewed about resident grooming |
| Director of Nursing | Director of Nursing | Interviewed about catheter care, staffing, and vaccination documentation |
| Dietary Employee #1 | Dietary Employee | Observed preparing meals and handling food with improper hygiene |
| Dietary Employee #2 | Dietary Employee | Observed handling food with improper hygiene |
| Administrator | Administrator | Provided policies and interviewed about fire hazard and staffing |
| MDS Coordinator | MDS Coordinator | Interviewed about missing care plan for Chronic Viral Hepatitis C |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about staffing and resident care |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 30, 2023
Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to ensure cleaning chemicals, wipes, and perineal cleaning items were properly contained and secured, and failure to ensure staff used gait belts and two staff for transfers for a resident who required such assistance.
Complaint Details
The complaint investigation substantiated that the facility failed to secure hazardous materials and failed to follow proper transfer protocols for Resident #1, resulting in a fall on 05/12/2023 where a gait belt was not used and only one staff assisted.
Findings
The facility failed to secure hazardous materials such as cleaning chemicals and wipes, left normal saline unsecured on a treatment cart, and failed to use gait belts and two staff during transfers for Resident #1, who required extensive assistance. Interviews with staff and residents confirmed these deficiencies, and facility policies regarding hazardous materials and transfer safety were reviewed.
Deficiencies (3)
Failure to ensure cleaning chemicals, wipes, and perineal cleaning items were contained and locked on 300 Hall (secure unit).
Failure to ensure normal saline was contained when not in use and left unattended on treatment cart.
Failure to ensure staff used gait belts and two staff for transfers for Resident #1 who required extensive assistance.
Report Facts
Residents sampled: 4
Resident #1 BIMS score: 15
Resident #1 Fall risk score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Interviewed about cabinet locks and transfer procedures |
| Registered Nurse #1 | RN | Interviewed about normal saline storage and use |
| Certified Nursing Assistant #2 | CNA | Interviewed about transfer assistance and storage of hazardous materials |
| Licensed Practical Nurse #1 | LPN | Interviewed about gait belt use and storage of hazardous materials |
| Director of Nursing | DON | Interviewed about transfer assistance, gait belt use, and storage policies |
| Administrator | Administrator | Interviewed about transfer assistance, gait belt use, and storage policies |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 30, 2023
Visit Reason
The inspection was conducted due to concerns about accident hazards and inadequate supervision in a nursing home, specifically related to the improper storage of cleaning chemicals and supplies, and failure to use gait belts and two staff for transfers for a resident requiring such assistance.
Complaint Details
The investigation was complaint-related, focusing on a fall incident involving Resident #1 on 05/12/23 where only one staff member assisted without a gait belt, contrary to the resident's care plan requiring two staff and gait belt use. The complaint was substantiated by observations, interviews, and record reviews.
Findings
The facility failed to ensure hazardous materials such as cleaning chemicals, wipes, and normal saline were properly secured and contained. Additionally, staff did not use gait belts or two-person assistance when transferring a resident who required extensive assistance, resulting in a fall. Interviews with staff and residents confirmed these deficiencies, and facility policies regarding storage and transfer safety were reviewed.
Deficiencies (3)
Failure to ensure cleaning chemicals, wipes, and perineal cleaning items were contained and locked in the secure unit.
Failure to ensure normal saline was contained and not left unattended on treatment cart.
Failure to ensure staff used gait belts and two staff for transfers for a resident requiring extensive assistance, resulting in a fall.
Report Facts
Resident requiring two staff for transfers: 1
Residents sampled: 4
Resident's BIMS score: 15
Fall incident date: May 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Interviewed about cabinet locks and storage practices. |
| RN #1 | Registered Nurse | Interviewed about normal saline storage and use. |
| CNA #2 | Certified Nursing Assistant | Interviewed about transfer assistance and storage of hazardous materials. |
| LPN #1 | Licensed Practical Nurse | Interviewed about gait belt use and storage of hazardous materials. |
| Director of Nursing | Director of Nursing | Interviewed about transfer assistance, gait belt use, and storage policies. |
| Administrator | Administrator | Interviewed about transfer assistance, gait belt use, and storage policies. |
| CNA #3 | Certified Nursing Assistant | Named as the staff who performed the transfer on Resident #1 on 05/12/23 without using a gait belt. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 23, 2023
Visit Reason
The inspection was conducted due to complaints regarding residents being treated without dignity and respect, failure to provide ordered treatments and medications, and safety hazards within the facility.
Complaint Details
The investigation was complaint-driven based on allegations of dignity violations, failure to provide ordered treatments and medications, and safety hazards. The report documents interviews, observations, and record reviews supporting these complaints.
Findings
The facility failed to ensure residents' dignity and privacy by allowing opposite sex residents to share a bathroom, failed to provide ordered pain medication, lotion, and wound treatment to sampled residents, and failed to maintain a safe environment by not repairing a broken grab bar in a resident's bathroom.
Deficiencies (5)
Failure to ensure residents were treated with dignity and respect, including privacy violations with shared bathrooms between opposite sex residents.
Failure to provide pain medication for Resident #1 as ordered, including delays and lack of physician notification.
Failure to provide physician ordered lotion for Resident #2 and failure to document administration.
Failure to provide wound treatment for Resident #3, including lack of physician orders and failure to change dressing since 05/17/23.
Failure to repair broken grab bar in Resident #3's bathroom, creating a safety hazard.
Report Facts
Residents sampled: 7
Pain medication tablets received: 12
Pain medication administered: 1
Resident #1 BIMS score: 5
Resident #2 BIMS score: 14
Resident #3 SAMS score: 3
Date dressing last changed: May 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about dignity issues and medication procedures |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about bathroom sharing and dignity |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reported exposure incident and communication with DON and Corporate Nurse Manager |
| Social Services Director | Social Services Director | Interviewed about room assignments and dignity concerns |
| Director of Nursing | Director of Nursing | Interviewed about room assignments, medication procedures, wound care, and facility policies |
| Administrator | Administrator | Interviewed about room assignments, maintenance procedures, and policy expectations |
| Registered Nurse #1 | Registered Nurse | Interviewed about wound care responsibilities |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about wound care and dressing orders |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about wound care and dressing changes |
| Maintenance Staff | Maintenance Staff | Interviewed about repair of grab bar and maintenance procedures |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 23, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to treat residents with dignity and respect, failure to provide ordered treatments and medications, and safety hazards within the facility.
Complaint Details
The investigation was complaint-driven based on reports of residents being exposed to opposite sex residents in shared bathrooms and failure to provide ordered treatments and maintain a safe environment.
Findings
The facility failed to ensure residents were treated with dignity and respect by allowing opposite sex residents to share a bathroom leading to exposure incidents. The facility also failed to provide ordered pain medication, lotion, and wound treatment to sampled residents. Additionally, the facility did not maintain a safe environment by failing to repair a broken grab bar in a resident's bathroom.
Deficiencies (5)
Failure to provide residents with privacy and prevent exposure in shared bathrooms between opposite sex residents.
Failure to provide pain medication for Resident #1 as ordered and timely.
Failure to provide physician ordered lotion for Resident #2 and failure to document administration.
Failure to provide wound treatment and dressing changes for Resident #3, including failure to obtain physician orders and document care.
Failure to repair broken grab bar in Resident #3's bathroom, creating a safety hazard.
Report Facts
Residents sampled: 7
Residents affected: 3
Medication tablets received: 12
Medication administered: 1
BIMS score Resident #1: 5
BIMS score Resident #2: 14
SAMS score Resident #3: 3
Date grab bar fixed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Interviewed regarding bathroom privacy, pain medication procedures, and maintenance reporting |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding bathroom sharing and dignity issues |
| Licensed Practical Nurse #1 | LPN | Reported exposure incident and communication with DON and Corporate Nurse Manager |
| Social Services Director | SSD | Interviewed about room assignments and bathroom sharing justification |
| Director of Nursing | DON | Interviewed about room assignments, pain medication procedures, wound care responsibilities, and facility policies |
| Administrator | Administrator | Interviewed about room assignments, bathroom privacy, maintenance reporting, and staff expectations |
| Nursing Assistant #1 | NA | Interviewed about bathroom sharing and resident mobility |
| Registered Nurse #1 | RN | Interviewed about wound care responsibilities and dressing changes |
| Licensed Practical Nurse #3 | LPN | Interviewed about wound care and dressing orders |
| Licensed Practical Nurse #4 | LPN | Interviewed about wound care and dressing documentation |
| Maintenance Staff | Maintenance Staff | Interviewed about maintenance reporting and repair of grab bar |
Inspection Report
Routine
Deficiencies: 9
Date: Apr 1, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident trust account management, transfer notifications, PASARR screening, medication administration via PICC line, respiratory care, food safety, infection control, and COVID-19 protocols.
Findings
The facility was found deficient in multiple areas including failure to provide quarterly trust account statements to residents, failure to notify residents or representatives of transfers/discharges, incomplete PASARR screening prior to admission, improper administration of IV antibiotics by untrained LPNs, inadequate respiratory care supplies and oxygen management, food safety violations including expired and improperly stored food, lapses in infection control practices including quarantine and PPE use, failure to timely report COVID-19 status to residents and families, and inadequate COVID-19 staff testing according to community transmission levels.
Deficiencies (9)
Failed to provide quarterly trust account statements to residents managing funds.
Failed to notify residents or representatives in writing of transfers/discharges to hospital.
Failed to ensure PASARR screening was completed prior to admission for residents with mental illness or intellectual disabilities.
Failed to ensure safe and appropriate administration of IV antibiotics via PICC line by untrained LPNs.
Failed to provide safe and appropriate respiratory care including oxygen administration and emergency supplies at bedside.
Failed to procure, store, prepare, and serve food in accordance with professional standards including expired food, unsealed containers, and poor hygiene practices.
Failed to implement infection prevention and control program including proper PPE use, quarantine signage and supplies, and resident masking.
Failed to timely report COVID-19 status changes to residents and families within required timeframe.
Failed to perform COVID-19 testing on staff according to community transmission levels and outbreak protocols.
Report Facts
Residents affected by trust account deficiency: 44
Residents affected by transfer notification deficiency: 11
Residents sampled for PASARR screening: 4
LPNs without PICC line certification: 4
Residents on quarantine: 1
Residents census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication administration deficiency related to PICC line antibiotic infusion without proper training. |
| Director of Nursing | Director of Nursing | Named as supervisor responsible for ensuring LPN competency and involved in interviews about deficiencies. |
| Business Office Manager | Business Office Manager | Named in deficiencies related to trust account statements and transfer notifications. |
| Physical Therapy Coordinator | Physical Therapy Coordinator | Named in infection control deficiency related to resident mask use during therapy. |
| Dietary Aide #2 | Dietary Aide | Named in food safety deficiencies related to hygiene and food handling. |
Inspection Report
Routine
Deficiencies: 9
Date: Apr 1, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident trust account management, transfer/discharge notifications, PASARR screening, medication administration via PICC line, respiratory care, food safety, infection control, and COVID-19 protocols.
Findings
The facility was found deficient in multiple areas including failure to provide quarterly trust account statements, failure to notify residents or representatives of transfers/discharges, incomplete PASARR screening, improper administration of PICC line antibiotics by untrained staff, inadequate respiratory care supplies and oxygen management, food safety violations, lapses in infection control practices including quarantine and PPE use, failure to timely report COVID-19 status to residents and families, and inadequate COVID-19 staff testing.
Deficiencies (9)
Failed to ensure quarterly statements detailing trust account activity were provided to residents or their representatives.
Failed to provide timely notification to residents or representatives before transfer or discharge to hospital.
Failed to ensure PASARR screening was completed prior to admission for residents with mental disorders or intellectual disabilities.
Failed to ensure safe and appropriate administration of IV fluids via PICC line by licensed practical nurses lacking PICC line training.
Failed to provide safe and appropriate respiratory care including proper oxygen administration and emergency supplies at bedside for residents with tracheostomy and oxygen needs.
Failed to procure, store, prepare, and serve food in accordance with professional standards including expired food items, unsealed containers, unclean equipment, and improper hand hygiene by staff.
Failed to implement infection prevention and control program adequately including resident mask use during quarantine, proper PPE stocking, and waste disposal.
Failed to report COVID-19 status changes to residents and families within required timeframe.
Failed to perform COVID-19 testing on staff according to community transmission levels and outbreak protocols.
Report Facts
Residents affected by trust account deficiency: 44
Residents affected by transfer notification deficiency: 11
Residents sampled for PASARR screening: 4
LPNs without PICC line certification: 4
Residents affected by respiratory care deficiency: 3
Residents affected by infection control deficiency: 1
Residents affected by COVID-19 reporting deficiency: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication administration deficiency related to PICC line antibiotic infusion without proper training. |
| Director of Nursing | Director of Nursing | Named as supervisor responsible for ensuring LPN competency and involved in interviews regarding PICC line administration and respiratory care. |
| Business Office Manager | Business Office Manager | Named in deficiencies related to trust account statements and transfer/discharge notifications. |
| Administrator | Facility Administrator | Named in interviews regarding trust account statements, transfer notifications, and COVID-19 reporting. |
| LPN #6 | Licensed Practical Nurse | Observed and interviewed during PICC line antibiotic administration. |
| Physical Therapy Coordinator | Physical Therapy Coordinator | Observed assisting resident on quarantine without mask. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control and quarantine practices. |
| Dietary Aide #2 | Dietary Aide | Observed with poor hand hygiene and food handling practices. |
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