Deficiencies (last 3 years)
Deficiencies (over 3 years)
12.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
144% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the appropriate use and care of feeding tubes, specifically evaluating medication administration through a percutaneous endoscopic gastrostomy (PEG) tube for one resident.
Findings
The facility failed to provide appropriate treatment and care for one resident with a PEG tube by not flushing the tube with water prior to medication and feeding administration as ordered, potentially risking tube clogging and complications.
Deficiencies (1)
Failed to flush PEG tube with water before medication and feeding administration as ordered for Resident #11.
Report Facts
Water flush volume before and after meds: 30
Water flush volume before and after bolus feeding: 60
Staff Assessment for Mental Status (SAMS) score: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #3 | Observed administering medications and feeding without flushing tube prior to administration | |
| Nurse Practitioner #4 | Interviewed regarding importance of flushing PEG tube to prevent clogging | |
| Director of Nursing | Interviewed regarding importance of flushing PEG tube with medications and feedings |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding the appropriate use and care of feeding tubes, specifically focusing on medication administration through a percutaneous endoscopic gastrostomy (PEG) tube for Resident #11.
Findings
The facility failed to provide appropriate treatment and care for Resident #11 receiving medication through a PEG tube, specifically by not flushing the tube with water prior to medication and feeding as ordered, which could lead to tube clogging and complications.
Deficiencies (1)
Failed to flush PEG tube with water before medication and feeding as ordered for Resident #11.
Report Facts
Water flush volume before and after meds: 30
Water flush volume before and after feeding: 60
Staff Assessment for Mental Status (SAMS) score: 2
Assessment Reference Date: Aug 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #3 | Observed medication administration and acknowledged importance of flushing PEG tube | |
| Nurse Practitioner #4 | Interviewed regarding importance of flushing PEG tube to prevent clogging | |
| Director of Nursing | Interviewed regarding importance of flushing PEG tube with medications and feedings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 17, 2025
Visit Reason
The inspection was conducted based on a complaint regarding inadequate incontinence care and infection control practices for Resident #1 at The Springs Magnolia nursing home.
Complaint Details
The complaint alleged inadequate incontinence care and infection control for Resident #1. The complaint was substantiated based on observations, interviews, and record reviews confirming failures in care and infection prevention.
Findings
The facility failed to provide appropriate incontinence care that promoted cleanliness and prevented infection, as well as failed to ensure proper hand hygiene and infection control procedures during care. Observations and interviews revealed that staff did not clean the resident properly, used contaminated gloves without changing, and placed soiled clothing on the floor instead of in trash bags.
Deficiencies (2)
Failure to provide appropriate incontinence care promoting cleanliness and preventing urinary tract infections for Resident #1.
Failure to ensure proper hand hygiene and infection control procedures during incontinence care for Resident #1.
Report Facts
Assessment Reference Date: Apr 8, 2025
Care Plan Initiation Date: Apr 14, 2025
Inspection Date: Jun 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Observed and interviewed regarding inadequate incontinence care and infection control practices | |
| Director of Nursing (DON) | Interviewed regarding proper care procedures and infection control policies | |
| Administrator | Interviewed regarding facility policies on incontinence care and infection control |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 17, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with appropriate care standards for residents who are continent or incontinent of bowel/bladder, infection prevention and control, and hand hygiene practices during incontinence care.
Findings
The facility failed to provide proper incontinence care to Resident #1, including inadequate cleaning of the perineal area and wheelchair, improper handling of soiled clothing, and failure to perform hand hygiene before and after care. Staff interviews and policy reviews confirmed these deficiencies, with minimal harm or potential for actual harm noted.
Deficiencies (2)
Failure to provide incontinence care that promoted cleanliness, prevented odor, and infections for Resident #1.
Failure to ensure proper hand hygiene and infection control procedures during incontinence care for Resident #1.
Report Facts
Assessment Reference Date: Apr 8, 2025
Date of Observation: Jun 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Observed providing inadequate incontinence care and improper hand hygiene |
| Director of Nursing | Director of Nursing | Interviewed regarding incontinence care and infection control policies |
| Administrator | Administrator | Interviewed regarding incontinence care procedures and infection control |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication storage, safety, food handling, and infection control at The Springs Magnolia nursing home.
Findings
The facility was found deficient in multiple areas including failure to notify proper state authority of a new mental illness diagnosis, unsecured medication storage, medications stored at residents' bedsides, improper food storage practices, and inadequate hand hygiene during incontinent care, all posing minimal harm or potential for harm to residents.
Deficiencies (5)
Failed to notify proper state authority of a new diagnosis of bipolar disorder for Resident #53.
Failed to ensure the treatment cart used to store medication was locked when unattended by staff.
Failed to ensure 2 residents (#23 and #49) did not have medications stored at the bedside.
Failed to ensure canned goods were dent free and cleaning supplies were not on the puree prep table while food was being prepared.
Failed to ensure staff provided proper hand hygiene while providing incontinent care to Resident #61 to prevent cross contamination.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Medication bottle size: 32
BIMS score: 11
BIMS score: 12
Dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Voiced that Resident #53 did not have bipolar diagnosis upon admission and that state authority was not notified | |
| Licensed Practical Nurse (LPN) #7 | Voiced that treatment cart did not lock and medications could be harmful if accessed | |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding alcohol found near Resident #23 | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about medication left at Resident #49's bedside | |
| Director of Nursing (DON) | Confirmed medications should not be left at bedside and staff should use clean/dirty hand technique during peri-care | |
| Certified Nursing Assistant (CNA) #6 | Observed performing improper hand hygiene during incontinent care of Resident #61 | |
| Certified Nursing Assistant (CNA) #5 | Observed assisting with Resident #61 and signed in-service on peri-care | |
| Dietary Manager | Confirmed food safety practices and policies | |
| Dietary Aide #8 | Observed pureeing food with cleaning bucket on prep table |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident care, safety, medication storage, food handling, and infection control.
Findings
The facility was found deficient in multiple areas including failure to notify proper state authority of a new mental illness diagnosis, unsecured medication storage, medications left at residents' bedside, dented canned goods and improper food preparation practices, and inadequate hand hygiene during incontinent care.
Deficiencies (5)
Failed to notify the proper state authority when aware of a new diagnosis of mental illness for Resident #53.
Failed to ensure the treatment cart used to store medication was locked when unattended by staff.
Failed to ensure 2 residents (#23 and #49) did not have medications stored at the bedside.
Failed to ensure canned goods were dent free and cleaning supplies were not on the puree prep table while food was being prepared.
Failed to ensure staff provided proper hand hygiene while providing incontinent care to Resident #61 to prevent cross contamination.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Weight of dented canned good: 7
BIMS score: 11
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #7 | Voiced that the treatment cart did not lock and medication could be harmful if accessed | |
| Administrator | Voiced treatment cart should be locked and provided documentation on policies | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about alcohol found at Resident #23's bedside | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about medication left at Resident #49's bedside | |
| Director of Nursing (DON) | Confirmed medications should not be left at bedside and staff should use clean/dirty hand technique | |
| Certified Nursing Assistant (CNA) #6 | Observed and interviewed regarding improper hand hygiene during peri-care | |
| Certified Nursing Assistant (CNA) #5 | Signed in-service on peri-care | |
| Dietary Manager | Confirmed food safety practices and dented can policy | |
| Dietary Aide #8 | Observed pureeing food with cleaning bucket on prep table |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following a fall incident involving Resident #1, related to failure to follow the resident's care plan concerning transfers.
Complaint Details
The investigation was substantiated as the facility failed to follow the care plan for Resident #1, leading to a fall. Residents affected were few.
Findings
The facility failed to follow Resident #1's care plan for transfers, resulting in a fall when staff attempted to transfer the resident without using the mechanical lift as required. Staff acknowledged being familiar with the care plan but deviated due to urgency and equipment failure.
Deficiencies (1)
Failure to follow Resident #1's care plan concerning transfers, resulting in a fall.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in the fall incident and transfer failure leading to Resident #1's fall. |
| CNA #2 | Certified Nursing Assistant | Named in the fall incident and transfer failure leading to Resident #1's fall. |
| Director of Nursing | Director of Nursing | Interviewed regarding staff competencies and access to care plans. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following a fall incident involving Resident #1, related to failure to follow the resident's care plan concerning transfers.
Complaint Details
The visit was complaint-related due to a fall incident involving Resident #1. The complaint was substantiated as the facility failed to follow the resident's care plan for transfers, resulting in the fall.
Findings
The facility failed to follow Resident #1's care plan for transfers, resulting in a fall when staff attempted to transfer the resident without using the mechanical lift as required. Staff acknowledged the lift was not used due to equipment failure and time constraints, leading to the resident falling during transfer.
Deficiencies (1)
Failure to follow Resident #1's care plan concerning transfers, resulting in a fall.
Report Facts
Residents sampled: 3
Date of fall incident: Jan 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Interviewed regarding the fall incident and transfer procedures. | |
| Certified Nursing Assistant (CNA) #2 | Interviewed regarding the fall incident and transfer procedures. | |
| Director of Nursing (DON) | Interviewed about staff competencies and access to care plans. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 15, 2023
Visit Reason
The inspection was conducted due to allegations of misappropriation of resident funds and failure to maintain proper receipts for charges imposed by the facility on residents' trust accounts.
Complaint Details
The complaint investigation was triggered by identification of the facility Business Office Manager stealing funds from resident accounts. The police have an ongoing investigation. The facility conducted an incomplete audit and was unable to provide documentation of a thorough investigation or receipts for the funds spent.
Findings
The facility failed to ensure receipts were filed for charges imposed on six residents' trust funds and did not thoroughly investigate the misappropriation of funds after the Business Office Manager was identified as stealing from resident accounts. The administrator was unable to produce receipts or explain the expenditures.
Deficiencies (2)
Failed to ensure receipts were filed for charges imposed by the facility for 6 residents.
Failed to thoroughly investigate misappropriation of funds for 6 residents after Business Office Manager was identified as stealing funds.
Report Facts
Amount spent by Resident #1: 845
Amount spent by Resident #5: 495
Amount spent by Resident #6: 795
Amount spent by Resident #7: 2700
Amount spent by Resident #8: 350
Amount spent by Resident #9: 100
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 15, 2023
Visit Reason
The inspection was conducted due to allegations of misappropriation of resident funds and failure to maintain receipts for charges imposed by the facility on residents' trust accounts.
Complaint Details
The complaint investigation was triggered by identification of the facility Business Office Manager stealing funds from resident accounts. The police have an ongoing investigation. The facility's audit was incomplete and lacked documentation of a thorough investigation.
Findings
The facility failed to ensure receipts were filed for charges imposed on six residents' trust funds and failed to thoroughly investigate the misappropriation of funds after the Business Office Manager was identified as stealing from resident accounts. The administrator was unable to produce receipts or explain the expenditures.
Deficiencies (2)
Failure to ensure receipts were filed for charges imposed by the facility for 6 residents.
Failure to thoroughly investigate misappropriation of funds for 6 residents after identification of theft by Business Office Manager.
Report Facts
Residents affected: 6
Total amount spent without receipts for Resident #1: 845
Total amount spent without receipts for Resident #5: 495
Total amount spent without receipts for Resident #6: 795
Total amount spent without receipts for Resident #7: 2700
Total amount spent without receipts for Resident #8: 350
Total amount spent without receipts for Resident #9: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Business Office Manager | Identified the theft by the facility Business Office Manager and conducted an incomplete audit. | |
| Administrator | Unable to produce receipts or explain expenditures related to residents' funds. | |
| Business Office Manager | Identified as stealing funds from resident accounts. |
Inspection Report
Routine
Census: 72
Deficiencies: 8
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of The Springs Magnolia nursing home to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to accurately document advance directives, inadequate hydration practices, lack of oxygen use signage, improper storage of discontinued narcotics, failure to prepare and serve meals according to nutritional and consistency standards, poor food safety and hygiene practices, and malfunctioning call light systems.
Deficiencies (8)
Failed to ensure advanced directive information was accurately documented in the medical record for resident wishes regarding DNR/CPR.
Failed to ensure water was accessible and provided per physician orders for hydration for resident #10.
Failed to ensure posting of cautionary and safety signs for oxygen use in resident rooms and facility entrances.
Failed to ensure discontinued narcotics were properly stored and locked in a permanently affixed compartment.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs.
Failed to ensure pureed food items were blended to a smooth, lump free consistency.
Failed to ensure food items stored in the refrigerator were covered and dated, dietary staff washed hands properly, and ice machines were clean.
Failed to ensure call light system was functioning properly in resident bathrooms and rooms.
Report Facts
Residents affected by advance directive deficiency: 6
Residents affected by hydration deficiency: 2
Residents affected by oxygen signage deficiency: 4
Residents affected by meal preparation deficiency: 12
Total census: 72
Residents affected by call light deficiency: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #2 | Mentioned in relation to hydration deficiency and call light system issues. | |
| Licensed Practical Nurse #1 | Mentioned in relation to oxygen setup and signage deficiency. | |
| Licensed Practical Nurse #2 | Mentioned in relation to hydration deficiency. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding advance directives, hydration, oxygen signage, narcotics storage, and call light system. |
| Dietary Employee #1 | Mentioned in relation to meal preparation and food safety deficiencies. | |
| Dietary Employee #2 | Mentioned in relation to meal preparation deficiency. | |
| Dietary Employee #3 | Mentioned in relation to pureed food consistency deficiency. | |
| Dietary Supervisor | Interviewed regarding meal preparation, food safety, and hand washing policies. | |
| Maintenance Employee #1 | Mentioned in relation to call light system repair. | |
| Certified Nursing Assistant #1 | Mentioned in relation to pureed food consistency deficiency. |
Inspection Report
Routine
Census: 72
Deficiencies: 8
Date: Jun 8, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at The Springs Magnolia nursing home.
Findings
The facility was found deficient in multiple areas including inaccurate documentation of advance directives, failure to provide adequate hydration per physician orders, lack of oxygen use signage, improper storage of discontinued narcotics, failure to prepare and serve meals according to planned menus and dietary needs, poor food handling and sanitation practices, and malfunctioning call light systems in resident rooms.
Deficiencies (8)
Failed to ensure advanced directive information was accurately documented in the medical record for resident wishes regarding DNR status.
Failed to ensure water was accessible and provided per physician orders for hydration for resident.
Failed to ensure posting of cautionary and safety signs for resident rooms indicating oxygen use.
Failed to ensure discontinued narcotics were properly stored and locked before destruction.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to ensure food items stored in refrigerator were covered and dated; dietary staff failed to wash hands properly; ice machines not clean.
Failed to ensure call light system was functioning properly in resident bathroom and bathing area.
Report Facts
Residents affected: 6
Residents affected: 2
Residents affected: 14
Total census: 72
Residents affected: 12
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #2 | CNA | Mentioned in hydration and call light system findings |
| Licensed Practical Nurse #1 | LPN | Mentioned in oxygen setup and signage findings |
| Licensed Practical Nurse #2 | LPN | Mentioned in hydration findings |
| Director of Nursing | DON | Interviewed regarding advance directives, hydration, oxygen signage, narcotics storage, and call light system |
| Dietary Employee #1 | Dietary Employee | Mentioned in meal preparation and food handling deficiencies |
| Dietary Employee #2 | Dietary Employee | Mentioned in meal preparation deficiencies |
| Dietary Employee #3 | Dietary Employee | Mentioned in pureed food consistency deficiencies |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding menu and food safety practices |
| Maintenance Employee #1 | Maintenance Employee | Mentioned in call light system repair |
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