Inspection Reports for
Three Rivers Health and Rehabilitation
33904 Highway 63 E, Marked Tree, AR, 72365
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 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
Occupancy
Latest occupancy rate
25% occupied
Based on a August 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 27
Deficiencies: 4
Date: Aug 29, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, hygiene, accident prevention, and food safety at Three Rivers Health and Rehabilitation Center.
Findings
The facility was found deficient in providing adequate assistance with activities of daily living including bathing, grooming, and foot care for residents requiring such assistance. Additionally, the facility failed to maintain an accident/hazard free environment for some residents and did not ensure proper hand hygiene practices in the kitchen.
Deficiencies (4)
Failure to provide necessary assistance with activities of daily living to maintain good hygiene and grooming for residents requiring help.
Failure to provide appropriate foot care, including keeping toenails clean and trimmed for residents requiring assistance.
Failure to ensure an accident/hazard free environment and adequate supervision to prevent accidents for sampled residents.
Failure to ensure proper hand hygiene was performed in the kitchen, increasing risk of foodborne illness.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: Many
Number of residents on unit: 27
Baths per day: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | CNA | Interviewed regarding residents' hygiene and bathing care deficiencies |
| Licensed Practical Nurse #6 | LPN | Interviewed regarding residents' hygiene and diabetic nail care |
| Registered Nurse #7 | RN | Interviewed regarding residents' nail care needs |
| Director of Nursing | DON | Interviewed regarding importance of activities of daily living and accident prevention |
| Certified Nursing Assistant #1 | CNA | Observed providing care and interviewed regarding fall mat absence |
| Certified Nursing Assistant #2 | CNA | Observed providing care and interviewed regarding fall mat absence |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding fall mat requirement and safety |
| Dietary Aide #8 | Dietary Aide | Observed and interviewed regarding hand hygiene deficiencies in food preparation |
| Dietary Aide #9 | Dietary Aide | Observed and interviewed regarding hand hygiene deficiencies in food preparation |
| Dietary Manager | Manager | Interviewed regarding hand hygiene policies and practices in kitchen |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 10
Date: Aug 18, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident rights, care, environment, medication storage, food safety, and pest control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, inadequate notification of family for changes in condition, failure to provide proper briefs, unsafe and unclean environment, improper treatment and documentation of skin tears, failure to provide adequate hydration, improper medication storage and labeling, food safety violations leading to immediate jeopardy, ineffective pest control, and failure to implement effective quality assurance measures.
Deficiencies (10)
Failed to maintain privacy and dignity for residents during care procedures and provide proper briefs.
Failed to notify resident's family of changes in condition for a resident in contact isolation.
Failed to provide timely notice of discharge and appeal rights to a resident.
Failed to maintain a safe, clean, and homelike environment; presence of holes, water hazards, insect infestations, and unreported maintenance issues.
Failed to assess, report, and notify physician for residents with skin tears/wounds; bandages undated and no treatment orders.
Failed to ensure residents on special diets received proper hydration and care; thickened liquids not properly provided.
Failed to store drugs and biologicals properly; expired medications found; medication rooms left unlocked and accessible to unauthorized personnel.
Failed to procure, store, prepare, and serve food in accordance with professional standards; food items stored at unsafe temperatures; poor hygiene practices; resulted in immediate jeopardy due to foodborne illness affecting multiple residents.
Failed to implement effective quality assurance and performance improvement to prevent repeated medication storage deficiencies.
Failed to maintain effective pest control program; presence of flies, dead insects, spider webs, and inadequate cleaning schedules.
Report Facts
Residents affected: 94
Expired syringes of Heparin: 19
Expired Saline Flush syringes: 21
Temperature readings: 54
Temperature readings: 60
Temperature readings: 42
Temperature readings: 50
Temperature readings: 62
Temperature readings: 69
Residents reporting gastric symptoms: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Named in privacy and dignity deficiency and skin tear treatment deficiency |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding privacy and dignity, notification of family, and hydration orders |
| Assistant Director of Nursing | ADON | Interviewed regarding privacy, briefs, medication room security, and food safety |
| Director of Nursing | DON | Provided census, policy information, and interviewed regarding hydration and quality assurance |
| Certified Nursing Assistant #5 | CNA | Interviewed regarding briefs and medication room security |
| Registered Nurse #1 | RN | Observed medication room security and interviewed regarding skin tear treatment |
| Dietary Manager | DM | Interviewed regarding food safety, refrigerator issues, and foodborne illness |
| Housekeeping Supervisor | HK Supervisor | Interviewed regarding cleaning schedules and pest control |
| Maintenance #1 | Maintenance Staff | Interviewed regarding environmental rounds and pest control |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a resident in a wheelchair was not properly secured during transport in the facility's van, resulting in the wheelchair tipping over backwards and causing injury.
Complaint Details
The complaint investigation found Immediate Jeopardy due to unsafe transport practices. The resident was injured when the wheelchair tipped over because the van driver failed to secure the front straps. The resident initially refused ER transport but later was hospitalized with multiple cervical spine fractures and hematoma. The van driver was suspended and retraining was initiated.
Findings
The facility failed to ensure safe transport of a resident in a wheelchair, resulting in Immediate Jeopardy to resident health or safety. The van driver did not secure the front wheels of the wheelchair properly, causing the resident to flip backwards during transport. The resident sustained fractures and was hospitalized. The facility implemented a Plan of Removal including suspension of the van driver, van taken out of service, retraining of van drivers, and enhanced monitoring.
Deficiencies (1)
Failure to ensure the van driver safely transported a resident in a wheelchair by not securing the front wheels to J-hooks, resulting in the wheelchair tipping over backwards.
Report Facts
Residents requiring wheelchair transport: 13
Vertebral body height loss: 20
Date of last van driver competency checkoff: Mar 16, 2022
Date of last correct lift operation competency: Aug 23, 2022
Plan of Removal acceptance time: 526
Inspection Report
Census: 96
Deficiencies: 3
Date: Jun 9, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to infection control, medication storage, and proper disposal of garbage and refuse at the nursing home.
Findings
The facility was found deficient in maintaining infection control during a stage 4 pressure ulcer dressing change, securing medications on medication carts, and properly containing trash in outside dumpsters. These deficiencies posed risks of infection, medication access by residents, and potential pest infestation.
Deficiencies (3)
Failed to ensure infection control practices during a stage 4 pressure ulcer dressing change for one resident.
Failed to store drugs and biologicals in locked compartments on the medication cart with limited access for one of four medication carts.
Failed to ensure trash was properly contained within two outside dumpsters to minimize potential for pest infestation.
Report Facts
Residents affected: 96
Medication carts: 4
Outside dumpsters: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Named in infection control deficiency related to wound care | |
| Licensed Practical Nurse (LPN) #1 | Named in medication storage deficiency for leaving medications unsecured | |
| Director of Nursing (DON) | Interviewed regarding infection control, medication storage, and garbage disposal policies | |
| Maintenance Director | Interviewed regarding responsibility for ensuring trash containment |
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