Inspection Reports for
Valley Springs Rehabilitation and Health Center
228 Pointer Trail West, Van Buren, AR, 72956
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than Arkansas average
Arkansas average: 5.2 deficiencies/year
Deficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
91% occupied
Based on a December 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 8
Date: Jan 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility operations at Valley Springs Rehabilitation and Health Center.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, incomplete PASRR screenings, inadequate care planning for dementia and wounds, lack of physician order details for BiPAP use, failure to complete fall risk assessments after falls, poorly maintained fall mats, food safety and sanitation violations in the kitchen, and lapses in infection control practices including hand hygiene and catheter care.
Deficiencies (8)
Failure to ensure comprehensive assessment accurately reflected resident's status and needs, specifically for BiPAP use documentation.
Failure to complete Preadmission Screening and Resident Review (PASRR) for mental disorders or intellectual disabilities.
Failure to develop and implement a complete care plan addressing all resident needs including dementia care and wound care.
Failure to provide appropriate treatment and care according to physician orders, specifically lack of monitoring instructions for BiPAP and incomplete fall risk assessments after a fall.
Failure to ensure nursing home area was free from accident hazards; fall mats were torn and improperly placed.
Failure to provide appropriate treatment and services to residents with dementia, including lack of care planning for behaviors and distress.
Failure to procure, store, prepare, distribute, and serve food in accordance with professional standards; including uncovered food, dirty kitchen equipment, and poor hand hygiene by dietary staff.
Failure to provide and implement an infection prevention and control program; lapses in hand hygiene during meal service and improper catheter care.
Report Facts
Residents reviewed for care plan: 26
Residents with dementia care plan deficiency: 2
Residents with PASRR deficiency: 1
Residents with BiPAP order deficiency: 1
Residents with fall risk assessment deficiency: 1
Residents with fall mat deficiency: 1
Residents with infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed deficiencies related to BiPAP use, care planning, fall risk assessments, fall mats, and infection control |
| MDS Coordinator | MDS Coordinator | Confirmed inaccuracies in MDS documentation and care planning for residents #236 and #27 |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Confirmed fall mat condition and catheter bag dragging on floor |
| Dietary Staff #1 | Dietary Cook | Confirmed kitchen sanitation issues and food storage violations |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Observed failing to sanitize hands between passing food trays |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Confirmed importance of hand hygiene when passing food trays |
| Maintenance Director | Maintenance Director | Confirmed ice machine cleaning frequency and condition |
| Social Services Director | Social Services Director (SSD) | Confirmed PASRR screening not completed for Resident #24 |
Inspection Report
Deficiencies: 1
Date: Jan 24, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with comprehensive resident assessments, specifically reviewing the accuracy of assessments related to respiratory care for Resident #236.
Findings
The facility failed to ensure that the comprehensive assessment accurately reflected Resident #236's respiratory status and needs, particularly regarding the use and monitoring of a BiPAP device. Documentation discrepancies were noted in the resident's care plan, Medicare 5-day MDS, and Medication Administration Record.
Deficiencies (1)
Failure to ensure a comprehensive assessment accurately reflected Resident #236's status and needs related to BiPAP use and monitoring.
Report Facts
Residents affected: 1
BiPAP settings: 40
BiPAP settings: 10
BiPAP settings: 5
BiPAP settings: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed Resident #236 wore a BiPAP nightly and acknowledged incomplete documentation |
| MDS Coordinator | MDS Coordinator | Confirmed Medicare 5-day MDS did not note resident had a BiPAP |
Inspection Report
Routine
Deficiencies: 2
Date: Dec 21, 2023
Visit Reason
The inspection was conducted to ensure the nursing home environment was free from accident hazards and that adequate supervision was provided to prevent accidents.
Findings
The facility failed to ensure that hazardous items such as a bottle of after shave, a razor, and shaving cream were removed from resident areas, and failed to ensure medication cups were discarded after administration, posing potential risks to residents.
Deficiencies (2)
Failure to remove hazardous items (after shave, razor, shaving cream) from resident areas.
Failure to discard medication cup after administration, leaving medication residue accessible.
Report Facts
Medication administration time: 8.35
Medication cup observation time: 8.39
Medication cup interview time: 8.4
After shave bottle size: 4
Number of residents sampled: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #3 | Administered medication and left medication cup on table | |
| Certified Nursing Assistant (CNA) #1 | Removed spoon from medication cup and confirmed shaving responsibilities | |
| Director of Nursing (DON) | Provided policy on medication cup disposal and confirmed hazardous items should not be left accessible | |
| Nurse Consultant #2 | Provided list of residents needing shaving assistance |
Inspection Report
Routine
Census: 96
Deficiencies: 8
Date: Dec 21, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident rights, safety, nutrition, food handling, and facility maintenance at Valley Springs Rehabilitation and Health Center.
Findings
The facility was found deficient in multiple areas including failure to serve meals simultaneously to residents at the same table, lack of visible State Ombudsman contact information, unsanitary pest control devices in the dining room, unsafe medication administration practices, failure to remove hazardous shaving items, inadequate nutritional interventions after significant weight loss, improper food storage and kitchen hygiene, and damaged window blinds compromising resident privacy.
Deficiencies (8)
Failed to ensure meals were served at the same time for all residents sitting at the same table to promote dignity and respect.
Failed to ensure the State Ombudsman's contact information was visible and made available to all residents.
Failed to ensure pest control devices were removed from the dining room after becoming saturated with insects.
Failed to ensure medication cups were discarded after administration to prevent potential injury or accidents.
Failed to remove hazardous shaving items from resident areas to prevent potential harm.
Failed to implement nutritional interventions after significant weight loss to minimize further weight loss.
Failed to ensure food stored in refrigerator and freezer was covered or sealed; kitchen floors were not clean; and facial hair was not covered by hairnet.
Failed to ensure window blinds in resident room were in good condition, compromising privacy.
Report Facts
Residents affected: 2
Residents affected: 96
Residents affected: 1
Residents affected: 6
Residents affected: 1
Residents affected: 92
Missing slats: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Consultant #1 | Asked about meal tray for Resident #18 | |
| Housekeeping Supervisor | Confirmed unsanitary fly traps and meal serving times | |
| Dietary Supervisor | Confirmed meal serving times and food storage practices | |
| Administrator | Confirmed meal serving times, fly traps unsanitary, and blinds condition | |
| Director of Nursing (DON) | Director of Nursing | Interviewed about Ombudsman information, medication administration, shaving hazards, and nutritional interventions |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Left medication cup on table after administration |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Removed spoon from medication cup and confirmed shaving responsibilities |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Discussed nutritional supplement substitution |
| Dietary Staff #1 | Observed without hairnet over beard | |
| Maintenance Supervisor | Commented on condition of blinds |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 11
Date: Sep 23, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident rights, accurate assessments, care planning, safety, food service, infection control, and immunization practices.
Findings
The facility was found deficient in multiple areas including failure to ensure advanced directives were available in medical records, inaccurate Minimum Data Set (MDS) assessments, incomplete PASRR screenings, inadequate care plan updates, unsafe wheelchair harness use, unsecured sharp objects on secure unit, improper food temperature and preparation, poor food storage and hygiene practices, ineffective quality assurance and performance improvement (QAPI) implementation, inadequate infection control practices related to laundry handling, and incomplete pneumococcal immunization documentation.
Deficiencies (11)
Failed to ensure Advanced Directives were available in medical records for sampled residents.
Failed to ensure Minimum Data Set (MDS) assessments were coded accurately for sampled residents.
Failed to complete PASRR screenings in accordance with state process for residents with serious mental disorders.
Failed to ensure care plans were reviewed and revised to accurately reflect resident needs.
Failed to ensure training, assessments, and physician orders were implemented to prevent wheelchair harness injury; failed to ensure scissors were not in possession of residents on secure unit.
Failed to ensure food was served at safe and appetizing temperatures.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to ensure foods stored in freezer, refrigerator, and dry storage were covered, sealed, and dated; failed to ensure dietary staff washed hands before handling clean equipment or food; failed to maintain ice machines and scoop holders in clean condition.
Failed to follow and implement an appropriate plan of action to correct and monitor quality deficiencies from prior surveys including MDS coding and accident/hazard prevention.
Failed to ensure staff handling dirty laundry wore personal protective equipment to prevent cross contamination and infection spread.
Failed to ensure pneumococcal immunizations were administered to eligible residents and records updated accordingly.
Report Facts
Residents affected: 79
Residents sampled for MDS review: 18
Residents affected by food temperature issue: 59
Residents affected by pureed food consistency issue: 7
Residents affected by food storage and hygiene issues: 77
Residents affected by infection control laundry PPE issue: 79
Residents sampled for pneumococcal immunization review: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #6 | CNA | Witnessed wheelchair harness incident with Resident #1 |
| Licensed Practical Nurse #2 | LPN | Provided details on wheelchair harness incident with Resident #1 |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including wheelchair harness incident, infection control, and immunization tracking |
| Social Service Director | SSD | Interviewed regarding advanced directives and PASRR documentation |
| MDS Coordinator | Interviewed regarding MDS coding and care plan updates | |
| Dietary Manager | DM | Interviewed and observed regarding food temperature, food preparation, storage, and hygiene practices |
| Dietary Employee #2 | Observed handling food without proper hand hygiene | |
| Laundry Employee #1 | Observed handling dirty laundry without gloves | |
| Administrator | Interviewed regarding QAPI and prior deficiencies |
Viewing
Loading inspection reports...
