Inspection Reports for
White River Healthcare
1569 AR Highway 56, Calico Rock, AR 72519, AR, 72519
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
125% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 7
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident notification of transfer/discharge, bed hold policies, accident hazard prevention, staffing competencies, food safety, arbitration agreements, and infection prevention and control.
Findings
The facility was found deficient in timely written notification to residents or representatives regarding transfers and bed hold policies, ensuring resident environments were free from accident hazards, employing qualified dietary staff, maintaining food service equipment and storage in sanitary conditions, providing clear arbitration agreements, and implementing proper infection prevention and control practices including hand hygiene and cleaning of equipment.
Deficiencies (7)
Failed to notify resident/representative or Power of Attorney in writing of resident's transfer/discharge to hospital.
Failed to notify resident representatives or Power of Attorney in writing of bed hold policy upon resident transfer or discharge.
Failed to ensure resident environment was free from accident hazards; medications and wound cleanser improperly stored in Resident #31's room.
Failed to employ staff with appropriate competencies and skills for food and nutrition service; dietary manager not yet certified.
Failed to ensure food service equipment was clean and food stored safely; issues with refrigerator seals, thawed frozen items, dirty can opener blade, and unclean deep fryer baskets.
Failed to provide arbitration agreements that clearly informed residents or representatives about neutral and fair arbitration process.
Failed to ensure proper hand hygiene between residents, cleaning of personal equipment (fan), and adherence to Enhanced Barrier Precautions for a tube fed resident.
Report Facts
Residents reviewed for notification: 1
Residents reviewed for accident hazard: 1
Residents reviewed for arbitration agreements: 4
Residents reviewed for infection control: 1
Date of Minimum Data Set for Resident #5: Nov 6, 2024
Date of Minimum Data Set for Resident #31: Sep 10, 2024
Date of Minimum Data Set for Resident #7: Aug 20, 2024
Date of Resident #5 order to ER: Aug 13, 2024
Date of telephone message sent: Aug 14, 2024
Date of dietary manager position start: Dec 31, 2022
Number of small bowls observed uncovered: 20
Number of thawed fortified shakes and ice creams: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed wound cleanser and medications should not be in Resident #31's room |
| Director of Nursing | Confirmed medications should not be self-administered by Resident #31 | |
| Dietary Manager | Confirmed dietary certification not started, described food safety and sanitation issues | |
| Social Director | Confirmed notification process via telephone message system, no written notices sent | |
| Administrator | Confirmed dietary manager status and arbitration agreement omission | |
| C.N.A. #2 | Certified Nursing Assistant | Observed failing to perform hand hygiene before resident care |
| LPN #3 | Licensed Practical Nurse | Observed medication administration and confirmed Enhanced Barrier Precautions signage |
| Infection Preventionist nurse | Confirmed dirty fan in Resident #7's room and importance of cleaning |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as the annual survey of White River Healthcare to assess compliance with regulatory requirements across multiple areas including resident notification, safety, staffing, food service, arbitration agreements, and infection control.
Findings
The facility was found deficient in several areas including failure to notify residents or representatives in writing about transfers and bed hold policies, inadequate supervision to prevent accident hazards, insufficiently qualified dietary staff, unsanitary food storage and equipment conditions, incomplete arbitration agreements, and lapses in infection prevention and control practices such as improper hand hygiene and unclean personal equipment.
Deficiencies (7)
Failure to notify resident/representative or Power of Attorney in writing of resident's transfer/discharge to hospital.
Failure to notify resident representatives or Power of Attorney in writing of the bed hold policy upon transfer to hospital.
Failed to ensure resident environment remained free of accident hazards; medications and wound cleanser improperly stored in resident room.
Failed to employ staff with appropriate competencies and skills sets for food and nutrition service; dietary manager not yet certified.
Failed to ensure equipment was clean and food stored safely; multiple observations of dirty seals, thawed frozen foods, dirty can opener blade, rust, and cross contamination risks in kitchen.
Arbitration agreements failed to inform residents or representatives that arbitration venue must be neutral and agreed upon by both parties.
Failed to ensure proper hand hygiene between residents, cleaning of personal equipment, and adherence to Enhanced Barrier Precautions for a tube fed resident.
Report Facts
Residents reviewed for notification process: 1
Residents reviewed for accident hazard: 1
Residents reviewed for infection prevention: 1
Number of residents sampled for arbitration agreements: 4
Date of annual Minimum Data Set for Resident #5: Nov 6, 2024
Date of annual Minimum Data Set for Resident #7: Aug 20, 2024
Date of quarterly Minimum Data Set for Resident #31: Sep 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed wound cleanser, nasal spray, and cough drops should not be in Resident #31's room. |
| Director of Nursing | Confirmed medications should not be self-administered by Resident #31 and confirmed concerns about medication misuse. | |
| Dietary Manager | Confirmed dietary certification classes not started, described unsanitary kitchen conditions, and confirmed concerns about food safety and cross contamination. | |
| Administrator | Confirmed Dietary Manager's employment date and ongoing certification efforts; acknowledged possible omission in arbitration agreements; confirmed infection control concerns with dirty fan. | |
| Social Director | Confirmed facility uses computerized telephone message system for resident/representative communication and that no written notifications are sent for bed hold policy or hospital transfer reasons. | |
| C.N.A. #2 | Certified Nursing Assistant | Observed failing to perform hand hygiene between resident contacts and acknowledged hand hygiene should have been performed. |
| LPN #3 | Licensed Practical Nurse | Observed administering medications to Resident #7 and confirmed Enhanced Barrier Precautions signage meaning. |
| Infection Preventionist Nurse | Confirmed dirty fan in Resident #7's room and explained cleaning responsibility and infection risk. |
Inspection Report
Routine
Deficiencies: 5
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at White River Healthcare.
Findings
The facility was found deficient in multiple areas including failure to maintain a current surety bond for resident funds, incomplete care plans addressing oxygen needs, inadequate activities of daily living (ADL) care and nail care for residents, failure to follow physician orders for oxygen therapy, and lapses in infection prevention practices during medication administration. All deficiencies were cited with minimal harm or potential for actual harm to residents.
Deficiencies (5)
Failure to ensure a current and up-to-date Surety Bond to secure residents' personal funds.
Failure to develop and implement a comprehensive care plan addressing oxygen needs for Resident #20.
Failure to provide adequate care and assistance for activities of daily living, including personal hygiene and nail care, for Residents #15, #22, and #25.
Failure to provide safe and appropriate respiratory care by not following physician orders for oxygen flow rates for Residents #20 and #22.
Failure to implement infection prevention and control practices during medication administration, including hand hygiene and glove use.
Report Facts
Residents affected: 40
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 26
Surety Bond amount: 35000
Trust fund balance: 18101.16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager (BOM) | Provided surety bond documentation and trust fund account list | |
| Chief of Business Operations (CBO) | Discussed surety bond status and documentation with surveyor | |
| Licensed Practical Nurse (LPN #1) | Interviewed regarding oxygen orders and observed medication administration practices | |
| Director of Nursing (DON) | Interviewed regarding care plans, oxygen therapy, ADL care, and infection control policies | |
| MDS Coordinator | Interviewed about care plan responsibilities and updates | |
| Certified Nursing Assistants (CNA #1 and CNA #2) | Observed and interviewed regarding nail care and ADL assistance | |
| Licensed Practical Nurse (LPN #2) | Interviewed regarding oxygen flow rate checks |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at White River Healthcare.
Findings
The facility was found deficient in multiple areas including failure to maintain a current surety bond for resident funds, incomplete care plans addressing oxygen needs, inadequate activities of daily living (ADL) care and nail care for residents, improper oxygen therapy administration not following physician orders, and failure to follow infection prevention protocols during medication administration.
Deficiencies (5)
Failed to ensure a current and up-to-date Surety Bond to secure residents' personal funds.
Failed to develop and implement a comprehensive care plan addressing oxygen needs for Resident #20.
Failed to ensure Activities of Daily Living were maintained for 3 sampled residents, affecting hygiene and safety.
Failed to provide safe and appropriate respiratory care by not following physician orders for oxygen flow rates for Residents #20 and #22.
Failed to implement infection prevention and control practices during medication administration, including hand hygiene and glove use.
Report Facts
Residents affected: 40
Trust fund balance: 18101.16
Surety bond amount: 35000
Residents affected: 3
Residents affected: 26
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager (BOM) | Provided information and documentation related to surety bond | |
| Chief of Business Operations (CBO) | Discussed surety bond status and provided documentation | |
| Licensed Practical Nurse (LPN #1) | Interviewed regarding oxygen orders and observed medication administration practices | |
| MDS Coordinator | Interviewed about care plan responsibilities and oxygen care planning | |
| Director of Nursing (DON) | Interviewed about care plans, oxygen therapy, ADL care, nail care, and infection control policies | |
| Certified Nursing Assistants (CNA #1 and CNA #2) | Interviewed and observed regarding nail care and ADL assistance | |
| Licensed Practical Nurse (LPN #2) | Interviewed regarding oxygen flow rates for Resident #22 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation related to a cognitively impaired resident exhibiting exit-seeking behaviors and elopement from the facility, as well as concerns about care planning and documentation of resident behaviors.
Complaint Details
The investigation was triggered by a complaint regarding Resident #1 eloping from the facility on 06/11/23 and exhibiting exit-seeking behaviors. The complaint was substantiated by staff interviews and record reviews showing failure to have a care plan prior to the elopement and inadequate supervision. Documentation failures were also noted for Resident #3's wandering behaviors.
Findings
The facility failed to develop and implement a timely care plan for a resident at risk for elopement, failed to prevent the resident from exiting the facility unsupervised, and failed to maintain accurate medical records regarding resident behaviors. Multiple staff interviews confirmed the resident's exit-seeking behaviors and previous elopement incidents.
Deficiencies (3)
Failed to develop and implement a care plan for a resident exhibiting exit-seeking behaviors until after an elopement incident.
Failed to prevent a cognitively impaired resident from exiting the facility without staff supervision.
Failed to maintain accurate medical records regarding a resident's exit-seeking behaviors and wandering.
Report Facts
Residents sampled: 3
Elopement duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding Resident #1's elopement history and care plan requirements. |
| Certified Nursing Assistant #1 | CNA | Reported Resident #1's exit-seeking behaviors and elopement incident. |
| Certified Nursing Assistant #2 | CNA | Reported Resident #1's wandering and exit-seeking behaviors. |
| Certified Nursing Assistant #3 | CNA | Observed Resident #1 outside the facility during elopement. |
| Certified Nursing Assistant #4 | CNA | Reported on residents' exit-seeking behaviors. |
| Certified Nursing Assistant #5 | CNA | Reported on residents' exit-seeking behaviors. |
| Certified Nursing Assistant #6 | CNA | Reported Resident #1's exit-seeking behaviors and prior elopement. |
| Licensed Practical Nurse #1 | LPN | Reported Resident #3's exit-seeking behaviors and lack of documentation. |
| Licensed Practical Nurse #2 | LPN | Reported Resident #1 as a wanderer. |
| Licensed Practical Nurse #3 | LPN | Reported details of Resident #1's elopement incident. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop and implement adequate care plans and supervision to prevent elopement and wandering behaviors in residents at risk.
Complaint Details
The complaint investigation found that Resident #1 eloped from the facility on 06/11/23 and was found outside for less than 10 minutes. Staff interviews revealed multiple instances of exit-seeking behavior by Resident #1 that were not properly documented or addressed prior to the elopement. The facility also failed to document exit-seeking behavior of Resident #3. The Director of Nursing acknowledged that care plans and behavior documentation should have been in place.
Findings
The facility failed to develop and implement a timely care plan for a resident exhibiting exit-seeking and wandering behaviors, resulting in the resident eloping from the facility. Additionally, the facility failed to maintain accurate medical records documenting residents' wandering behaviors and did not provide adequate supervision to prevent accidents related to wandering and elopement.
Deficiencies (3)
Failed to develop and implement a complete care plan for a resident exhibiting exit seeking behaviors.
Failed to prevent a cognitively impaired resident from exiting the facility without staff supervision.
Failed to maintain an accurate medical record regarding a resident's behaviors for wandering.
Report Facts
Residents sampled: 3
Date of elopement: Jun 11, 2023
Date care plan initiated: Jun 12, 2023
Date of survey: Jun 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding Resident #1's wandering and care plan status |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Reported Resident #1's exit-seeking behavior and supervision practices |
| Certified Nursing Assistant #2 | Certified Nursing Assistant (CNA) | Reported Resident #1's exit-seeking behavior |
| Certified Nursing Assistant #3 | Certified Nursing Assistant (CNA) | Reported seeing Resident #1 outside the facility |
| Certified Nursing Assistant #4 | Certified Nursing Assistant (CNA) | Reported on exit-seeking residents including Resident #1 and Resident #3 |
| Certified Nursing Assistant #5 | Certified Nursing Assistant (CNA) | Reported on exit-seeking residents including Resident #1 and Resident #3 |
| Certified Nursing Assistant #6 | Certified Nursing Assistant (CNA) | Reported Resident #1's exit-seeking behavior |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Reported Resident #1's elopement and Resident #3's exit-seeking behavior |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) | Reported Resident #1 and Resident #3's exit-seeking behavior |
| Licensed Practical Nurse #3 | Licensed Practical Nurse (LPN) | Reported details concerning Resident #1's elopement |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Aug 12, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to timely report suspected abuse, neglect, or theft, specifically related to unexplained bruising on a resident.
Complaint Details
The complaint investigation found that bruises on Resident #6 were not reported or investigated timely. The Director of Nursing acknowledged the failure to report and initiated an investigation during the survey. The bruising was considered a possible sign of abuse.
Findings
The facility failed to investigate and report a bruise of unknown origin on Resident #6 in accordance with state law, potentially affecting all 50 residents. Additionally, the facility failed to ensure proper food safety practices including clean storage of dishware, maintenance of dietary equipment, and dating of nutritional supplements, potentially affecting 49 residents.
Deficiencies (2)
Failure to timely report suspected abuse related to unexplained bruising on Resident #6.
Failure to ensure dishware is stored in a clean location, dietary equipment is maintained in good working condition, and nutritional supplements are dated with a use by date.
Report Facts
Residents affected: 50
Residents affected: 49
Nutritional milkshakes counted: 17
Date of last professional hood cleaning: 202104
Date of hood inspection: May 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to failure to report bruising and initiation of investigation |
| Dietary Manager | Dietary Manager | Named in relation to food safety deficiencies and knowledge of hood cleaning and nutritional supplement dating |
| Maintenance Employee | Named in relation to knowledge of hood cleaning and inspection | |
| Business Office Manager | Named in relation to hood cleaning and inspection report |
Inspection Report
Routine
Census: 50
Deficiencies: 3
Date: Aug 12, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations related to timely reporting of suspected abuse, neglect, or theft, and to evaluate food safety and dietary equipment maintenance in the facility.
Findings
The facility failed to timely report a bruise of unknown origin on a resident and did not investigate or report it as required by state law. Additionally, the facility failed to ensure dishware was stored in a clean location, dietary equipment was properly maintained, and nutritional supplements were dated with use-by dates, posing potential risks for foodborne illness.
Deficiencies (3)
Failed to timely report suspected abuse related to bruising on Resident #6.
Failed to ensure dishware was stored in a clean location and dietary equipment was maintained in good working condition.
Failed to date nutritional supplements with use-by dates in the nourishment refrigerator.
Report Facts
Residents affected: 50
Residents affected: 49
Nutritional milkshakes counted: 17
Date of last professional hood cleaning: 202104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided resident list and commented on bruise reporting and investigation | |
| Dietary Manager | Interviewed regarding hood vent cleaning, nutritional supplement dating, and dietary equipment maintenance | |
| Maintenance Employee | Interviewed about hood vent cleaning and inspection | |
| Business Office Manager | Interviewed about hood vent cleaning and inspection reports |
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