Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
79% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Oct 31, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, facility environment, medication administration, and food service.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and hygiene, inaccurate and untimely resident assessments and care plans, unsafe medication administration practices including pre-popping medications, failure to maintain a safe and clean environment including water damage and unclean air vents, and failure to serve food at safe temperatures and maintain sanitary kitchen conditions.
Deficiencies (8)
Failure to shave, clean hands and face, and change clothing for Resident #2, violating resident dignity.
Failure to maintain a clean, safe, homelike environment including unrepaired water damage, stained furniture, and dirty air conditioning units.
Failure to ensure accuracy and timely completion of Minimum Data Set (MDS) assessments for Resident #2.
Failure to develop and update complete care plans with accurate information for Residents #2, #14, and #23.
Failure to provide adequate assistance with activities of daily living for Resident #2, including shaving, cleaning after meals, and changing soiled clothing.
Failure to prevent pre-popping of medications prior to administration for 7 residents, including Resident #5, #11, #15, #16, #26, #28, and #49.
Failure to serve hot foods at safe temperatures and cold dairy products cold, compromising food palatability and safety.
Failure to maintain sanitary kitchen environment including unclean ice machine scoop holder, expired food items, dirty walls and floors, chipped floor tiles, and improper hand hygiene by dietary staff.
Report Facts
MDS Assessment Reference Date: Sep 18, 2024
MDS Assessment Reference Date: Aug 9, 2024
MDS Assessment Reference Date: Oct 15, 2024
Temperature: 54.8
Temperature: 108.1
Temperature: 113
Temperature: 111.7
Temperature: 107.4
Temperature: 98.7
Temperature: 109
Temperature: 101.1
Temperature: 110.1
Temperature: 110
Temperature: 95.9
Temperature: 97
Temperature: 93
Temperature: 96.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in medication pre-popping deficiency and interview about medication administration practices |
| CNA #4 | Certified Nursing Assistant | Named in resident hygiene and dressing deficiencies for Resident #2 |
| Director of Nursing | Director of Nursing | Named in interviews confirming deficiencies in resident care, MDS accuracy, and medication administration |
| Administrator | Facility Administrator | Named in interviews regarding MDS inaccuracy follow-up and medication administration issues |
| MDS Coordinator | MDS Coordinator | Named in interviews regarding MDS assessment and care plan inaccuracies |
| CNA #3 | Certified Nursing Assistant | Named in observation and interview related to food service temperature and food cart handling |
| Dietary Aide | Dietary Aide | Named in observations of improper hand hygiene and food handling in kitchen |
| Lead Dietary | Lead Dietary | Named in observation of unclean ice machine scoop holder |
Inspection Report
Routine
Deficiencies: 4
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with safety, housekeeping, and maintenance standards to ensure a safe environment free from accident hazards and to maintain sanitary, orderly, and comfortable conditions for residents.
Findings
The facility failed to ensure medications were properly stored and contained, and mattresses fit bed frames to prevent injury for sampled residents. Additionally, housekeeping and maintenance deficiencies were noted, including peeling walls and torn mattresses that could cause harm to residents.
Deficiencies (4)
Failure to ensure medications were stored and contained properly for Resident #41, including presence of rubbing alcohol and pills left on the floor.
Failure to ensure mattress fit the bed frame for Resident #53, with a one-foot gap exposing the bed frame.
Failure to maintain sanitary and orderly environment, including peeling wall with hole behind Resident #40's bed.
Torn and peeling mattress with plastic shreds hanging on Resident #18's bed, posing risk of skin tears.
Report Facts
Gap between mattress and bed frame: 12
Hole diameter: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Provided information about medication storage and mattress condition |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Commented on medication storage concerns for Resident #41 |
| Maintenance #1 | Maintenance Staff | Responded to questions about mattress gap and wall damage, and reported repairs |
| Administrator | Administrator | Provided information about maintenance reporting procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure residents were assessed and deemed safe to self-administer updraft treatments using a nebulizer, specifically for Resident #4.
Complaint Details
The complaint investigation found that Resident #4 was left alone with a nebulizer running without staff supervision, contrary to facility policy and CMS guidelines. Staff and administration acknowledged that nurses are responsible for staying with residents during updraft treatments to ensure proper administration and safety.
Findings
The facility failed to ensure that Resident #4 was properly assessed and supervised during nebulizer treatments, resulting in potential risk of accidental overdose or respiratory complications. Staff interviews confirmed that nurses are responsible for staying with residents during such treatments, but Resident #4 was found alone with the nebulizer running.
Deficiencies (1)
Failed to ensure residents were assessed and deemed safe to self-administer updraft treatments using a nebulizer, risking accidental overdose or respiratory complications.
Report Facts
Residents affected: 1
Assessment Reference Date: Mar 6, 2023
Physician Order Start Date: Jan 22, 2023
Care Plan Initiated Date: Jan 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Named in relation to failure to supervise Resident #4 during nebulizer treatment | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about self-administration and supervision of updraft treatments | |
| Director of Nursing (DON) | Interviewed regarding facility policies and staff expectations on nebulizer treatment supervision | |
| Administrator | Interviewed regarding responsibility and expectations for staff supervision during updraft treatments |
Inspection Report
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
The inspection was conducted to assess compliance with medication administration policies, specifically regarding residents' self-administration of updraft treatments using a nebulizer.
Findings
The facility failed to ensure that residents were properly assessed and deemed safe to self-administer nebulizer treatments, as evidenced by one resident receiving treatment unsupervised, posing potential risk of overdose or respiratory complications.
Deficiencies (1)
Failed to ensure residents were assessed and deemed safe to self-administer updraft treatments using a nebulizer, risking accidental overdose or respiratory complications.
Report Facts
Residents in sample: 4
Residents affected: 1
Assessment Reference Date: Mar 6, 2023
Physician Order Start Date: Jan 22, 2023
Care Plan Initiated Date: Jan 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Mentioned in relation to failure to supervise Resident #4 during nebulizer treatment | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about self-administration and nurse responsibilities during updraft treatments | |
| Director of Nursing (DON) | Interviewed about facility policies and staff expectations regarding nebulizer treatments | |
| Administrator | Interviewed about staff responsibilities and policy adherence for nebulizer treatments |
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Jul 29, 2022
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided to residents.
Findings
The facility was found deficient in multiple areas including failure to provide timely and understandable transfer notifications to residents and representatives, inaccurate and untimely Minimum Data Set (MDS) assessments, incomplete care plans especially related to anticoagulant therapy and post-fall care, inadequate discharge planning and options counseling, poor personal hygiene assistance, unsafe smoking supervision and hazardous smoking areas, improper medication storage temperatures, incomplete pharmacist medication reviews in resident records, and food safety violations including improper food labeling, storage, and preparation.
Deficiencies (14)
Failed to notify residents and/or representatives in writing of the reason for hospital transfer in a language they understand for 3 residents.
Failed to ensure the Resident Assessment Instrument (RAI) was used and coded correctly, including inaccurate MDS coding for wandering and medication use.
Failed to complete quarterly MDS assessments timely for 1 resident.
Failed to accurately document weight loss in MDS for 1 resident.
Failed to develop and implement comprehensive care plans for residents on anticoagulant therapy and for residents with falls with major injury.
Failed to assess and document residents' interest in receiving information about returning to the community.
Failed to ensure residents were regularly assisted with shaving, grooming, and hair shampooing to maintain good hygiene.
Failed to supervise residents while smoking and maintain a safe, hazard-free smoking area.
Failed to ensure pharmacist's monthly medication reviews were placed in resident medical records.
Failed to ensure medications were stored at proper temperatures; medication refrigerator lacked thermometer and recorded temperatures above recommended levels.
Failed to ensure oral surgeon referral was made and family involvement documented for a resident with severe dental issues.
Failed to ensure pureed food was blended to a smooth, lump-free consistency; spaghetti puree contained lumps.
Failed to ensure food storage and preparation areas were sanitary, including proper labeling, dating, sealing of food items, and appropriate dishwasher sanitizer levels.
Failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan to address previously identified deficiencies related to MDS accuracy.
Report Facts
Residents affected by transfer notification deficiency: 3
Residents affected by wandering and MDS coding deficiencies: 2
Residents affected by untimely MDS completion: 1
Residents affected by inaccurate weight loss documentation: 1
Residents affected by anticoagulant care plan deficiency: 1
Residents affected by fall care plan deficiency: 1
Residents affected by dental referral deficiency: 1
Residents affected by pureed food preparation deficiency: 7
Residents affected by food safety deficiencies: 57
Residents affected by QAPI deficiency: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Mentioned in relation to smoking supervision deficiency |
| Assistant Director of Nursing | ADON | Mentioned in multiple interviews and responsible for MDS and medication storage oversight |
| MDS Coordinator | Mentioned in relation to MDS coding and care plan deficiencies | |
| Social Services Director | SSD | Mentioned in relation to discharge planning and options counseling |
| Dietary Manager | DM | Mentioned in relation to food preparation and safety deficiencies |
| Administrator | Interviewed regarding multiple deficiencies including smoking area hazards and QAPI |
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