DEWITT NURSING HOME
Non profit - Corporation
60 Beds
Independent
Data: November 2025
Trust Grade
40/100
#195 of 218 in AR
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
DeWitt Nursing Home has a Trust Grade of D, indicating below-average care with some significant concerns. Ranking #195 out of 218 facilities in Arkansas places it in the bottom half, and it is the lowest-ranked option in Arkansas County. Unfortunately, the facility is worsening, with issues increasing from 7 in 2023 to 14 in 2024. Staffing is somewhat stable, with a 3 out of 5 rating and a lower turnover rate of 33%, which is better than the state average. However, there are serious concerns, including the failure to ensure that a Registered Nurse was available for sufficient hours each day, as well as issues with food safety and cleanliness, indicating potential risks for residents.
- Trust Score
- D
- In Arkansas
- #195/218
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 33% turnover. Near Arkansas's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Arkansas facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 14 minutes of Registered Nurse (RN) attention daily — below average for Arkansas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 11%
No red flags
7 → 14 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 7 issues
2024: 14 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (33%)
15 points below Arkansas average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Arkansas average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 33%
13pts below Arkansas avg (46%)
Typical for the industry
The Ugly 31 deficiencies on record
Sept 2024
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record reviews, and facility policy reviews the facility failed to ensure personal and medical information was protected for 1 sampled (Resident #14) resident.
The ...
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Based on observations, interviews, record reviews, and facility policy reviews the facility failed to ensure personal and medical information was protected for 1 sampled (Resident #14) resident.
The findings include:
According to Physician's orders Resident #14 had a diagnoses of sequelae of cerebral infarction and depression
A review of the annual Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 8/21/2024 revealed Resident #14 scored 14 indicating cognitively intact.
A Care Plan for Resident #14 (problem date: 8/21/2024) revealed Resident #14 had Activities of Daily Living (ADL) self-care deficit as evidenced by: left side weakness due to Cerebrovascular accident (CVA).
On 09/11/24 at 7:30 AM, the Surveyor observed Registered Nurse (RN) #3 enter Resident #14's room and close the door. The Surveyor noted that the Medication Administration Record on the medication cart was open and displayed the resident's personal and medical information.
On 09/11/24 at 7:32 AM, RN #3 stated the Medication Administration Record (MAR) was open and the resident's information was visible. RN #3 stated anyone passing could potentially see the resident's date of birth , medical diagnosis, orders, name, and room number.
On 09/12/24 at 09:00 AM the Director of Nursing (DON) stated prior to the nurse walking away the MAR should be closed or the tab flipped over the MAR so no one can see the MAR. DON stated if the MAR is not closed or covered someone could walk up and read the MAR.
A policy titled Resident Rights documented 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:. privacy and confidentiality;.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 (Resident #24) of 1 sampled resident ...
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Based on observation, interview, record review, and facility policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 (Resident #24) of 1 sampled resident reviewed for abuse.
The findings are:
On 09/09/2024, the surveyors entered the facility to investigate an allegation of abuse for Resident #24.
On 09/09/2024 at 1:12 PM, Resident #24 was sitting up in a recliner in the resident's room. The resident was asked about the alleged incident and Resident #24 stated the resident barely remembered the incident. The resident stated the staff member was assisting the resident to a chair and the resident had difficulty walking. The resident denied any injuries.
Resident #24's Physician's Orders, dated 09/01/2024 through 09/30/2024, were reviewed and indicated the resident had a diagnosis of impaired thinking ability (dementia).
A quarterly Minimum Data Set with an Assessment Reference Date of 07/10/2024 was reviewed and indicated a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment.
The Resident Plan of Care, with a review date of 07/10/2024, was reviewed and indicated Resident #24 had an activity of daily living (ADL) self-care deficit and required assistance with walking.
On 09/10/2024, a 7734 Incident & Accident Information report, with a submission date of 05/01/2024 at 10:31 [AM], was reviewed and indicated the type of incident was abuse and the specific abuse was physical and verbal. The summary of incident indicated the resident's feelings were hurt and was thrown into a chair. The findings and actions taken indicated the resident was examined, no bruises were found, but the resident was crying and was reassured the incident would be investigated. There was a witness statement from the alleged staff member and a witness statement from the Administrator. There were no body audits completed on non-cognitive residents on the hall. There were no witness statements from other cognitive residents or other staff members. There was no in-service conducted on abuse with the staff members after the incident. There was no indication the alleged staff member was removed from all resident care, only the alleged victim's care, pending the investigation
On 09/12/2024 at 2:34 PM, the Director of Nursing (DON) was interviewed and asked who completed the report of alleged abuse for Resident #24 and stated she did. She was asked what happens when an abuse allegation is reported and she stated an investigation is immediately started and the following events take place: they speak to the resident, if known, the person whom the allegation is against, and the person who reports the incident; get witness statements, and the family and police are notified. She stated during the investigation, the alleged person has no access to the resident and is taken off the schedule, at times, until the investigation is completed.
She stated the alleged resident who received the abuse and other residents who mentioned if something happened received body audits. The DON was asked if any other staff and cognitively intact residents were interviewed. She stated they try to determine if others saw, heard, or witnessed anything and would interview them. She was asked if she did body audits on the cognitively impaired residents on the hall of the alleged incident and she stated no. She confirmed she was not sure if she interviewed other staff members or cognitively intact residents who resided on the hall of the alleged incident. She stated she thought the alleged staff member was taken off the hall, but did not remember without looking at the report.
An Abuse/Neglect Policy and Procedure, with an effective date of 09/24/2024, was reviewed and indicated the facility would attempt to identify and will investigate any reported violation or allegation of same. The abuse policy indicated during the investigation, any individual suspected of resident abuse would be placed on administrative leave without pay and is banned from returning to the facility while being investigated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review, and interview, the facility failed to ensure a comprehensive plan of care was updated to include the use of oxygen for 1 (Resident #20) of 1 sampled resident who was reviewed f...
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Based on record review, and interview, the facility failed to ensure a comprehensive plan of care was updated to include the use of oxygen for 1 (Resident #20) of 1 sampled resident who was reviewed for oxygen use.
The findings are:
On 09/09/2024 at 12:29 PM, Resident #20 was not in the resident's room and there was an oxygen (O2) concentrator on, and the flow rate was set at 2.5 liters per minute (l/min). At 12:36 PM, the resident was sitting up in a recliner with nasal cannula (NC) prongs in the resident's nose. The oxygen concentrator was on, and the flow rate was set at 2.5 l/min.
Resident #20's annual Minimum Data Set (MDS) with an Assessment Reference Date of 07/09/2024 was reviewed and indicated the resident had a Brief Interview for Mental Status score of 9, which indicated moderately cognitively intact and received oxygen therapy.
Resident #20's Physician's Orders for 09/01/2024 through 09/30/2024 were reviewed and indicated an order for oxygen at 2 liters/NC as needed for shortness of breath.
Resident #20's Resident Plan of Care, with a review date 07/09/2024, was reviewed and oxygen use was not indicated.
On 09/12/2024 at 1:15 PM, the Director of Nursing (DON) was interviewed and asked if she was completing the MDS assessments and she stated yes. She was asked when the care plans were updated, and she stated quarterly. She stated the information put in from the MDS triggers what all needs to be care planned.
On 09/12/2024, the DON stated the facility did not have a policy for care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure oxygen was administered at the physician's ordered flow rate to decrease the potential for respiratory complications f...
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Based on observation, interview, and record review, the facility failed to ensure oxygen was administered at the physician's ordered flow rate to decrease the potential for respiratory complications for 1 (Resident #20) of 1 sampled resident reviewed for oxygen therapy.
The findings are:
On 09/09/2024 at 12:36 PM, Resident #20 was sitting up in a recliner with nasal cannula (NC) prongs in the resident's nose. The oxygen concentrator was on, and the flow rate was set at 2.5 liters per minute (l/min).
Resident #20's annual Minimum Data Set with an Assessment Reference Date of 07/09/2024 was reviewed and indicated the resident had a Brief Interview for Mental Status score of 9, which indicated moderately cognitively intact and received oxygen therapy.
Resident #20's Physician's Orders for 09/01/2024 through 09/30/2024 were reviewed and indicated oxygen 2 liters/NC as needed for shortness of breath.
Resident #20's Resident Plan of Care, with a review date 07/09/2024, was reviewed and oxygen use was not indicated.
On 09/10/2024 at 3:44 PM, Resident #20 was sitting up in a recliner with nasal cannula prongs in the resident's nose. The O2 concentrator was on and set at 2.5 l/min.
On 09/10/2024 at 4:04 PM, during an interview and concurrent observation, Licensed Practical Nurse (LPN) #2 was asked to look at the O2 concentrator to observe the flow rate. She looked at the oxygen concentrator and confirmed the resident's flow rate was set at two and a half liters (2.5l). She confirmed the resident's current physician's ordered oxygen flow rate was 2 liters. She was asked who checks the oxygen flow rate and she stated the nurse on shift checked the rate once a day. She was asked why the oxygen flow rate should be checked and she stated to make sure the flow rate was correct rate.
On 09/12/2024 at 1:31 PM, the Director of Nursing was asked if the oxygen flow rate was on the medication administration record (MAR) for the nurses to check. She stated she did not think the MAR indicated the oxygen was to be checked for the correct liters.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observations, interviews, record review, and facility policy review, the facility failed to ensure dignity was maintained for 2 sampled (Resident #21, #31) sampled residents.
The findings in...
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Based on observations, interviews, record review, and facility policy review, the facility failed to ensure dignity was maintained for 2 sampled (Resident #21, #31) sampled residents.
The findings include:
1. According to Physician's orders, Resident #31 had a diagnosis of transient cerebral ischemic attack.
a. A review of the admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 7/05/2024 revealed Resident #31 scored 13 on a Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact and had an indwelling catheter.
b. A Care Plan for Resident #31 (problem date: 7/05/2024) revealed Resident #31 was experiencing incontinent episodes of bowel and/or bladder.
c. On 09/09/24 at 12:53 PM, the Surveyor observed Resident #31 sitting in wheelchair in the room. The Surveyor noted the catheter bag was uncovered and easily visible.
d. On 09/09/24 at 1:46 PM, the Surveyor observed Resident #31 sitting in wheelchair in the hallway. The Surveyor noted the catheter bag was uncovered and easily visible.
e. On 09/09/24 at 1:46 PM, Certified Nursing Assistant (CNA) #5 confirmed Resident #31's catheter bag was uncovered and visible. CNA #5 stated the catheter bag should be covered. I don't know why the catheter bag does not have a cover.
f. On 09/12/24 at 09:00 AM, the Director of Nursing (DON) stated Resident #31 had an indwelling catheter and the catheter had been observed uncovered. The DON stated is it important for an indwelling catheters to be covered to maintain the dignity of the resident
2. According to Physician's Orders, Resident #21 had a diagnosis of vascular dementia.
a. A review of the quarterly MDS with the ARD of 6/08/2024 revealed Resident #21 scored 2 on a BIMS, indicating severe cognitive impairment.
b. A Care Plan for Resident #21 (problem date: 12/07/2023) revealed Resident #21 had impaired cognitive skills evidenced by short term memory loss related to inability to care for self without assistance and being a fall risk.
c. On 09/11/24 at 09:43 AM, the Surveyor observed Certified Nursing Assistant (CNA) #4 pushing Resident #21 to the room in a shower chair. The Surveyor noted that Resident #21 was not fully covered, the right side of upper thigh was exposed.
d. On 09/11/24 at 09:44 AM, CNA #4 confirmed Resident #21 was not covered all the way.
e. On 09/12/24 at 9:00 AM, the Director of Nursing (DON) stated staff should ensure residents are cover down to the knees when transporting the resident from the shower room to the room in a shower chair to maintain the resident's dignity.
f. A policy titled, Dignity, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a helping the resident to keep urinary catheter bag covered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
Based on interviews, record review, and policy review, the facility failed to provide access to resident personal funds during the evening and weekends.
The findings are:
1. On 09/11/2024 at 1:30 PM,...
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Based on interviews, record review, and policy review, the facility failed to provide access to resident personal funds during the evening and weekends.
The findings are:
1. On 09/11/2024 at 1:30 PM, the surveyor spoke with members of the Resident Council regarding residents being able to gain access to their trust funds during the evening and weekend. Resident #28 indicated that if you don't get your money on Friday, you don't have any money for the weekend. Resident #10 indicated that if you don't get your money during the week, you won't have any for the weekend.
2. On 09/12/2024 at 9:00 AM, the Business Office Manager (BOM) indicated that as far as she knew the residents didn't get money on the weekend. The BOM indicated the residents get money before the weekend, or they don't get it.
a. A policy titled, Management of Resident's Personal Funds, provided by the BOM on 09/12/2024 at 9:45 AM did not address how or when residents can access personal funds.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
Based on interviews, record review, and policy review, the facility failed to provide quarterly personal funds account statements to residents or legal representatives.
1. On 09/11/2024 at 1:30 PM, d...
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Based on interviews, record review, and policy review, the facility failed to provide quarterly personal funds account statements to residents or legal representatives.
1. On 09/11/2024 at 1:30 PM, during an interview the members of the Resident Council stated they do not receive a statement of their personal funds account.
a. On 09/12/2024 at 9:00 AM, during an interview the Business Office Manager (BOM) she does not send out quarterly statements to the resident or their legal representatives, but she will print a statement when a resident asks for one.
b. A policy titled, Management of Resident's Personal Funds, provided by the BOM on 09/12/2024 at 9:45 AM, did not address quarterly statements.
2. On 09/12/2024 at 9:00 AM, the BOM indicated the they have a separate petty cash that they use to keep resident's money. The BOM indicated that she did not know how much money could be held in an account without drawing interest for Medicaid residents.
a. Review of a list titled, Residents In House Account provided by the BOM on 09/12/2024 at 9:56 AM, revealed twenty-one residents who had an in-house account, seven of those residents were Medicaid residents and had balances over $50.00. Resident #23 had a balance of $120.14; Resident #10 had a balance of $51.02; Resident #4 had a balance of $147.14; Resident#15 had a balance of $211.50; Resident #18 had a balance of $99.25; and Resident #6 had a balance of $61.00.
3. A policy titled, Management of Resident's Personal Funds, provided by the BOM on 09/12/2024 at 9:45 AM did not address in-house accounts or petty cash accounts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on record review, and interview, the facility failed to ensure care plans were revised at least quarterly and/or when the residents care needs changed for 1 (Resident #24) of 12 (Residents #2, #...
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Based on record review, and interview, the facility failed to ensure care plans were revised at least quarterly and/or when the residents care needs changed for 1 (Resident #24) of 12 (Residents #2, #4, #6, #10, #14, #20, #21, #22, #24, #28, #30 and #31) sampled residents whose care plans were reviewed.
The findings are:
Resident #24's, Physician's Orders, dated 09/01/2024 through 09/30/2024, were reviewed and indicated a diagnosis of loss of thinking abilities that interfere with daily life (dementia) and right artificial hip joint. There were two orders dated 03/06/2024 for a pain medication. One order indicated one tablet by mouth, and the second order indicated two tablets by mouth, and both were as needed for pain. An order dated 06/25/2024 indicated a patch for pain apply one patch every 72 hours and cover with a [brand name] clear adhesive.
The quarterly Minimum Data Set with an Assessment Reference Date of 07/01/2024, was reviewed and indicated the resident had a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment, and the resident was taking an opioid, which is a high-risk pain medication.
b. Resident #24's Resident Plan of Care, with a review date of 07/09/2024, was reviewed and indicated a pain patch 12 micrograms per hour and cover with a clear adhesive every 3 days. The plan of care did not include any signs, symptoms or adverse reactions to monitor the resident for.
On 09/12/2024 at 1:24 PM, the Director of Nursing was interviewed and asked if Resident #24 had an order for pain patches, a high-risk medication, and she stated yes. She was asked should the medication be care planned and she stated yes. She was asked why, and she stated for possible side effects of the medication to monitor the resident for. She stated the facility did not have a policy for care plans.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and facility policy review, the facility failed to ensure potential hazardous chemicals were securely locked away.
The findings include:
1. On 09/09/24 at 11:04 AM,...
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Based on observations, interviews, and facility policy review, the facility failed to ensure potential hazardous chemicals were securely locked away.
The findings include:
1. On 09/09/24 at 11:04 AM, the Surveyor observed an unlocked closet door titled, Janitor on East Hall. The Surveyor noted cleaning chemicals inside the unlocked closet door.
2. On 09/09/24 at 11:04 AM, the Surveyor observed an unlocked Whirlpool room with cleaning chemicals and aerosol can of degreaser.
a. On 09/09/24 at 11:05 AM, the Director of Nursing (DON) stated the Whirlpool room and the Janitor's closet doors should be locked when unattended when not in use.
3. On 09/09/24 at 11:17 AM, the Surveyor observed a closet door unlocked with a sign posted on the door that stated, If you open this door-please latch it back this door needs to be locked latched at all times!!on South Hall. The Surveyor noted several cleaning chemicals and aerosol cans in the unlocked closet.
a. On 09/09/24 at 11:18 AM, during an interview Housekeeping #6 stated the door with the signage that states it should be latched at all times was not latched. Housekeeping #6 stated cleaning supplies that could be harmful were stored in the unlocked closet.
4. On 09/09/24 at 11:23 AM, the Surveyor observed a closet door unlocked titled, Soiled Linen on North Hall.
a. On 09/09/24 at 11:25 AM, during an interview the Director of Nursing stated the unlocked door to the closet labeled Soiled Linen should be locked.
5. On 09/11/24 at 08:10 AM, the Surveyor observed an unattended housekeeping cart with a spray bottle hanging from the handle and the door slightly ajar.
a. On 09/11/24 at 08:10 AM, during an interview Housekeeping staff #6 stated the spray bottle was air freshener. Housekeeping staff #6 stated the keys in her possession did not lock or unlock the housekeeping cart therefore she could not lock it.
b. On 09/11/24 at 09:30 AM, during an interview the Environmental Supervisor stated the door to the closets titled, Janitor, Soiled Linen , Whirlpool, and door with the signage that states If you open this door-please latch it back This door needs to be locked latched at all times!! should be locked when not in use, because a resident could get hurt or get into the chemicals. The Environmental Supervisor stated some of locks on the housekeeping are broken and, We have never locked them in the year and half that I have been here.
A policy titled, Policy and Procedure for Chemical Storage indicated The designated [Environmental Services] EVS area should be as follows: have locks fitted to all doors and restrict access only to cleaning staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review, the facility failed to ensure nurse staffing was posted to include the census and names direct care staff with the total number of hours worked an...
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Based on observations, interviews, and record review, the facility failed to ensure nurse staffing was posted to include the census and names direct care staff with the total number of hours worked and actual hours worked per shift by licensed and unlicensed staff.
The findings include:
On 09/11/24 at 9:34 AM, the Surveyor noted a staff log on a table near the entrance. The Surveyor noted there was one name written on the staffing log.
On 09/12/24 at 9:00 AM, the Director of Nursing (DON) stated there was a staff log visible, but it was incomplete. The DON stated the staff log did not have the census listed or all the staff members working at the time. The DON confirmed that the staff logs from previous days were also incomplete and did not have the total number of hours worked and actual hours per shift for licensed and unlicensed staff, and the facility did not have that information required but will from now on.
On 09/12/24 at 10:25 AM, the DON provided the Surveyor with documentation that indicated the facility did not have a policy and procedure on staffing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and facility policy review, the facility failed to ensure that medications and/or biologicals were securely locked away.
The findings include:
On 09/11/24 at 7:30 AM...
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Based on observations, interviews, and facility policy review, the facility failed to ensure that medications and/or biologicals were securely locked away.
The findings include:
On 09/11/24 at 7:30 AM, the Surveyor observed Registered Nurse (RN) #3 enter a resident's room and close the door. The Surveyor noted that the medication cart left unattended in the hallway was unlocked.
On 09/11/24 at 7:32 AM, RN #3 stated the unattended medication cart was unlocked and stated someone could have gotten in the unlocked medication cart and taken the medications.
On 09/12/24 09:00 AM, the Director of Nursing (DON) stated the nurses should lock the medication cart prior to leaving the cart unattended and staff and/or residents could get into the medication cart if left unlocked.
A policy titled Storage of Medications indicated, 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and facility policy review, the facility failed to ensure food items were properly stored and labeled in the refrigerator and freezer in 1 of 1 kitchen, and failed to ...
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Based on observation, interview, and facility policy review, the facility failed to ensure food items were properly stored and labeled in the refrigerator and freezer in 1 of 1 kitchen, and failed to ensure the ice machine was properly cleaned in 1 of 1 kitchen.
The findings are:
On 09/09/2024, initial kitchen rounds were performed, and the following observations were made:
1. At 11:24 AM, the freezer had clear packages of pancakes with no dates on either side of the wrapper. There was a piece of toast in a clear plastic bag dated 9/3/24, with no indication what the date meant.
2. At 11:34 AM, the Dietary Manager (DM) was interviewed, and concurrent observations were made. She was asked to check the ice machine located in the kitchen. With gloved hands, she took a clean, white paper towel, placed the paper towel on the area where the ice falls inside the ice machine, swiped from right to left, and she stopped mid-center. This surveyor and the DM looked at the paper towel, and there was a transfer of yellow residue to the paper towel. The DM took another clean paper towel and started in the middle of the ice machine where the ice falls, swiped mid-center, all the way left and there was a transfer of yellow residue to the paper towel. The DM was asked to describe the color of the residue, and she stated, Tan. She was asked who cleans the ice machine and she stated she checked it that morning but did not clean the area that she was asked to swipe. She stated maintenance cleans the ice machine yearly.
3. At 11:39 AM, the refrigerator in the kitchen contained the following items:
a. A clear plastic bag of cooked hamburger meat dated 9/8/24 with no indication of what the date meant.
b. A container of black-eyes peas with a preparation (prep) date of 9/7/24, and the use by date was blank.
c. A clear container with a green top labeled pork loin with a prep date of 9/7/24, and the use by date was blank. The green lid on the clear container was not completely sealed.
On 09/09/24 at 11:42 AM, the DM was asked to look at the green lid that covered the clear container of pork loin inside the refrigerator in the kitchen. She was asked if the container was sealed, and she stated the container was not properly sealed. She was asked what the use by date was for the container with the green lid and she stated, The policy states we can keep it for three days and then throw it out. She was asked if that date was indicated on the container, and she stated it was not. She was asked if there were use by dates on the other items listed above, and she stated, No ma'am.
4. At 11:51 AM, in the stand-up freezer, there was a bag of frozen chicken breasts, confirmed by the DM, with no date on either side of the bag.
An Ice Machine Cleaning Schedule policy, not dated and provided by from DM on 09/12/2024, was reviewed and indicated weekly cleaning of the ice storage compartment, around the edges and areas where ice contact is made would be done and documented on the cleaning schedule log.
A Storage policy, updated 11/12/2019 and provided by the DM on 09/12/2024, was reviewed and indicated all foods stored in the refrigerator would be tightly covered, labeled, and dated, and leftovers would be destroyed in 72 hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, record review, and facility policy review, the facility failed to ensure isolation signage was posted in an area to alert staff, residents and visitors which precautio...
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Based on observation, interview, record review, and facility policy review, the facility failed to ensure isolation signage was posted in an area to alert staff, residents and visitors which precautions were required before entering a resident's room who was positive for Coronavirus Disease 2019 (COVID-19) for 1 (Resident #15) of 1 sampled resident who was reviewed for isolation precautions, and failed to ensure the water management program contained the necessary components and was consistently implemented to monitor for Legionella and other water-borne pathogens in 1 of 1 facility.
The findings are:
1. On 09/09/2024 at 11:10 AM, the entrance conference was conducted with the Administrator. She was asked if any residents were on transmission-based precautions, and she stated two residents in the facility were positive for COVID-19. The 3.0 Resident Roster, provided by the Administrator the same morning, was reviewed later in the day and did not indicate any residents had infections.
On 09/09/2024 at 1:01 PM, Resident #15 was in the room sitting up in a wheelchair and the door was open. There was a tan trash bin with a clear liner on the outside of the doorway. This surveyor stepped to the left of the doorway and observed two different signs posted on the door to the room. One sign indicated the personal protective equipment (PPE) was to be removed outside of the room and placed in the trash, unless a [type] mask was being used for the staff member's protection. The other sign indicated the resident was required to wear a surgical/cloth mask, if capable, when staff was in the room performing care. As this surveyor was standing in the doorway talking with the resident, an unidentified staff member walked up the hallway with a mask on and stated, Ma'am, [Resident #15] has COVID and is not supposed to have that door open. There was no other signage on the resident's door, doorway or walls on either side of the doorway, to indicate the resident was on contact or droplet precautions. There was a yellow isolation cart across the hall and to the side of another resident's doorway.
On 09/09/2024, Resident #15's hard chart was reviewed. There was no order on the Physician's Orders, dated 09/01/2024 through 09/30/2024, to indicate the resident was on contact/droplet precautions.
An annual Minimum Data Set with an Assessment Reference Date of 08/07/2024 was reviewed and indicated Resident #15 had a Brief Interview for Mental Status score of 9, which indicated moderate cognitive impairment.
On 09/10/2024 at 3:49 PM, Resident #15 was sitting in the doorway of the resident's room in a wheelchair with no mask on. There was a beige trash can outside the resident's room with a clear plastic bag in it. There was no isolation signage on the resident's door to indicate the resident was on contact/droplet precautions.
On 09/10/2024 at 3:53 PM, Licensed Practical Nurse (LPN) #2 was interviewed with concurring observations and asked if Resident #15 was on isolation precautions and she replied ,yes, droplet for COVID. She was asked how the staff and visitors knew what type of precautions and she stated signs on the door. The nurse was asked to state what the sign on the door indicated regarding PPE, and she stated, how to take off the PPE.
On 09/12/2024 at 9:08 AM, the Infection Preventionist (IP) was asked what type of precautions Resident #15 was on and he stated, respiratory precautions. He was asked what PPE was required and he stated, gowns, face shield, face mask and full PPE. He was asked how staff / visitors knew what type of precautions to use for residents on isolation and he stated, by the signage posted outside the door. He was asked who was responsible for putting up the signage for staff / visitors. He stated, he, the DON, or Administrator could do it.
2. On 09/11/2024 at 1:15 PM, the Maintenance Supervisor provided a Legionella Water Management Program policy and a diagram of the water flow. He was asked if this was all he had for the facility's Water Management Program and he stated, Yes. Another surveyor asked, What about your water temperatures? and he stated, I have that in another book. I think things got divided out to others.
On 09/11/2024 at 10:00 AM, a Nursing Home Water Temp Check document, provided by the Maintenance Supervisor, was reviewed. 2024 was written under the title and four columns were labeled as follows: date, room, room, room. There were dates in each row under the date section, and each room column had a room number and temperature, but it did not indicate if the temperature was in Celsius or Fahrenheit. The log did not indicate where the temperatures were taken, such as the faucets. The log did not include any temperatures for any hot water heaters, boiler rooms, sinks, showers or the whirlpool, which were indicated on the diagram.
On 09/12/2024 at 8:47 AM, the Administrator was asked to provide everything she had regarding the facility's water management program since the Maintenance Supervisor stated items may have been divided out over time to others. There was no information provided regarding the water management team members, no identified areas where Legionella could grow, no identification of situations that could lead to Legionella growth or control measures in the incident of an outbreak. There was no date to indicate when or if the program was reviewed / updated. The Administrator did not provide any other information prior to the surveyor's exit of the building.
A Legionella Water Management Program policy, not dated, was reviewed and indicated the purpose of the water management program was to identify areas in the water system where Legionella bacteria could grow and spread and to reduce the risks of the disease. The policy indicated the elements to be included in the water management program to include the team members, a detailed description and diagram of the facility's water system, identified areas in the water system that could encourage Legionella growth, identified situations that could lead to Legionella growth, yearly review, or sooner of the water management program, and specific control measures for Legionella.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs o...
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Based on record review and interview, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 32 residents.
The findings are:
1. A review of the Comprehensive Facility Assessment, dated November 2017, was reviewed and did not contain the following required information:
a. Documentation of staff involved with developing the assessment, which must include a member of the governing body, the medical director, the administrator, the director of nursing, and direct care staff.
b. An initiated and/or revision date of completion to show a minimum of a yearly review
c. The resident population including the facility's resident capacity
d. The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population
e. The care required by the resident population, using evidence-based, data-driven methods that consider an evaluation of diseases, conditions, physical and behavioral health needs, cognitive status, acuity of the resident population consistent with resident assessments to help the facility understand the potential implications regarding the intensity of care and services needed
f. Staffing plan to evaluate of the overall number of facility staff needed to ensure available and sufficient number of qualified staff are available to meet each resident's needs based on the facility census and address staffing needs for each resident unit and each shift to ensure coordination and continuity of care
g. Competency-based skill set approach to make informed staffing decisions to ensure there are a sufficient number of staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice as identified through the resident assessments and plans of care
h. Plan to recruit and retain enough medical personnel who are adequately trained and knowledgeable in the care of residents and/or how management expectations of medical personnel.
i. The facility's resources including all buildings and/or other physical structures and vehicles, medical and non-medical equipment necessary to provide for the needs of residents, services provided (physical therapy, pharmacy, behavioral health, etc.), and all personnel, (management, direct care staff, and volunteers) which include employees and contracted employees along with their education and competencies
j. Heath information technology resources for managing resident records and sharing information with other organizations
k. A contingency plan for events that do not require the activation of the facility emergency plan but have the potential to impact resident care, such as the availability of direct care nurse staffing or other resources needed for care of residents.
2. On 09/12/2024, the Administrator was asked to provide all data she had pertaining to the facility's assessment, including the emergency preparedness. She stated she knew she did not have the dietary information regarding the food and those vendors. The Administrator provided more modules for the public emergency service. She was asked for the information regarding the staff training, competencies, resident acuity levels and she stated she was not done completing the modules on the computer and knew she did not have all the required information. She stated she was scheduled to attend a meeting on how to complete the facility assessment later in the month.
Oct 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure 2 Residents (Resident #19 and Resident #17) catheters were properly secured to prevent potential complications. The fi...
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Based on observation, record review, and interview, the facility failed to ensure 2 Residents (Resident #19 and Resident #17) catheters were properly secured to prevent potential complications. The findings are:
The following observations were made on 10/02/23 for Resident #17:
At 11:52 AM Resident #17 was in bed, catheter at bedside with no device to secure the catheter was in place.
At 4:34 PM, Resident #17 was in bed with catheter at bedside. Infection Control Preventionist (ICP) was asked to check for a leg band or catheter stabilization device. The ICP confirmed there was no leg band or catheter stabilization device.
The following observations were made on 10/2/23 for Resident #19:
At 12:28 PM, Resident #19's catheter drainage bag was hanging from the right bed frame. No device to secure the catheter was in place.
At 5:40 PM, observed Resident #19's, catheter drainage bag hanging from the bed frame. No device to secure the catheter was in place.
On 10/03/23 at 08:15 AM, observed Resident #19 with catheter drainage bag attached to the side of the wheel chair. No device to secure the catheter was in place.
During an interview on 10/04/23 at 3:28 PM, Licensed Practical Nurse (LPN) #2 confirmed the catheter tubing should be secured with a leg strap and a catheter stabilization device.
During an interview on 10/04/23 at 3:23 PM, the Director of Nursing (DON) confirmed the catheter tubing should be secured with a leg strap.
Review of the facility policy titled, Incontinent and Catheter Care no date, showed, secure catheter strap .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the confidentiality of resident records were kept private by closing the paper medication administration record when n...
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Based on observation, interview, and record review, the facility failed to ensure the confidentiality of resident records were kept private by closing the paper medication administration record when not in use. The findings are:
On 10/04/2023 at 4:39 PM during a medication pass observation Licensed Practical Nurse (LPN) #3 walked away from the medication cart with the medication administration record left open visible on the medication cart.
During interview on 10/04/2023 at 4:45 PM, LPN #3 said the medication administration record should be closed prior to leaving the cart.
During interview on 10/04/2023 at 5:00 PM, the Director of Nursing (DON) said prior to leaving the medication cart the medication administration record should be closed.
Record review on 10/05/2023 at 8:08 AM of the facility policy titled, HIPAA [Health Insurance Portability and Accountability Act] showed all employees are to protect the residents health information such as, closing the MARs [medication administration records] when the medication cart is unattended.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to ensure the residents environment was free of potential accident/hazards for 23 residents who are mobile and who reside in the ...
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Based on observation, record review and interview, the facility failed to ensure the residents environment was free of potential accident/hazards for 23 residents who are mobile and who reside in the facility. The findings are:
The following observations were made on 10/03/2023:
a. At 9:40 AM, a can of disinfectant spray was in Resident #16's bathroom.
b. At 11:08 AM, a can of disinfectant spray was in Resident #16's bathroom.
c. At 12:36 PM, in south hall, a container of germicidal wipes was sitting on top of an isolation cart.
d. At 5:11PM, a can of disinfectant spray was in a Resident #16's bathroom.
Review of the germicidal wipes label showed WARNING call a poison control center or the doctor for treatment. Eye damage can occur.
Review of the disinfectant spray label showed hazardous to humans, extremely flammable, and harmful if absorbed through skin.
During interview on 10/04/23 at 11:31 AM, Certified Nursing Assistant (CNA) #4 confirmed the back of the disinfectant spray can said it was hazardous to residents and the spray should not have been stored in Resident #16's bathroom.
During interview on 10/04/2023 at 11:33 AM, the DON confirmed the disinfectant spray should not have been stored in Resident #16's bathroom.
On 10/04/23 at 11:36 AM, the Surveyor requested a chemical storage policy, and the Administrator confirmed there was no policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview the facility failed to ensure that medications were stored properly for 1 medication room an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview the facility failed to ensure that medications were stored properly for 1 medication room and 1 of 2 medication carts. The findings had the potential to affect 32 who reside at the facility. The findings are:
The following observations were made on [DATE] at 12:10 PM:
a. In the medication room was 1 vial of Ativan 30 ml (milliliters) in the emergency kit, with a prescription number of 6766402, and the resident had expired on [DATE].
b. In medication cart #1, the following was observed:
1. Two opened vials with 15 ml each with no open dates.
2. One vial of tuberculin with an open date of [DATE] and an expiration date of [DATE].
3. One bottle Novolin R insulin with an open date of [DATE].
4. One Toujeo pen with an open date of [DATE].
5. Seven Phenobarbital tablets belonging to a resident who was discharged home on [DATE].
During interview on [DATE] at 12:28 PM, Licensed Practical Nurse (LPN) # 2 said after residents are discharged , expire, or the medication has expired or been discontinued, the Director of Nurses (DON) picks up the narcotics monthly and the other medications are left in the drawer. LPN #2 confirmed that insulin, lidocaine, and tuberculin can be used once opened 28 and 45 days.
During interview on [DATE] at 2:11 PM, the DON said the last time the narcotics were sent off for destruction was in April, and confirmed insulin, lidocaine, and Tuberculin last 28 days once opened.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents...
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Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets. The findings are:
During observation on 10/04/23 at 10:47 AM, Dietary Employee (DE)
#1 placed 5 fried catfish into a blender, 4 slices of bread and broth. She pureed the mixture. At 10:54 AM, she poured the pureed fried breaded catfish into a pan on the steam table. The consistency of the pureed fried bread catfish was lumpy, thick, and not smooth with pieces of fish in the mixture.
During observation on 10/04/23 at 10:56 AM, DE #1 used a 4-ounce spoon to place 5 servings of squash into a blender to puree. At 10:57 AM she poured the pureed squash into a pan on the steam table. The consistency of the pureed squash was runny and was not formed.
During observation on 10/05/23 at 7:59 AM, the pureed pancakes were lumpy and not smooth, and the pureed oatmeal was runny and not formed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on record review and interivew, the facility failed to ensure a Registered Nurse (RN) worked at least 8 consecutive hours a day, 7 days a week, each week. The findings are:
On 10/4/23 review of ...
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Based on record review and interivew, the facility failed to ensure a Registered Nurse (RN) worked at least 8 consecutive hours a day, 7 days a week, each week. The findings are:
On 10/4/23 review of the RN staffing timecards from March 2023 to June 2023 showed, no RN worked at the facility for 3/25/23, 3/26/23, 4/1/23, 4/9/23, 6/4/23, and on 6/11/23 a RN worked only 8:44 AM to 2:54 PM.
During interview on 10/4/23 at 4:01 PM, the Director of Nurses (DON) confirmed the findings in A.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, failed to ensure dented food cans were promptly removed/ discarded to prevent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, failed to ensure dented food cans were promptly removed/ discarded to prevent the growth of bacteria; 2 of 2 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen; foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed /discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential cross contamination and hot food was maintained at 135 degrees or above to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 32 residents who receive meals from the kitchen. The findings are.
The following observation were made on 10/04/23 in the kitchen:
a. At 7:47 AM, on a rack an opened, unsealed bag of coffee containing loose coffee filters.
b. At 7:49 AM, there was a wet black/gray residue on the panel of the ice machine. Dietary Employee (DE) #1 wiped the area with a tissue, and the wet black/gray residue easily transferred to the tissue. DE #1 confirmed the black/gray residue on the tissue, and the ice from the ice machine is used to fill beverages served to the residents at mealtimes.
c. At 7:53 AM, the following spices were on a rack above the food preparation counter, with no received or open dates: black pepper, Greek seasoning, onion powder, salt seasoning, ground cinnamon, garlic powder, Italian seasoning, bottle of brown seasoning, and a container of oregano with an expiration date of 2/17/2023.
d. At 8:02 AM, the following observations were made on a shelf in the refrigerator.
1. An opened bag of shredded cheese.
2. A bottle of strawberry syrup with an expiration date of 09/05/2023.
e. At 8:07 AM, an uncovered, unsealed, and open box of Italian vegetable blend was on a shelf in the walk-in freezer.
f. At 8:43 AM, DE #1 removed a box of dinner rolls from the freezer and placed it on the counter. She picked up a bottle of spray oil and spread it inside a pan. Then opened a box. Without washing her hands, she placed gloves on her hands, removed dinner rolls from a bag inside the box and placed them on a tray to be baked and served to residents for lunch meal. During interview on 10/05/2023 at 12:29 PM, DE #1 confirmed she should you have washed her hands after touching dirty objects and before handling clean equipment.
During observation on 10/04/23 at 9:40 AM, the water and ice machine spout in the kitchenette on east hall had a black/brown flaky residue on them. The Dietary Supervisor wiped the area, and black/brown flaky residue transferred to the tissue.
The Dietary Supervisor confirmed the black/gray residue, and the ice from the ice machine is used to fill the water pitchers in the residents rooms.
During observation on 10/02/23 at 10:40 PM, two dented cans were on a rack in the dry storage room. One can of tuna and one can of Lima Beans.
The following observations were made on 10/04/23 at 9:43 AM.
a. In the refrigerator a bottle of chocolate syrup and
picante sauce was on a shelf unlabeled in reference to whom they belong to with no received or open date.
b. In the freezer, [NAME] ice cream, a box of strawberry short cake, and a bag of pancake sausage sticks were unlabeled in reference to whom they belong to with no received or open date.
c. A box of rice treats were on top of the freezer in the medication room with an expiration date of 08/27/23.
During observation on 10/04/23 at 10:59 AM, DE #2 with gloved hands, pulled her mask up. Without changing gloves, or washing her hands, she picked up a plastic bowl with her thumb inside the bowl. When she was ready to scoop peach halves into the bowl to be served to the resident for lunch. The surveyor immediately asked DE #2 what you should have done after touching dirty objects and before handling clean equipment? she stated, Removed the gloves and washed my hands.
During observation on 10/04/23 at 11:32 AM, the temperature of the mashed potatoes on the steam table by the Dietary Employee (DE) #1 was 110 degrees Fahrenheit. The above food item was not reheated before being served to the residents.
Review of the facility policy titled, Hand Washing. showed hands should be washed when starting a shift, after touching anything that may contaminate your hand, and before putting on gloves and when changing gloves between tasks.
Jun 2022
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure oxygen tubing and a humidifier bottle was dated...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure oxygen tubing and a humidifier bottle was dated for 1 (Resident #25) of 2 (Resident #25 and Resident #10) sampled residents who had a Physician's Order for Oxygen. The findings are:
Resident #25 was admitted on [DATE] with a diagnosis of coronary artery disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/22 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS).
a. A Physician's Order dated 12/15/21 documented, Oxygen @ [at] 2 liters per NC [Nasal Cannula] PRN [as needed] .
b. The Care Plan dated 8/27/21 with a revision date of 6/1/22 documented, . has oxygen ordered .will have no episodes of hypoxia .
c. On 6/27/22 at 1:30 p.m., the nasal cannula was lying on the bed beside. The oxygen tubing nor the humidifier bottle were dated indicating when it was changed.
d. On 6/28/22 at 3:40 p.m., the oxygen was in use with the nasal canula in place. The oxygen tubing and humidifier bottle were not dated indicating when it had been changed.
e. On 6/29/22 at 10:57 a.m., the DON was asked to provide a copy of the facility policy for the use of oxygen.
f. On 6/29/22 at 11:45 a.m., the DON was asked, What is the process when changing oxygen tubing and the humidifier bottle? The DON answered, The tubing and humidifier bottles should be changed every Sunday on day shift and should have the date, time, and nurse's initials on both.
g. On 6/29/22 at 1:45 p.m., Licensed Practical Nurse (LPN) #2 was asked, When is the oxygen tubing and humidifier bottle changed? LPN #2 stated, Every Sunday morning. LPN #2 was asked, What is the process for changing oxygen tubing and humidifier bottles? LPN #2 stated, The tubing is changed along with the water bottle and the tubing storage bag is also changed. LPN #2 was asked, Is there anything else that is required once the oxygen tubing and humidifier bottle has been changed? LPN #2 stated, The O2 [oxygen] tubing and the water bottle should be dated, timed, and have the nurse's initials on them and the storage bag should have date, time, residents name, and nurse's initials written on it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure residents fingernails were clean and trimmed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure residents fingernails were clean and trimmed to promote good personal hygiene and grooming for 2 of 2 (Resident #21 and #131) sample mix residents who were dependent for nail care and failed to ensure thorough incontinent care was provided to promote good hygiene and prevent odors for 1 (Resident # 14) of 16 (#10, #20, #27, #8, #28, #21, #5, #14, #2, #14, #2, #131, #9, #7, #6, #24, #17, #24, #17, #3, and #25) sampled residents who were incontinent and dependent on staff for incontinent care. The findings are:
1. Resident #21 had diagnoses of Dementia, Rheumatoid Arthritis, and Pain. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/22 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview of Mental Status (BIMS) and was totally dependent on 2 staff for bed mobility, transfer, and hygiene.
a. The care plan documented, . ADLS [Activities of Daily Living] requires two persons for total care .
b. On 06/27/22 at 11:17 AM, Resident #21 was sitting in a Geri chair in the hallway looking out the window. Her fingernails were approximately 1/2 inch long and jagged touching the pad of the hand.
b. On 06/27/22 at 03:06 PM, the resident was lying in the bed. Her fingernails were approximately 1/2 inch long and jagged touching the pad of the hand.
c. On 06/28/22 at 01:59 PM, the resident was lying in the bed. Her fingernails were approximately 1/2 inch long and jagged touching the pad of the hand. The Certified Nursing Assistant (CNA) # 3 was asked, Tell me what you see with her fingernails? She said, They are long. They need to be clipped.
2. Resident #131 had a diagnosis of Dementia. An admission MDS with an ARD of 06/21/22, documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a BIMS and required limited assistance of 1 person for hygiene.
a. On 06/27/22 at 11:03 AM, the resident was sitting in the hallway. Her fingernails were long, thick, and jagged approximately 1/2 inch long.
b. On 06/27/22 at 3:14 PM, the resident was standing in the hallway by the nurse's station. The DON was helping the resident button up her sweater. The resident had long and jagged fingernails approximately 1/2 inch long.
3. On 06/30/22 at 08:49 AM, the Director of Nursing (DON) was asked, Should residents have sharp jagged nails? She said, No.
4. On 06/30/22 at 08:55 AM, the DON provided a Nail Care Policy that documented, Purpose: To provide cleanliness, prevent spread of infection. For comfort and prevent skin problems .
1. Resident #14 had diagnoses of Mental Retardation, Insulin Diabetic Mellitus, and Leukemia. A Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/9/22 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS); required total assistance of 2 people for bed mobility, transfer, and toilet use; and always incontinent of bowel and bladder.
a. The Care plan documented, . ADL [Activities of Daily Living] Problem Date: 02/04/2022 . is to be provided with comfort care per two persons . incontinent care to be rendered every two hours and as needed .
b. On 06/27/22 at 11:40 AM, Certified Nursing Assistant (CNA) #1 and #2 was in the resident's room. They did not wash their hands. CNA #1 had a clear bag at the foot of the resident bed and peri wipes on the nightstand by the bed. CNA #2 was standing by a lift next to the resident's bed. CNA #1 donned gloves used a wipe and wiped across the resident's peri area. She discarded the wipe, used a clean wipe, and wiped down the right leg. She discarded the wipe, used a clean wipe, and wiped down the left leg. She discarded the wipe. She used a clean wipe and wiped down the inside of the right leg. She discarded the wipe, used a clean wipe, and wiped down the inside of the left leg. She discarded the wipe. She did not spread the labia apart. They rolled the resident toward the wall on her left side. The CNAs removed their gloves and donned clean gloves. They did not wash or sanitize hands. CNA #1 used a wipe and wiped down the right leg. She discarded the wipe. She used a clean wipe and wiped down the left leg. She discarded the wipe. She used a clean wipe and wiped up the crack of the buttock area. She discarded the wipe. She did these two more times and discarded the wipe after each use. The wipe had a brown substance on the wipe after each time. CNA #2 said, There that's good. She started to put the brief on the resident. The CNA was stopped and asked to don gloves and wipe up the center on the crack again. The CNA donned clean gloves and wiped up the center on the crack. There was a brown substance on the wipe. She discarded the wipe. She did these two more times and discarded the wipe after each use. The wipe had a brown substance on the wipe and the last one was clear. CNA # 2 was asked, Was she thoroughly cleansed before I ask you to wipe again? She said, She must have gone again. The CNAs removed their gloves and did not wash or sanitize hands. They then used the lift to transfer the resident to the Geri chair.
c. 06/28/22 at 03:41 PM, the DON was asked, Should the staff spread the labia apart when provided peri care on a female resident? She said, Yes. The DON was asked, Should the staff wash their hands prior to and after incontinent care? She said, Yes.
d. 06/29/22 at 07:40 AM, the DON provided a policy and procedure, Incontinent Care that documented, Incontinent care is provided to as part of daily hygiene and rooming of males and females . Procedure: MALE: . 3. Wash hands . 5. Put on gloves .7. Take off catheter leg strap if resident has a catheter. 8.Using moisture wipes support the penis and wipe around the urinary meatus in a circular motion. 9. Wipe the head of the penis in a circular motion. If uncircumcised pull back foreskin and wipe in a circular motion and then return foreskin to normal position 10. Support the tubing at the meatus and cleanse down the tubing 3-4 inches making sure tubing stays below the level of the bladder. 11. Hold penis by the head or foreskin and cleans [NAME] and on top of both sides and bottom of shaft wiping away from the meatus. 12. Cleanse scrotum in a front-to-back motion . 16. Change gloves when through with the front before turning to the back . Keep catheter tubing in front of the resident during the turn .30 Replace leg strap to hold catheter tubing in place . 40 Wash hands . Female: Same steps as above . 2. Separate the labia and wipe from front to back. This make take several wipes .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure a transfer was properly conducted by not placing pressure under the arms and lifting by the waistband to prevent the p...
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Based on observation, record review, and interview, the facility failed to ensure a transfer was properly conducted by not placing pressure under the arms and lifting by the waistband to prevent the potential for injury
for 1 (Resident # 20) of 5 (#6, #8, #9, #19, #20) sample residents who needed assistance with transfers. The findings are:
1. The DON provided a policy for Transfer/Gait Belt that documented, . 2. Ensure that you have enough staff to assist (1 person/2 person assist) .3. Explain the purpose of the Gait Belt and procedure for using it to resident. 4. Put Gait Belt on over the resident's clothing and around the waist. 5. Make sure the belt is snuggly in place .
2. Resident #20 had Diagnoses of Muscle Weakness, Dementia and Repeated Falls. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/20/22 documented the resident scored 3 (0-7 indicates cognitively impaired) on a Brief Interview for Mental Status (BIMS); required extensive assistance of two persons for bed mobility, dressing, toileting, bathing, and transfers; and not steady when walking.
a. The care plan documented, . ADLs [Activities of Daily Living] 05/20/22 . requires 2 person for care. He has lower extremity weakness. He can stand and transfer using his walker with assist .
b. On 06/28/22 at 3:58 PM, Certified Nursing Assistant (CNA) # 4 and # 5 assisted the resident to a sitting position on the side of the bed. CNA #4 placed her right hand in the resident's left arm pit and used her left hand to pull the resident up by the waist of his pants. CNA #5 used her right hand to pull the resident up by the waist of his pants. CNAs #4 and #5 lifted the resident at the same time by the waist of his pants and hand in arm pit. They walked the resident to his wheelchair approximately 2 feet and sat him down.
c. On 06/28/22 at 4:15 PM, CNA # 4 was asked, Are you supposed to place your hand in the resident's arm pit? She said, No, I'm supposed to use a gait belt. The CNA was asked, Are you supposed to hold him up by the waist of his pants? She said, No.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure a urinary catheter was secured by a leg strap, urinary catheter bag and drainage tubing were kept below the resident's...
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Based on observation, record review, and interview, the facility failed to ensure a urinary catheter was secured by a leg strap, urinary catheter bag and drainage tubing were kept below the resident's bladder and did drag on the floor to prevent potential cross contamination that could result in Urinary Tract Infection for 1 of 1 (Resident #20) who had an indwelling urinary catheter.
Resident #20 had diagnoses of Muscle Weakness, Dementia and Repeated Falls. The admission Minimum Data Set (MDS) with an Assessment Reference Date of 05/20/22 documented the resident scored 3 (0-7 indicates cognitively impaired impaired) on a Brief Interview for Mental Status (BIMS); required extensive assistance of two persons for bed mobility, dressing, toileting, bathing, transfers; and was not steady when walking.
a. The physician orders documented, . foley catheter 16 Fr [French] 30 cc [cubic centimeter] bulb .
b. The Care plan documented, .Catheter .has an indwelling catheter due to Benign Prostatic Hyperplasia . Provide catheter care per policy . Keep drainage bag below level of bladder . Keep catheter tubing free of kinks.
c. On 06/27/22 at 03:21 PM, the resident was sitting in wheelchair in his room. He had a catheter bag attached to the bottom rail of the wheelchair. Certified Nursing Assistant (CNA) #1 pushed the resident up the hall by the nurse's station. The catheter tubing was dragging on the floor. The CNA was asked, Should his catheter tubing be touching the floor? She said, No.
d. On 06/28/22 at 09:39 AM, the resident was sitting in a wheelchair at the nurse's station. He had blood-tinged urine in the catheter tubing and the tubing was being dragged on the floor.
e. On 06/28/22 at 03:20 PM, CNA #4 and #5 went in the resident's room. They did not wash their hands. CNA #4 placed a clear bag at the foot of the resident's bed and peri wipes on the nightstand by the bed. CNA #4 walked to the other side of the bed. They donned clean gloves. The resident did not have a leg band on, and the catheter tubing was laying under the resident's right leg. CNA #4 picked up the penis and tried to pull the foreskin back. She wiped around the penis head and folded the cloth over and wiped again. She discarded the wipe. She retrieved a clean wipe and did the same step again. She held catheter tubing taunt and wiped down the tubing. She folded the wipe over and did it again. She discarded the wipe. She removed her gloves and donned clean gloves. The CNA's rolled the resident over to his right side. She used a wipe and wiped up the right buttock. She discarded the wipe. She used a wipe and wiped up the left buttock. She discarded the wipe. She used a wipe and wiped up the crack of buttock. She discarded the wipe. She placed a clean brief on the resident. They did not change gloves or sanitize hands. She picked up the catheter bag above the resident head and placed through the right leg of the brief. She picked up the catheter bag above the resident head and placed through the right pant leg. She placed the catheter tubing under the resident's right leg and got the resident up to the wheelchair.
f. On 06/28/22 at 04:15 PM, CNA #4 was asked, Are you supposed to wash your hands before you start? She said, Yes. CNA was asked, Are you supposed to clean all areas when providing catheter care? She said, Yes. CNA was asked, Are you supposed to wash your hands when completed care? She said, Yes.
g. On 06/28/22 at 04:40 PM, the Director of Nursing (DON) was asked, Should staff wash their hands before they start catheter care? She said, Yes. She was asked, Are they supposed to clean all areas when providing catheter care? She said, Yes. The DON was asked, Are they supposed to wash their hands when care is completed? She said, Yes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation of the medication pass on the 08:00 am on 6/29/22 and record review and interview, the facility failed to ensure the medication error rate was less than 5%. Physician orders were ...
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Based on observation of the medication pass on the 08:00 am on 6/29/22 and record review and interview, the facility failed to ensure the medication error rate was less than 5%. Physician orders were not followed for 2 residents (Resident #13, and 22) of 6 residents observed during the medication passes resulting in medication errors. Medication errors were made by 2 Licensed Practical Nurses (LPN); (LPN #1 and #2) out of 2 Licensed Nurses that were observed administering medications in the facility. The failed practice had the potential to affect 31 residents who received medications administered from the Nurses on East, North and South Halls in the facility according to a list provided by the Director of Nursing (DON) on 6/27/22. The medication error rate was 8% based on 25 administration medications with 2 errors observed. The findings are:
1. Resident #13 had a Physician Order dated on 4/26/22 for Lasix 20 mg (milligrams) po (by mouth) daily for diagnosis of Hypertension.
a. On 6/29/22 at 7:50 am., LPN #2 pulled the medication card from the medication cart with a label that documented, Lasix 40 mg po QD [daily]. The LPN administered Lasix 40 mg.
b. On 6/30/22 at 8:35 am., LPN #3 was asked to verify the medication card. The LPN was asked, What does the physician order say? The LPN stated, Lasix 20 mg. The LPN was asked, What does the card say? The LPN stated, Oh Lord it says, Lasix 40 mg.
c. On 6/30/22 at 8:49 am., the DON was asked, Did you verify the card? She said, Yes it says Lasix 40 mg.
2. Resident # 22 had a physician order dated on 12/27/13 Zyrtec 10 mg 1 po HS (hour of sleep) at 6:00 pm for Allergic Rhinitis.
a. On 6/29/22 at 8:40 am., LPN #1 pulled the medication bottle from the medication cart with a label that documented, Zyrtec 10 mg. The Medication Administration Record [MAR] documented the time as 1800 [6:00 p.m.].
b. On 6/30/22 at 8:49 am., the DON was asked, What time was the medication to be administered? She stated, 1800. The DON was asked, Is 8:40 am the correct time for administration? She stated, No.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure medications were labeled and stored accordance ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure medications were labeled and stored accordance with state law and accepted principles of pharmacy laws and regulations. This failed practice had the potential to affect 1 resident who has orders for Clotrimazole cream, no residents had orders for Santyl Cream, and 1 resident had an order for Albuterol Sulfate inhaler had according to al list provided by the Director of Nursing (DON) on the East and North Halls and had the potential to affect 2 residents who resided on the South Hall according to al list provided by the DON. The findings are:
1. On 6/29/22 at 8:40 am., Licensed Practical Nurse (LPN) #1 retrieved a Symbicort inhaler from the South medication cart. There was no label on the inhaler. The LPN was asked, How do you know who the inhaler belongs to without a label on the inhaler? She said, I see what you are saying. She found a label that had been torn off in the top drawer of the medication cart. There was no way to verify if the label belonged on the Symbicort inhaler.
2. On 6/29/22 at 8:45 am., in the East and North medication cart there was 1 tube of Clotrimazole cream and 1 tube of Santyl cream in the with no label or date on the tubes. The LPN was asked, how do you know who they belong to? She said, I don't know. There was 1 Albuterol inhaler in the top drawer of the medication cart without a label. The LPN was asked, Who does that belong to? She said, Resident, (She did not say a name) it fell out of her purse. We put in here because she can't have it in her room. She came here with it. The LPN was asked, Should it have a label on it? She said, Yes.
3. On 6/29/22 at 10:57 am., the DON provided a policy for Storage of Medications that documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .
4. On 6/29/22 at 11:33 am., the LPN #1 walk into resident room [ROOM NUMBER] and left the medication cart unlocked. The LPN checked the resident's blood sugar.
a. On 6/29/22 at 11:45 am., LPN #1 was asked, Did you leave your medication cart unlocked and unattended? She said, Yes, I thought about that after I walked in the room.
b. On 6/29/22 at 11:49 am., the DON was asked, Should the staff leave their medication cart unlocked and unattended? She said, No.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complicatio...
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Based on observation, record review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets, as documented on the list provided by the Dietary Supervisor on 6/28/22 at 10:47 AM. The findings are:
1. On 6/27/22 at 11:31 AM., the following observations made on the steam table were:
a. A pan of pureed breaded beef steak with bread was on the steam table. The consistency of the pureed meat was thick, lumpy and not smooth. There were pieces of meat visible in the mixture.
b. A pan of pureed Brussel Sprouts was on the steamtable. The consistency of the pureed vegetables was running,
2. On 6/27/22 at 12:10 PM., Certified Nursing Assistant (CNA) #3 was asked to describe the consistency of the pureed food items served to the residents on pureed diet for lunch. She stated, Pureed meat was lumpy and pureed vegetables was runny.
3. On 6/27/22 at 12:13 PM., Certified Nursing Assistant (CNA) #4 was asked to describe the consistency of the pureed food items served to the residents on pureed diet for lunch. She stated, Pureed meat was more like mechanical soft meat.
4. On 6/27/22 at 12:15 PM., Certified Nursing Assistant #5 was asked to describe the consistency of the pureed food items served to the residents on pureed diet for lunch. She stated, Pureed meat was chunky and the pureed vegetable was thin.
5. On 6/27/22 at 12:22 PM., Dietary Employee #3 was asked to describe the consistency of the pureed food items served to the residents on pureed diet for lunch. She stated, Pureed meat was lumpy and the pureed vegetables was too thin.
6. On 6/27/22 at 12:24 PM., Dietary Employee #4 was asked to describe the consistency of the pureed food items served to the residents on pureed diet for lunch. She stated, Pureed meat was thick and lumpy and pureed vegetables was too thin.
7. On 6/27/22 at 3:43 PM., Dietary Employee #3 placed 5 servings of catfish into a blender, added chicken broth and pureed. At 3:47 PM, she poured the pureed catfish into in a pan and placed it in the oven. The consistency of the pureed fish was lumpy and not smooth. There are pieces of fish in the mixture.
8. On 6/27/22 at 3:56 PM., Dietary Employee #3 used 4 oz [ounce] spoon to place 5 servings of vegetable blend into a blender and pureed. At 3:57 PM, She poured the pureed vegetable blend in a pan and placed it on the steamtable. She stated, It supposed to the thicker. It's running.
9. On 6/27/22 at 4:44 PM., Dietary Employee #3 placed the pureed food items on plates to be served to the residents on pureed diet. She was immediately asked to describe the consistency of the pureed food items. She stated, Pureed fish was too thick and lumpy and pureed vegetables were too thin.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure garbage had a lid within 1 of 3 garbage dumpsters to decrease the potential for pest infestation. These failed practices had the poten...
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Based on observation and interview, the facility failed to ensure garbage had a lid within 1 of 3 garbage dumpsters to decrease the potential for pest infestation. These failed practices had the potential to affect all residents who resided in the facility, according to the list provided by the Dietary Supervisor on 6/28/2022 The findings are:
a. On 6/27/22 at 11:20 AM, one trash can by the exit door leading to the kitchen was almost full of clear trash bags. There were 2 flies flying over the trash. There was no lid on it.
b. On 6/28/22 at 7:53 AM, the Maintenance Employee was asked to measure the distance from where the one dumpster was located, outside the exit door leading to the kitchen. He measured the distance and stated, From dumpster outside the kitchen measured 16 feet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure maintenance services were provided to maintain ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure maintenance services were provided to maintain a safe, functional, and comfortable environment for residents as evidenced by failure to ensure vent covers on the window units were free of sharp jagged edges, and windowsills were free from sharp objects. This had the potential to affect 31 residents who resided in the facility according to the census and condition. The findings are:
1. On 06/27/22 at 03:32 PM, in room [ROOM NUMBER] there was a window unit that did not have a vent cover. There was a sharp and jagged, rusted metal grate across the open vent with 3 screws holding it in. There were rusted sharp, jagged edges on the metal grate. There was a nail sticking up from the window seal approximately 1/4 inch sticking up.
2. On 06/28/22 at 11:12 AM, room [ROOM NUMBER] had a vent cover that was broken over the window unit. The plastic piece was approximately 18 inches long with sharp, jagged edges. There was a rusted metal grate across the open vent with 3 screws holding it in.
3. On 06/28/22 at 11:23 AM, room [ROOM NUMBER] had a vent cover that was broken over the window unit. There was a rusted metal grate across the open vent with 3 screws holding it in. There were rusted sharp, jagged edges on the metal grate.
4. On 06/28/22 at 11:32 AM, room [ROOM NUMBER]'s window unit had a broken vent cover. There were broken plastic pieces with sharp, jagged edges.
5. On 06/28/22 at 11:35 AM, room [ROOM NUMBER]'s window unit was still without a vent cover. There was a sharp and jagged, rusted metal grate across the open vent with 3 screws holding it in. There were rusted sharp, jagged edges on the metal grate. There was a nail sticking up from the window seal approximately 1/4 inch sticking up.
6. On 06/28/22 at 11:38 AM, room [ROOM NUMBER] had a vent cover broken over the window unit. There was a rusted metal grate across the open vent with 3 screws holding it in. There were rusted sharp, jagged edges on the metal grate.
7. On 06/28/22 at 11:41 AM, room [ROOM NUMBER] had a vent cover broken over the window unit. There was a rusted metal grate across the open vent with 3 screws holding it in. There were rusted sharp, jagged edges on the metal grate.
8. On 06/29/22 at 01:20 PM, room [ROOM NUMBER]'s window unit was without a vent cover. There was sharp and jagged, rusted metal grate across the open vent with 3 screws holding it in. There were rusted sharp, jagged edges on the metal grate. There was a nail sticking up from the window seal approximately 1/4 inch sticking up. The Maintenance Employee was asked, what could happen with that nail sticking up? He said, Skin tear. The Maintenance Employee was asked, what about the rusted screen? He said, Skin tear.
9. On 06/29/22 at 01:25 PM, room [ROOM NUMBER] a vent cover broken over the window unit. The plastic piece was approximately 18 inches long with sharp, jagged edges. There was a rusted metal grate across the open vent with 3 screws holding it in. The Maintenance Employee said, That looks really bad, the filter won't even stay down in that one. The Maintenance Employee was asked, How are you informed if there is a problem that needs to be corrected? He said, The facility is supposed to fill out work orders and place in the basket.
10. On 06/29/22 at 01:25 PM, The Maintenance Employee #2 provided a policy and procedure Maintenance on call/work order that documented, Work order baskets will be checked every day including weekends and holidays .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items; food items stored in the freezer and refrigerator were...
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Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items; food items stored in the freezer and refrigerator were covered or sealed, an ice scoop holder was maintained in clean and sanitary condition to prevent contamination; and hot foods was maintained at 135 degrees Fahrenheit or above on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 31 residents who received meals according to the list provided by the Dietary Supervisor dated 6/28/22 at (total census: 31). The findings are:
1. On 6/27/22 at 10:34 AM., Dietary Employee #1 was wearing gloves on her hands when she touched her mask, contaminating her gloved hands. Without changing gloves and washing her hands, she untied the bread bag, removed slices of bread, and placed them into a blender to be pureed. She was asked, What should you have done after touching dirty objects and before handling clean equipment and or food items? She stated, I should have changed gloves and washed my hands.
2. On 6/27/22 at 10:47 AM., an opened box of breaded beef fried steak was stored on a shelf in the walk-in freezer. The box was not covered or sealed.
3. On 6/27/22 at 10:48 AM., the following observation made in the walk-in refrigerator were:
a. An opened box of sausage was stored on the shelf in the walk-in refrigerator. The box was not covered or sealed.
b. An opened box of bacon was stored on a shelf in the walk-in refrigerator. The box was not covered or sealed.
4. On 6/27/22 at 10:50 AM., the following observation made in the kitchen area were.
a. Loose flour in the bin under the food preparation counter was crumbled. The Dietary Supervisor was asked, What was the reason the flour looks like that? She stated, The moisture got over it.
b. There were black particles on the sugar in a bin under the food preparation counter.
5. On 6/27/22 at 10:57 AM., the ice scoop holder on the counter by the ice machine had water standing in it. There were particles of gray matter floating in the water. The two scoops were stored directly in contact with residue. The Dietary Supervisor was asked to describe the appearance of what was observed in the water. She stated, It was stale water and contaminated. She was asked, Who uses the ice from the ice machine and how often do you clean ice machine. She stated, It supposed to be cleaned daily. She was asked does it look like it has been cleaned daily. She stated, No Ma'am. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms, and we use it in the kitchen to fill beverages served to the residents at meals.
6. On 6/27/22 at 11:31 AM., the temperature of the meat item on the steamtable when tested and read by Dietary Employee #3 was. Bread beef steaks 126 Degrees Fahrenheit. The above meat item was not reheated before being served to the residents.
7. There was a fly that was flying around the steam table.
8. On 6/27/22 at 12:00 PM., Dietary Employee #2 who was on the tray line assisting with lunch meal was wearing gloves on her hands, she picked tray cards and condiments and placed them on the trays. Without changing gloves and washing her hands, she removed ham and cheeses sandwiches and placed them on the plates to be served to the residents who requested for ham and cheese sandwich with their lunch meal.
9. On 6/27/22 at 3:31 PM., Dietary Employee #3 was wearing gloves on her hands. She pushed the blender motor closer to the counter. Contaminating the gloves. Without changing gloves and washing her hands. She used her gloved hand to place 5 servings of fried catfish into a blender to ground for the residents on mechanical soft diets. She was asked, What should you have done after touching dirty objects and before handling clean equipment and or food item? She stated, I should have removed the gloves and washed my hands.
10. On 6/27/22 at 3:39 PM., Dietary Employee #3 took out deep fryer baskets from the fryer. She opened the refrigerator, took out one container of chicken base and placed it on the counter. Without washing her hands, she picked up gloves from the glove box and placed on her hands, contaminating the gloves. She used her contaminated gloved hand to pick up a clean blade and attached it to the blades of the blender to be used in pureeing food items to be served to the residents on purred diets. The Dietary Employee was asked, When was about to pick up fried catfish and put into a blender to puree? She was asked, What should you have done after touching dirty objects and before handling clean equipment and or food item? She stated, I should have changed gloves and washed my hands.
11. On 6/27/22 at 4:32 PM., Dietary Employee #5 took one tray to the walk-in refrigerator and placed cartons of whole milk on it. She went to the storage room picked up cans of Shasta [soda] and placed them on the tray. She pushed a cart towards the clean side of the dish washing machine and without washing her hands, she picked up glasses by the rims and placed them on the trays to be used in serving beverages to the residents for supper. She was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands.
12. The facility's policy on hand washing documented, Employees are to wash hands after handling objects which are not clean.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Arkansas facilities.
- • 33% turnover. Below Arkansas's 48% average. Good staff retention means consistent care.
Concerns
- • 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Dewitt's CMS Rating?
CMS assigns DEWITT NURSING HOME an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Arkansas, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Dewitt Staffed?
CMS rates DEWITT NURSING HOME's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 33%, compared to the Arkansas average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Dewitt?
State health inspectors documented 31 deficiencies at DEWITT NURSING HOME during 2022 to 2024. These included: 31 with potential for harm.
Who Owns and Operates Dewitt?
DEWITT NURSING HOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 60 certified beds and approximately 39 residents (about 65% occupancy), it is a smaller facility located in DE WITT, Arkansas.
How Does Dewitt Compare to Other Arkansas Nursing Homes?
Compared to the 100 nursing homes in Arkansas, DEWITT NURSING HOME's overall rating (1 stars) is below the state average of 3.1, staff turnover (33%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Dewitt?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Dewitt Safe?
Based on CMS inspection data, DEWITT NURSING HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Arkansas. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Dewitt Stick Around?
DEWITT NURSING HOME has a staff turnover rate of 33%, which is about average for Arkansas nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Dewitt Ever Fined?
DEWITT NURSING HOME has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Dewitt on Any Federal Watch List?
DEWITT NURSING HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.