CRESTPARK FORREST CITY, LLC
For profit - Limited Liability company
100 Beds
CRESTPARK
Data: November 2025
Trust Grade
55/100
#144 of 218 in AR
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Crestpark Forrest City, LLC has a Trust Grade of C, indicating it is average compared to other nursing homes. In terms of rankings, it is #144 out of 218 facilities in Arkansas, placing it in the bottom half, but it is the only option in St. Francis County. The facility is worsening, with reported issues increasing from 8 in 2023 to 9 in 2024. Staffing is a relative strength, with a rating of 3 out of 5 stars and a low turnover rate of 23%, showing that staff tends to remain long-term. However, concerning incidents have occurred, such as expired food items being found in storage, indicating a lack of proper food safety practices, and meals not meeting dietary needs due to missing items like bread, affecting many residents' nutritional intake. Additionally, there is less RN coverage than 75% of state facilities, which raises concerns about adequate medical oversight.
- Trust Score
- C
- In Arkansas
- #144/218
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 23% annual turnover. Excellent stability, 25 points below Arkansas's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Arkansas facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Arkansas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
55/100
Bottom 34%
No red flags
8 → 9 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 8 issues
2024: 9 issues
The Good
-
Low Staff Turnover (23%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (23%)
25 points below Arkansas average of 48%
Facility shows strength in staff retention, fire safety.
The Bad
2-Star Overall Rating
Below Arkansas average (3.1)
Below average - review inspection findings carefully
Chain: CRESTPARK
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 33 deficiencies on record
Aug 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and review of the facility's policies and state requirements, the facility failed to ensure a safe and secure environment as evidenced by not adhering to the facilit...
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Based on observations, interviews, and review of the facility's policies and state requirements, the facility failed to ensure a safe and secure environment as evidenced by not adhering to the facility's policies and procedures after an accident/fall for 2 (Resident #48 and Resident #251) of 2 residents reviewed for a fall with serious injury.
The findings are:
On 08/06/2024 at 8:35 AM, observed Resident #48 during medication administration. Noticed extensive bruising to the resident's face. When asked what happened, Resident #48 stated, I rolled out of bed, and fell on the floor. I'm always doing that. When asked if she hurt herself, the resident stated, My left hip hurts. I'm afraid to get up and walk.
On 08/06/2024 at 8:45 AM, during an interview Licensed Practical Nurse (LPN) #12 stated she received report this morning and was told Resident #48 fell out of bed, but no injuries were noted. LPN #12 stated [LPN #14] notified the family but did not notify hospice or the provider to determine need to have resident evaluated. Nurse initiated neuro checks but did not advise on coming nurse of the continuing neuro checks. When asked what the protocol is when residents fall, LPN #12 stated, Assess the resident, obtain vital signs, call provider and hospice is applicable. Notify family, complete I&A [Incident and Accident] report, notify Director of Nursing (DON), continue to monitor resident or follow orders from provider.
Upon record review and interviews with Licensed Practical Nurse (LPN) #14, it was discovered resident fell two days prior as well on 08/04/2024. Hospice or the provider were not notified Resident #48 was not sent to the hospital for evaluation for either fall.
On 08/06/2024 at 8:56 AM, during an interview with Licensed Practical Nurse (LPN) #14 regarding the fall on 08/06/2024 LPN #14 stated, I walked into the room to check on resident, found her on the floor beside her bed. I assessed her, took vital signs, I didn't see any injuries on the resident except scratches on the back. I notified the son of the accident. I didn't notify hospice or the doctor, but the nurse on dayshift said she would call them since I didn't. When asked what the protocol is for a fall. She stated, assess the resident, notify the doctor and hospice if they are hospice residents, call the family, send them out if needed. LPN #14 further stated, I was under impression, we don't call the doctor if they aren't hurt, so I didn't.
On 08/6/2024 at 9:05 AM, during an interview with the Director of Nursing (DON) regarding the recent falls, she stated, I was unaware until about fifteen minutes ago that the resident had had falls. I don't know why this resident's provider or hospice was not notified per our policy. We will be providing follow up training to ensure everyone is on the same page.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to follow enhanced barrier precautions when flushing a feeding tube for 1 (Resident #3) of 1 sampled resident reviewed feeding t...
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Based on observation, record review, and interview, the facility failed to follow enhanced barrier precautions when flushing a feeding tube for 1 (Resident #3) of 1 sampled resident reviewed feeding tube care and on enhanced barrier precautions (EBP).
The findings are:
A review of Resident #3's Face Sheet revealed diagnoses to include Parkinson's, depression, and PEG (percutaneous endoscopic gastrostomy) tube management.
Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/2024 suggested a Brief Interview for Mental Status (BIMs) a score of 6 (0-7 indicates severe cognitive impairment). Section K0520B3 indicated Resident 3 had a feeding tube.
a. During an interview with the Director of Nursing (DON) on 08/06/24 at 2:59 PM, the DON confirmed the facility does not have Enhanced Barrier Precaution (EBP) signage, but they place a small bedside dresser outside the room with personal protective equipment (PPE). The DON stated all staff know that a small dresser outside the room is a sign of EBP. It was confirmed Resident #3 was on EBP due to a feeding tube, and staff knew because there was a small dresser outside the door.
b. Review of the Physician's Orders revealed there was not an order for Enhanced Barrier Precautions.
c. On 08/07/2024 at 9:30 AM, during a concurrent observation and interview, Licensed Practical Nurse (LPN) #12 was observed checking Resident #3's feeding tube for residual tube feeding, throwing away the overnight feeding and tubing and then flushing the feeding tube with 30cc [cubic centimeters] of free water. LPN #12 was not wearing any Enhanced Barrier Precautions (EBP) other than gloves. The Surveyor asked if Resident #3 was on Enhanced Barrier Precautions and LPN #12 confirmed Resident #3 was not on EBP and confirmed that she cannot think of any reason to put on PPE. The Surveyor observed a small dresser outside the door. The bottom drawer was slightly open with blue gowns visible.
d. During an interview with the Administrator on 08/07/2024 at 4:00 PM, she confirmed a drawer outside the resident rooms indicated EBP, staff have been in-serviced, and she confirmed staff were expected to wear PPE when flushing a feeding tube because microbes could be transferred to the resident.
e. On 08/07/2024 at 4:13 PM, the Administrator provided a policy titled Gastrostomy Feedings that did not apply to EBP.
f. On 08/07/2024 at 4:16 PM, review of an Inservice Training dated 07/26/2024 on Enhanced Barrier Precautions (EBP) and other topics revealed, EBP recommendations now include use of EBP for residents with feeding tubes during high-contact resident care activities regardless of their multidrug-resistant organism status.
g. On 08/07/2024 at 4:20 PM, the Administrator provided a letter stating .[Facility Name] facility does not have a policy on Enhanced Barrier Precautions at this time .
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 observation, record review, and interview, the facility failed to ensure refrigerated narcotics were stored in a permanently affixed storage box to prevent misappropriation of resident medica...
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Based on observation, record review, and interview, the facility failed to ensure refrigerated narcotics were stored in a permanently affixed storage box to prevent misappropriation of resident medications.
The findings are:
On 8/07/2024 at 9:30 AM, during an observation of the medication storage area, the surveyor observed the red controlled medication lockbox was not secured inside the refrigerator. The box contained controlled medication.
On 8/07/2024 at 9:45 AM, during an interview with Licensed Practical Nurse (LPN) #13, when asked why it is important to secure the box inside the refrigerator, LPN #13 admitted it would be very easy to conceal the medication box due to the size and remove it from the facility.
Reviewed the facility's undated policy (received on 8/07/2024 at 10:39 AM from the Administrator) titled, Controlled Medication (Schedule II, III, IV, &V) Receiving, Recording, Storage, Accountability, and Disposition Of stated under the section labeled Storage, that narcotics will be kept in a locked container affixed inside a locked cabinet, inside the medication room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents fo...
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Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to 3 affect residents who received regular diets from 1 of 1 kitchen according to a list provided by Dietary Manager #11 on 08/06/24 at 9:33 AM.
The findings are:
1. On 08/05/24, the noon meal menu documented the residents who received regular diets were to receive 4 ounces of fried chicken.
2. On 08/05/24 at 12:16 PM, during the noon meal service Dietary [NAME] (DC) #1 served 2 fried chicken legs to 6 residents and 2 chicken wings to 5 residents.
3. On 08/05/24 at 12:36 PM, the surveyor asked Dietary Aide (DA) #4 to weigh the same amount of chicken legs served to the 6 residents for lunch, and the same amount of chicken wings served to the 5 residents for lunch. She did and the 2 legs weighed 2.5 ounces and the 2 wings weighed 1.2 ounces, instead of 4 ounces of fried chicken as per the menu. DA #4 stated, We should have given them more chicken.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
5. On 08/06/24 at 2:07 PM, Resident #23 stated the hot food was not hot at lunch today.
Based on observation, record review, and interview, the facility failed to ensure meals were served in a method ...
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5. On 08/06/24 at 2:07 PM, Resident #23 stated the hot food was not hot at lunch today.
Based on observation, record review, and interview, the facility failed to ensure meals were served in a method that maintained the appearance of hot products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 24 residents who received their meal trays in the dining room, 12 residents who received their meal trays in their rooms on the 100 Hall and 200 Halls, and 8 residents who received their meal trays in their room on the 700 Hall, as documented on a list provided by Dietary Manager #11 on 08/05/24 at 9:33 AM.
The findings are:
1. On 08/05/24 at 11:34 AM, Resident #23 stated the food is cold by the time it gets to us.
2. On 08/05/24 at 12:30 PM, an unheated food cart that contained 17 lunch trays was delivered to the dining room by Dietary Aide (DA) #3. At 1:08 PM, immediately after the last residents received their trays in their rooms in the dining, the temperatures of food items on a test tray were checked and read by DA #4 with the following results:
a. Vegetable blend - 97.7 degrees Fahrenheit.
b. English peas - 92.4 degrees Fahrenheit.
c. Ground fried chicken with no gravy - 92.6 degrees Fahrenheit.
3. On 08/06/24 at 7:29 AM, an unheated food cart that contained 12 breakfast trays for the 100 and 200 Halls were delivered to the 200 Hall by Certified Nursing Assistant (CNA) #6. At 7:35 AM, the food cart was pushed to the 100 Hall by CNA #8. At 7:49 AM, immediately after the last residents received their trays in their rooms on the 100 Hall, the temperatures of the food items on the trays used as test tray were checked and read by the CNA #8 with the following results:
a. Milk - 46.9 degrees Fahrenheit.
b. Sausage links - 91.9 degrees Fahrenheit.
c. Scrambled eggs - 103.6 degrees Fahrenheit.
d. Ground sausage - 84.5 degrees Fahrenheit.
4. On 08/06/24 at 7:30 AM, an unheated food cart that contained 8 breakfast trays was delivered to the 700 Hall by Certified nursing Assistant (CNA) #7. At 7:00 AM, immediately after the last residents received their trays in their rooms on the 700 Hall, the temperatures of food items on the trays used as test trays were checked and read by CNA #7 with the following results:
a. Milk - 45.5 degrees Fahrenheit.
b. Scrambled eggs - 106.6 degrees Fahrenheit.
c. Ground sausage - 88.1 degrees Fahrenheit.
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, interview, and facility policy review, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other co...
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Based on observation, interview, and facility policy review, 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 those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 2 residents who received pureed diets.
The findings are.
1. On 08/05/24 at 10:30 AM, a bowl that contained pureed strawberry cake was observed on the counter. Dietary [NAME] (DC) #1 stated, That is pureed strawberry cake, she covered the bowl with a lid and placed it in refrigerator to be served to the residents who required pureed food items. The consistency was runny, lumpy, and not smooth. There were pieces of strawberries in the mixture.
2. On 08/05/24 at 11:37 AM, Dietary Aide (DA) #3, used a 4 ounce spoon to place 2 servings of English peas into a bowl with its juice from a pan on the steam table.
3. On 08/05/24 at 11:38 AM, DA #3 poured 2 servings of English peas into a blender and pureed. At 11:40 AM, DA #3 poured the pureed English peas into a bowl. The consistency of the pureed peas was running and not formed.
4. On 08/05/24 at 11:43 AM, Dietary Aide (DA) #3 used a 4 ounce spoon to place 2 servings of vegetable blend from a pan on the steam table into a bowl and poured it into a blender and pureed. At 11:44 AM, DA #3 poured the pureed vegetable blend into a bowl. The consistency of the pureed vegetable blend was running and not formed. There were pieces of carrots in the mixture.
4. On 08/05/24 at 11:47 AM, DA #3 poured 2 servings of deboned chicken breast into a blender, added chicken broth, and pureed. At 11:48 AM, DA #3 poured the pureed fried chicken into a pan and placed it on the steam table. The consistency of pureed fried chicken was gritty and not smooth. There were pieces of chicken visible in the mixture.
5. On 08/05/24 at 11:58 AM, a pan of pureed bread with milk was on the steam table. The consistency of the pureed bread was too thick.
6. On 08/05/25 at 12:38 PM, DA #5 was asked to describe the consistency of the pureed bread with milk, pureed vegetable blend, pureed peas, and pureed cake. DA #5 stated, Pureed meat was gritty and not smooth, pureed vegetable blend was runny and had piece of carrots in it, and pureed bread with milk was too thick.
7. On 08/05/24 at 8:00 AM, the pureed sausage served to the residents on pureed diets was gritty, not formed and was not smooth. There were pieces of meat in the mixture.
8. On 08/06/24 at 8:04 AM, the surveyor asked Certified Nursing Assistant #9 who was assisting residents in the dining room to describe the consistency of the pureed sausage served to the residents on pureed diets. She stated, It looks more like ground meat. It is supposed to be like pudding.
9. On 08/06/24 at 8:08 AM, the surveyor asked Dietary Manager #11 to describe the consistency of the pureed sausage served to the residents on pureed diets. He stated, It looks more like mechanical soft meat.
10. On 08/06/24 at 8:09 AM, the surveyor asked DA #3 to describe the consistency of the pureed sausage served to the residents on pureed diets. DA #3 stated, It looks more like mechanical soft meat.
11. A facility policy titled, Consistency Alteration of Food & Fluid Mechanically Altered Foods & Thickened Liquids initiated 12/11/2010 indicated, .Pureed Consistency -Pureed items should be completely smooth without any pieces or chunks. -Mouth feel should be smooth and the consistency of PUDDING or MASHED POTATOES. -This texture requires very little to no effort to chew. -As presentation is important, gravy and smooth condiments should be added on top for visual appearance and taste, ex. ketchup/mustard on pureed hit dog with bun (to individual's preference). -When items are served, staff should always express to the patient what each food item is. -Refer to your facility spreadsheets/extension sheets for correct serving size .
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, interview, record review, and facility policy review, the facility failed to ensure 2 of 2 ice machines in the facility, one in the kitchen and one on the 400 Hall were maintaine...
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Based on observation, interview, record review, and facility policy review, the facility failed to ensure 2 of 2 ice machines in the facility, one in the kitchen and one on the 400 Hall were maintained in clean and sanitary condition to prevent food and beverage contamination; dairy products stored in the refrigerator were sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and 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 before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; kitchen ceiling tiles were cleaned to provide a sanitary environment for food preparation. The failed practices had the potential to affect 46 residents who received meals from the kitchen (total census: 48), as documented on a list provided by Dietary Manager #11 on 08/06/2024.
The findings are:
1. On 08/05/2024 at 9:46 AM, the ice machine panel in the kitchen where ice touches before dropping into the ice collector had brown colors on it. Dietary Manager #11 was asked to wipe the area. The brown residue easily transferred to the tissue. Dietary Manager #11 was asked to describe what was observed on the panel. He stated, It was black and brown dirt. Dietary Manager #11 was asked, Who uses the ice from the ice machine and how often do you clean it? He stated, We clean weekly, and we use it in the kitchen to fill beverages served to the residents at mealtimes.
2. On 08/05/2024 at 9:48 AM, an opened zip top bag that contained slices of cheese, was on a shelf in the refrigerator. The bag was not sealed.
3. On 08/05/2024 at 9:55 AM, the following observations were made in the storage room.
a. There were 5 bags of grits on a shelf in the storage room with an expiration date of 5/25/2024.
b. There were 8 bags of cream of wheat with an expiration date of 1/23/2023.
c. There were 3 containers of fajita marinade and seasoning with an expirations date of 7/23/2024.
d. An opened box of salt, the box was not covered.
e. A container of rubbed sage with an expiration date of 11/25/2023.
f. Eight of 8 boxes of tea with an expiration date of 05/16/2024.
g, Four of 4 bottles of lemon juice with an expiration 04/20/2024.
h. An opened gallon of barbeque sauce, the manufacturer's specification on the gallon specified, refrigerate after opening.
i. Two opened gallon containers of soy sauce, the manufacturer's specification on the gallon specified, refrigerate after opening.
4. On 08/05/2024 at 10:35 AM, the following observations were made in the walk-in refrigerator in a room leading to the dining room and the kitchen:
a. The ceiling tiles had an accumulation of black and grayish dust stuck on it. The surveyor asked Dietary Manager #11 to describe the condition of the ceiling tiles. He stated, That is an accumulation of black and gray dirt.
b. A half-gallon of butter milk in a milk crate with an expiration date of 7/26/2024.
c. An opened box of fresh buttery taste spread with an expiration date of 12/18/2023. Dietary Manager #11 stated, We don't use them.
d. A box that contained 20 cartons of probiotic yogurts had an expiration date of 7/26/2024
5. On 08/05/2024 at 10:48 AM, the ice machine panel in the break room on the 100 Hall, where ice touches before dropping into the ice collector, had wet black and brown colors on it. Dietary Manager #11 was asked to wipe the area. The wet black and brown residue easily transferred to the tissue. Dietary Manager #11 was asked to describe what was observed on the panel of the ice machine. He stated, It was black and brown dirt. Dietary Manager #11 was asked, Who uses the ice from the ice machine and how often do they clean it? He stated, The maintenance man cleans it, and that's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms. On 08/06/24 at 11:13 AM, the Maintenance Supervisor was asked how often they cleaned it. He stated, By-weekly.
6. On 08/05/2024 at 10:53 AM, Dietary [NAME] (DC) #2 pushed a food cart that contained a pan of fried chicken towards the food preparation area. Without washing her hands, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. She then used her contaminated gloved hands to debone chicken to be ground and or pureed to serve the residents on mechanical soft diets and pureed diets. The surveyor asked what should have done after touching dirty objects and before handling food items and or handling clean equipment? She stated, Washed my hands.
7. On 08/05/2024 at 11:25 AM, Dietary Aide (DA) #3 turned on the hand washing sink faucet and washed her hands. After washing her hands, she turned off the sink faucet with her hands, contaminating her hands, she removed tissue paper and dried her hands. Without rewashing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing foods items to be served to the residents who required pureed diets. When DA #3 was about to pour food items into a blender to puree, the surveyor immediately stopped her and asked what should have been done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands.
8. On 08/05/2024 at 11:58 AM, the temperature of the broccoli with cheese when checked and read by Dietary Aide #4 on the steam table was 117 degrees Fahrenheit. The surveyor asked Dietary Aide #4 what should you do when food items are not hot enough to serve. DA #4 stated, Reheat it.
9. A facility policy titled, Handwashing and Glove Usage in Food service stated, When Food Handlers must wash their hands .Before starting work.After leaving and returning to the kitchen/prep area .After touching anything else such as dirty equipment, work surfaces or cloths.
Jun 2024
2 deficiencies
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to provide adequate supervision to prevent a resident with...
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Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to provide adequate supervision to prevent a resident with moderate cognitive impairment and exit seeking behaviors from exiting the facility unsupervised for 1 (Resident #1) of 3 residents reviewed for elopement.
Findings include:
A review of the facility's undated policy titled, Wandering Resident Policy indicated, In an effort to prevent resident from wandering away from the facility, [Facility name] has door alarm systems on all appropriate doors. This system is to help alert any unauthorized exits of residents who may try to wander outside the facility unsupervised .staff will monitor all residents and those who have been identified as wanderer's on an ongoing basis to ensure all resident safety and privacy.
A review of the Face Sheet indicated the facility admitted Resident #1 with diagnoses that included unspecified dementia, unspecified fall, pneumonia, and chronic prostatitis.
The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. Section E regarding wandering and frequency of wandering indicated Resident #1 had wandering behavior of this type occurring 1 to 3 days.
A review of Resident #1's Baseline Care Plan on 01/03/2024, revealed the resident was a wanderer. The baseline care plan did not have any interventions documented.
A review of Resident #1's undated Nursing Assistant Care Plan (Closet Care Plan) revealed the resident was an elopement risk. The closet care plan did not have any interventions documented.
A review of Initial Elopement and Wandering Risk Assessment revealed Resident #1 was at risk for elopement/wandering at this time and a care plan for wandering/elopement risk will be initiated identified appropriate preventive interventions.
A review of Progress Note dated 01/05/2024 on the 3:00 PM to 11:00 PM shift documented, .ambulatory in the hall with his belongings stating he's going home .
A review of Progress Note dated 01/11/2024 at 10:20 PM documented, Resident found in another resident room with just a tee shirt on .
A review of Progress Note dated 01/12/2024 on the 3:00 PM to 11:00 PM shift documented, Confused to location. Thinks he is at home. Wandered x2 into another resident room .
A review of Progress Note dated 01/13/2024 on 7:00 AM to 1:00 p documented, .Ambulates with unsteady gait wandered in another resident's room .
A review of Progress Note dated 01/14/2024 at 10:32 AM documented, Resident ambulating with walker. Resident ambulated to double doors and pushed on door causing door alarm to go off. CNA [Certified Nursing Assistant] and writer rushed to door and removed resident from area .
A review of Progress Note dated 01/15/2024 at 10:50 AM documented, Admin [Administrator] informed resident not in room. Female resident informed staff she thought he was by the door. Upon looking outside of the doors, it is noted that 2 pairs of socks and glasses were on the ground outside the door. 1057 [10:57 AM] resident around side of building next to alternate exit approximately 60 feet from exit site. Resident states I was looking for my care. Resident brought back into facility .
During a concurrent observation and interview on 06/10/2024 at 12:04 PM, the Administrator and Surveyor walked out the double doors the resident went through and walked to the area where the resident was found. Resident #1 was found approximately 60 from the exit. The Administrator verbalized Resident #1's room was next to the double doors the resident exited. The Administrator confirmed Resident #1 was out of the facility approximately seven minutes.
CONCERN
(E)
📢 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
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on interviews, record review, facility document review, it was determined the facility failed to ensure the care plan was revised to accurately indicate wandering behaviors with interventions to...
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Based on interviews, record review, facility document review, it was determined the facility failed to ensure the care plan was revised to accurately indicate wandering behaviors with interventions to prevent the potential for elopement for 2 (Resident #1 and Resident #3) of 3 residents reviewed for wandering behaviors.
Findings include:
On 06/12/2024 at 9:19 AM, the Administrator stated the facility did not have a policy for care plans.
A review of the Face Sheet indicated the facility admitted Resident #1 with diagnoses that included unspecified dementia, unspecified fall, and pneumonia.
The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. Section E regarding wandering and frequency of wandering indicated Resident #1 had wandering behavior of this type occurring 1 to 3 days.
A review of the Initial Elopement and Wandering Risk Assessment for Resident #1 dated 01/03/2024 documented, Resident is at risk for elopement/wandering at this time. A care plan for wandering/elopement risk will be initiated identifying appropriate preventive interventions.
A review of Resident #1's Baseline Care Plan on 01/03/2024, revealed the resident was a wanderer. The baseline care plan did not have any interventions documented.
A review of Resident #1's undated Nursing Assistant Care Plan (Closet Care Plan) revealed the resident was an elopement risk. The closet care plan did not have any interventions documented.
A review of the Face Sheet indicated the facility admitted Resident #3 with diagnoses that included unspecified dementia, Alzheimer's disease with late onset, and anxiety disorder.
The admission MDS with an ARD of 05/22/2024 revealed Resident #3 had a BIMS score of 9 which indicated the resident had moderate cognitive impairment.
A review of the Initial Elopement and Wandering Risk Assessment for Resident #3 dated 05/10/2024 documented, Resident is at risk for elopement/wandering at this time. A care plan for wandering/elopement risk will be initiated identifying appropriate preventive interventions.
A review of Resident #3's Baseline Care Plan dated 05/10/2024, did not indicate wandering and elopement risks and no interventions were in place.
A review of Resident's #3's Care Plan for 05/10/2024 through 05/09/2025 did not indicate wandering and elopement risks and no interventions were in place.
During an interview on 06/11/2024 at 9:07 AM, the MDS Coordinator confirmed Resident #1 had a baseline care plan completed and did not have any interventions included. The MDS Coordinator confirmed Resident #1 was only admitted for 13 days and did not complete a comprehensive care plan.
Oct 2023
1 deficiency
CONCERN
(E)
📢 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review, observation and interview the facility failed to ensure incontinent care was provided in a timely manner for 1(Resident #1) of 3 (Resident #1, #2 and #3) sampled residents who ...
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Based on record review, observation and interview the facility failed to ensure incontinent care was provided in a timely manner for 1(Resident #1) of 3 (Resident #1, #2 and #3) sampled residents who depended on staff for incontinent care. The findings are:
A Care Plan with a problem date of 08/14/23 noted Resident #1 was to be provided prompt care as needed for incontinent episodes.
A Physicians Order dated 10/17/23 noted Resident #1 was on Contact isolation for 10 days.
On 10/23/23 at 11:34 AM, Resident #1 was on Droplet Precautions. The Surveyor asked Resident #1 how often staff checked on her. She stated, They brought me breakfast this morning and they didn't say a word to me. I haven't been changed this shift. I think I'm wet now. Resident #1 pulled her blanket back. Her brief and sheet were soaked with urine. She stated, I can't get out of bed or nothing. Sometimes I have to lay here in poop and pee all day. I figure they are busy, so I don't complain.
On 10/23/23 at 11:51 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 why Resident #1 was not checked on all day. She stated, Earlier today I had to give my other residents their showers. I get to my patients on isolation after I do all my showers. I am on my lunch break now. The Surveyor asked if Resident #1 should have to wait for long periods of time to receive care just because she is on isolation. She stated, I do her last because I don't want to get the other residents infected. The Surveyor asked how often Resident #1 should be checked for incontinence. She stated, Every two hours.
On 10/24/23 at 1:35 PM, during an interview CNA #2 stated she checks on her residents at least every two hours and just because they have Covid doesn't mean I go around them.
On 10/24/23 at 1:47 PM, during an interview CNA #3 stated she checks on her residents every two hours and that she does her isolation residents first.
On 10/24/23 at 1:54 PM, during an interview CNA #4 stated she checks on her all residents at least every two hours.
Aug 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the resident, or their responsible parties were provided with the opportunity to formulate an Advance Directive if desired, to allow...
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Based on record review and interview, the facility failed to ensure the resident, or their responsible parties were provided with the opportunity to formulate an Advance Directive if desired, to allow resident to make decisions regarding their care in the event of their incapacitation for 1 Resident (Resident #20) of 1 sampled resident and establish, maintain, and implement written policies and procedures regarding the residents' right to formulate an advance directive, refuse medical or surgical treatment. This failed practice had the potential to affect all 42 residents as documented on the Resident Matrix provided by the Administrator on 08/15/23 at 9:24 AM. The findings are:
a. On 08/14/23 at 3:58 PM, Resident #20's chart did not contain an Advance Directive or any documentation to indicate the resident declined to formulate one.
b. On 08/16/23 at 3:18 PM, the Administrator stated, I can't find an Advance Directive for [Resident #20]. I guess we don't have one for her.
c. The facility policy titled, Advance Directives, provided by the DON on 08/18/23 at 10:35 AM documented, .1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives . 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record .
d. On 08/18/23 at 10:38 AM, the Surveyor asked the DON when an Advanced Directive should be offered to a resident. The DON stated, On admission, and if there is a change of condition when we know they are terminal. The Surveyor asked the DON what would happen if there was no Advance Directive. The DON replied, We would get in trouble. If there is no Advance Directive, my responsibility would be to take care of the resident until we can get the Advance Directive from the family or Power of Attorney [POA]
CONCERN
(E)
📢 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
Safe Environment
(Tag F0584)
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 resident rooms were maintained in good repair, clean, and free...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident rooms were maintained in good repair, clean, and free of odors in 5 (Resident Rooms 113, 119, 120, 121 and 209) of 5 rooms on the 100 and 200 Halls. The findings are:
1. On 08/14/23 at 8:39 PM, the Surveyor entered Resident room [ROOM NUMBER] and observed a black substance on the vents of the air conditioning unit. Food debris was on the couch, the floor and in the air conditioning unit. A fall mat was lying under the bed smelled strongly of urine and was wet.
a. On 08/17/23 at 9:17 AM, the Surveyor entered Resident room [ROOM NUMBER] and observed food debris on the floor, in the air conditioner unit, and on the couch cushions. The air conditioner had a black substance on the vents. A fall mat under the bed was adhered to floor and smelled strongly of urine.
2. On 08/15/23 at 8:01 AM, the Surveyor entered Resident room [ROOM NUMBER] and observed the air conditioner to have a black substance on the vents. The air conditioner filter was dirty and covered with a black substance. The molding at the base of the wall directly below the sink was peeled away from the wall and protruded 12 inches into the room.
a. On 08/17/23 at 9:50 AM, the air conditioner and filter in Resident room [ROOM NUMBER] were partially covered in a black substance. The molding below the sink was peeled away from wall and protruded into the room.
3. On 08/15/23 at 8:06 AM, the Surveyor entered Resident room [ROOM NUMBER] and observed the air conditioner and filter to be dirty and partially covered with a black substance. The molding at the base of the wall below the sink was peeled away from the wall and protruded into the room.
a. On 08/17/23 at 9:40 AM, the Surveyor observed in Resident room [ROOM NUMBER], 10 inches of molding below the sink peeled away from wall and protruding into the room. The air conditioner had a black substance on the vents and was visible on the inside behind the vents.
4. On 08/15/23 at 8:18 AM the Surveyor entered Resident room [ROOM NUMBER] and observed a black substance on the air conditioner vents and a hole in the bottom of the wall behind the bed. The hole had chew marks around it.
a. On 08/17/23 at 10:02 AM, in Resident room [ROOM NUMBER] the black substance remained on the air conditioner vents and the hole behind the bed remained in the wall.
5. On 08/14/23 at 11:17 AM, the Surveyor entered Resident room [ROOM NUMBER] and observed that the window had a white cotton fabric bundled up between the screen and the glass window. The Surveyor asked the Resident why the fabric was placed there. The Resident stated, Because it leaks. The Surveyor asked who put it there. The Resident stated, I don't remember.
a. On 08/15/23 at 9:30 AM, the Maintenance Supervisor accompanied the Surveyor to Resident room [ROOM NUMBER] and was shown the window. The Resident in the room stated, Someone put it in there because it was leaking, but I don't remember who. The Maintenance Supervisor stated, I know that I recently fixed the ceiling due to a leak, but I didn't know that the window was leaking. It looks like the window is cracked. The Surveyor asked the Maintenance Supervisor how he knows when there is something that needs to be fixed. The Maintenance Supervisor stated Staff will fill out a form and put it in my mailbox. I didn't know anything about this.
7. On 08/17/23 at 3:32 PM, the Administrator reported the facility did not have a policy on facility upkeep and maintenance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #20's Physicians Order dated 09/01/20 documented, .Diet: ***Pimento cheese sandwich with supper tray*** .
a. On 08/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #20's Physicians Order dated 09/01/20 documented, .Diet: ***Pimento cheese sandwich with supper tray*** .
a. On 08/16/23 at 1:55 PM, Resident #20 was seated in a recliner in her room. She was crying and stated, I don't like tuna sandwiches and they didn't give me anything else. I'm [AGE] years old I should be able to eat what I want. The Surveyor asked, Did you ask for something else and tell them you didn't like tuna? Resident #20 stated, No, I don't want to cause problems or be a bother.
b. On 08/16/23 at 2:40 PM, the Surveyor asked the Dietary Manager (DM), What did [Resident #20] have for dinner last night? The DM stated, Tuna salad sandwich, soup, crackers, and a chocolate eclair. The Surveyor asked, Did [Resident #20] have a pimento cheese sandwich on her tray last night? The DM stated, I wasn't here for supper. The girls read the menu we leave and serve from the menu. The girls that were working last night will be back tomorrow between 11:30 AM and 7:00 PM.
c. On 08/17/23 at 11:28 AM, Resident #20 was in her room. The Surveyor asked, Did you eat dinner last night? Resident #20 stated, No, I got a sandwich and took one bite of it. It was not good, and the meat was all red and blue and looked wrong. The surveyor asked, Did you get a pimento sandwich on your supper tray last night? Resident #20 stated, No. Resident #20 took a foil wrapped sandwich from the bedside table and stated, Look, I saved it. Would you want to eat this?
d. On 08/17/23 at 2:40 PM, the Surveyor asked Dietary Employee (DE) #3, Can you tell me what was on [Resident #20's] supper tray last night, and on 08/15/23? DE #3 replied, A tuna fish sandwich, chicken noodle soup, and pudding. I wasn't here last night, but I can get the person that was for you. The Surveyor asked, Was there a pimento cheese sandwich on the super tray on 08/15/23? DE #3 stated, We are out of pimento cheese, but we just ordered it. The Surveyor asked, Do you ever go out and talk to the residents about their food preferences? DE #3 stated, I have a few times but not specifically [Resident #20]. I know she likes souse. [Resident #20] requested we include a souse sandwich every night if we have it. The Surveyor asked if there is a change in a resident's diet, how is the kitchen made aware. DE #3 replied, We get an order from the Director of Nursing (DON) or the nurse. The Surveyor asked if the physician made a change to a resident's diet how is the kitchen informed. DE #3 stated, An order is brought to the kitchen.
e. On 08/17/23 at 2:44 PM, the Surveyor asked DE #5, Are you familiar with [Resident #20]? DE #5 replied, No. The Surveyor asked, Can you tell me what was on [Resident #20's] supper tray last night? DE #5 stated A burger and french fries. The Surveyor asked, Was there a pimento cheese sandwich on the supper tray last night? DE #5 stated, No. The Surveyor asked, Was there any kind of sandwich on [Resident #20's] supper tray last night? DE #5 stated, No. The Surveyor asked, Do you ever go out and talk to the residents about their food preferences? DE #5 stated, Only the dining room, we don't go down to the 700 Hall. I don't even know what [Resident #20] looks like. The Surveyor asked if there is a change in a resident's diet, how is the kitchen made aware. DE #5 stated, One of the Certified Nurse Aids [CNAs] tell us. The Surveyor asked if the Physician makes a change to a resident's diet how is the kitchen informed. DE #5 stated, On a card.
f. On 08/17/23 at 2:56 PM, Resident #20's dietary meal card documented, .Likes .Breakfast: eggs, cereal, sausage, bacon, muffin .Lunch: chicken, pork chops, hamburger .Dinner: potatoes, green beans, cabbage, fruit . No dislikes were noted on the dietary card.
g. On 08/17/23 at 2:58 PM, the Surveyor asked DE #5, Are you aware if [Resident #20] has any dislikes? DE #5 stated, No, we never hear about any dislikes because they never bring it to the kitchen.
h. On 08/18/23 at 10:05 AM, the Surveyor asked the Dietary Supervisor in Training, Have you seen a physicians order for a pimento cheese sandwich to be added to [Resident #20's] supper plate every night? He stated, No, I haven't. The Surveyor asked, How does the kitchen receive diet orders? He stated, The DON brings the diet orders, we get slips. We don't get the physician's orders. The Surveyor asked who lets dietary know the resident's likes and dislikes. He stated, The Certified Nurses Assistants [CNAs] or the DON.
i. On 08/18/23 at 10:23 AM, the Surveyor asked the DON, how dietary was notified of a new or changed dietary order. The DON stated, We use a form that is printed and taken to dietary. Every month they get a report for diets, enhanced meals or snacks, and nighttime snacks. If there is a change, they get a dietary slip.
j. On 08/18/23 at 10:35 AM, the Surveyor asked the DON, Do you have a diet slip for the pimento cheese sandwich for [Resident #20]? The DON stated, That is before my time.
k. On 08/18/23 at 10:45 AM, the Surveyor asked the Dietary Supervisor in Training, Do you have a dietary slip for [Resident #20]? He stated, I'm not sure we save them. When they send them down, we make changes to the dietary card.
l. On 08/18/23 at 10:49 AM, the Dietary Supervisor in Training showed the Surveyor, Resident #20 ' s dietary card documenting, .Please don ' t give Tuna fish Please give pimento cheese sandwich with supper tray .
Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed; Physician Orders for a pimento cheese sandwich was provided on a supper tray for 1 (Resident #20) of 1 sampled resident. The failed practices had the potential to affect 2 residents who received pureed diets, 2 residents who received pureed meat only and 9 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 08/15/23 at 2:37 PM and 3 residents who had Physician Orders for sandwiches at supper according to a list provided by the Director of Nursing (DON) on 08/18/23 at 9:35 AM. The findings are:
1. The 08/14/23 lunch menu documented the residents who received pureed diets were to receive a #8 scoop of crunchy ranch chicken, a #8 scoop of pureed squash, a #8 scoop of pureed peas and a #8 scoop of pureed hummingbird cake. The residents on mechanical soft diets were to receive ground crunchy ranch chicken.
2. On 08/14/23 at 12:07 PM, the following observations were made during the noon meal service.
a. Dietary Employee (DE) #1 used a 2 ounce (1/4) cup spoon to serve a single portion of pureed ham, pureed peas and pureed squash, instead of a #8 scoop (4 ounces or ½ cup) as specified on the menu.
b. DE #1 used a 2 ounce (1/4) cup spoon to serve a single portion of pureed ham, instead of 4 ounces of crunchy ranch chicken.
c. On 08/14/23 at 12:25 PM, the Surveyor asked DE #4 the reason residents on mechanical soft diets and pureed diets were served ham, instead of crunchy ranch chicken. She stated, There was no reason.
d. On 08/14/23 at 12:32 PM, the Surveyor asked DE #1 what size spoon she used when serving pureed food items. She stated, I used a two ounce spoon to serve pureed meat, pureed peas, and pureed squash. The Surveyor asked how many servings she gave to each resident. She stated, I gave a serving each.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional ...
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Based on observation, record review, and interview, the facility failed to ensure hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed. The findings are:
1. On 08/15/23 at 7:30 AM, an unheated food cart that contained 4 trays for the breakfast meal was in the kitchenette area in the Dining Room. The Surveyor asked the Dietary Supervisor how long the food cart had been out. She stated, It was sent out at 7:20 AM. At 7:43 AM, Certified Nursing Assistant (CNA) #1 removed a tray from the food cart to be delivered to the resident. The Surveyor asked the Dietary Supervisor to check the temperatures of the food items on the tray. She did and stated:
a. Milk - 47 degrees Fahrenheit.
b. Oatmeal - 102 degrees Fahrenheit,
c. Scrambled eggs - 98.5 degrees Fahrenheit.
d. Pureed sausage - 96.8 degrees Fahrenheit.
2. On 08/15/23 at 7:48 AM, the Surveyor asked Resident #11 if his breakfast meal was hot, warm, or cold. He stated, The oatmeal is cold.
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 those res...
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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 those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 2 residents who received pureed diets and 2 residents who received pureed meat only, as documented on the list provided by the Dietary Supervisor on 08/15/23 The findings are:
1. On 08/14/23 at 11:56 AM, the following observations were made on the steam table:
a. A pan of pureed ham, the consistency of the pureed ham was lumpy and was not smooth.
b. A pan of pureed peas, the consistency of the pureed peas was gritty and was not smooth.
c. A pan of pureed bread with milk, the consistency was sticky and thick.
2. On 08/15/23 at 7:50 AM, the pureed sausage served to the residents on a pureed diet was gritty and not smooth. There were pieces of meat visible in the mixture. The Surveyor asked Certified Nursing Assistant (CNA) #1 to describe the consistency of the sausage served to the residents who required pureed diets. She stated, It was gritty.
a. On 08/13/23 at 7:51 AM, the Surveyor asked CNA #2 to describe the consistency of the pureed sausage. She stated, It was gritty.
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 and interview, the facility failed to ensure foods stored in the dry storage area, refrigerator, and freezer were covered, sealed and dated to minimize the potential for food born...
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Based on observation and interview, the facility failed to ensure foods stored in the dry storage area, refrigerator, and freezer were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; and 2 of 2 ice machines were maintained in clean and sanitary condition to prevent contamination of airborne particles. These failed practices had the potential to affect 42 residents who received meals from the kitchen, as documented on a list provided by the Assistant Dietary Supervisor on 08/15/23 at 2:37 PM. The findings are:
1. On 8/14/2023 at 10: 27 AM, the following observations were made in the kitchen:
a. An opened box of iodized salt was on the counter. The box was not covered.
b. An opened 8 pound bag of powdered sugar was on the counter. The bag was not sealed.
c. An opened 24 ounce bottle of grape jam was on the counter. The manufacture specification on the bottle, documented, Refrigerate after opening.
d. An open bag of bread was on the counter. The bag was not sealed.
2. On 08/14/23 at 10:29 AM, Dietary Employee (DE) #1 was wearing gloves on her hands when she pushed a cart that contained trays with dessert towards the refrigerator. She lifted the trash can lid and threw away tissue paper. Without changing gloves and washing her hands, she used her contaminated gloved hand to pick up paper bowls to be used in serving dessert and placed them on the counter with her gloved fingers inside of them. At 10:30 AM, she picked up a slice of hummingbird cake to place in a bowl. The surveyor immediately asked her what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands.
3. On 08/14/23 at 10:31 AM, a pan liner used to line the inside of the ice scoop holder had gray/brown residue on it. The Surveyor asked the Dietary Supervisor in Training to describe what was observed on the liner where ice scoop was resting in direct contact with residue. He stated, It was gray/brown dirt. The Surveyor asked how often you clean it. He stated, They are supposed to clean it daily.
4. On 08/14/23 at 10:32 AM, the back wall interior surfaces of the ice machine in the kitchen had an accumulation of black/brown residue on it. The Surveyor asked the Dietary Supervisor in training to wipe the black/brown residue. He did so, and the black/brown residue easily transferred to the tissue. The Surveyor asked the Dietary Supervisor in training, How often do you clean the ice machine and who uses the ice from the ice machine? He stated, We clean it weekly. We did not see that area when we cleaned it At 1:06 PM, the Surveyor asked the Dietary Supervisor who uses the ice from the ice machine. She stated, The CNAs use it to fill beverages served to the residents at meals.
5. On 08/14/23 at 10:44 AM, DE #1 was wearing gloves on her hands when she opened the refrigerator and removed a bottle of diet green tea and placed it on the counter, contaminating the gloves. Without changing gloves and washing her hands. She started to pick up slices of cake and place in a bowl to be served to the residents for lunch. The Surveyor immediately asked her what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have removed the gloves and washed my hands.
6. On 08/14/23 at 10:46 AM, the following observations were made in the 3 door freezer:
a. A 3 gallon container of vanilla ice cream was on a shelf. The lid was partially off. There was an ice scoop on top of the ice cream. The Surveyor asked the Dietary Supervisor in training to describe the appearance of the ice cream. He stated, It is refrozen ice cream. That should have been thrown away.
b. A box of vanilla ice cream was in the freezer. The ice cream had ice cycles on it. The Surveyor asked the Dietary Supervisor in training to describe the appearance of the ice cream. He stated, It was refrozen and has ice cycles on it.
7. On 08/14/23 at 10:49 AM, the following observations were made in the refrigerator:
a. A half-gallon of Bulgarian style cultured butter milk was on a shelf. The container documented, Best if used 7/28/2023.
b. A container of whipping cream was on a shelf had an expiration date of 2/15/2023.
c. A 24 ounce container of cottage cheese was on a shelf and had an expiration date of 7/29/2023.
d. An opened ziplock bag of cheese slices was on a shelf in the refrigerator. The bag was not sealed.
8. On 08/14/23 at 11:03 AM, a box of buttery spread that contained 113 butter cups was on a shelf. The box documented, Best by 08/04/2023.
9. On 08/14/23 at 11:11 AM, an opened box of bread sticks was on a shelf in the freezer. The box was not covered or sealed.
10. On 08/14/23 at 11:19 AM, four 5-pound bags of grits were on a shelf in the storage room. The bags had an expiration date of 7/9/2023.
11. On 08/14/23 at 11:33 AM, the following observations were made in the walk-in refrigerator:
a. Four half gallons of buttermilk was in a milk crate with an expiration date of 8/11/2023.
b. A 5 pound container of tuna salad was on a shelf, the container had an expiration date of 8/13/2023.
c. A 5 pound container of cottage cheese was on a shelf, the container had an expiration date of 3/13/2023.
d. Eight 32 ounce boxes of whipping cream was in a box on a shelf. The boxes documented, Best if used by 2/15/2023.
e. A bag of shredded slaw was on a shelf in the refrigerator, the box had no received date on it.
f. Two 8 pound containers of classic regular potato salad were in a box on a shelf. The boxes had an expiration date of 8/13/2023.
12. On 08/14/23 at 11:59 AM, DE #3 was wearing gloves on her hands when she pushed a cart that contained bowls of dessert close to the steam table, contaminating the gloves. At 12:03 PM, without changing gloves and washing her hands, she picked up slices of humming bird cake with her contaminated gloved hands and placed them on the tray compartments to be served to the residents for lunch.
13. On 08/14/23 at 1:05 PM, the interior surfaces of the ice machine located in the ice room on the 200 Hall had an accumulation of gray/brown residue on the back and sides. The Surveyor asked the Dietary Supervisor to wipe the gray/brown residue. She did so, and a black residue easily transferred to the tissue. The Surveyor asked the Dietary Supervisor, How often do you clean the ice machine and who uses the ice from the ice machine? The Dietary Supervisor stated, CNA's use it. The CNAs use it for the water pitchers in the residents' rooms. I think the Maintenance Man.
14. On 08/14/23 at 2:11 PM, the Maintenance Man stated, The storage service company cleans it 3 times every year. I will start cleaning it every week.
15. On 08/15/23 at 11:59 AM, DE #2 turned on the 3-compartment sink faucet and rinsed a spatula. She then turned off the faucet. Without washing her hands, she placed gloves on her hands contaminating the gloves. She picked up a clean blade and attached it to the base of the blender. When she was ready to pour peas into the blender to puree, the Surveyor immediately asked her what she should have done after using a tissue paper that you had used to dry your hands to wipe your face. She stated, I should have removed the gloves and washed my hands.
CONCERN
(E)
📢 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
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 08/14/23 at 12:37 PM, the Surveyor entered room [ROOM NUMBER] and observed a spider crawling on the floor near the residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 08/14/23 at 12:37 PM, the Surveyor entered room [ROOM NUMBER] and observed a spider crawling on the floor near the resident's bed.
4. On 08/14/23 at 1:00 PM, observed a cockroach on the wall in the facility Prayer Room.
5. On 08/17/23 at 10:31 AM, observed over 20 crickets in the floor of the 400 Hall.
6. On 08/14/23 at 9:16 AM, the Surveyor asked the resident in room [ROOM NUMBER] if she had witnessed any pests in the room. The resident reported seeing water bugs or roaches.
7. On 08/15/23 at 8:01 AM, the Surveyor entered room [ROOM NUMBER] and observed two spiders crawling along the baseboard near the resident's bed.
8. On 08/14/23 at 11:17 AM, the Surveyor asked the resident in room [ROOM NUMBER], Have you ever seen ants in your room? He stated, Yes and some roaches. They come in through the window.
9. On 08/14/23 at 11:30 AM, the Surveyor asked the resident in room [ROOM NUMBER], Have you ever seen ants or roaches in your room? He stated I have seen roaches. The other day one of the girls killed a big, ole spider on the wall.
10. On 08/14/23 at 11:56 AM, the Surveyor asked the resident in room [ROOM NUMBER], Have you ever seen ants or roaches in your room? He stated Yes, I've seen roaches and ants.
11. On 08/15/23 at 8:18 AM, the Surveyor asked the resident in room [ROOM NUMBER] if he had witnessed pests in the room. The resident reported seeing flies and roaches in the room. The Surveyor observed a hole in wall behind the bed that appeared to have marks made by a rodent chewing.
12. On 08/14/23 at 8:39 PM, the Surveyor asked the resident in room [ROOM NUMBER] if she had witnessed pests in her room. The resident reported she had witnessed roaches and mice in her room.
13. The following Termite and Pest Elimination Service Invoices provided by Cooperate Account Payable on 08/15/23 at 2:23 PM documented:
a. An Invoice dated 1/13/2023 documented, .Services Provided lnterior Pest Elimination . Checked all patient rooms for pest issues . Target Pests roaches .
b. An Invoice dated 1/28/2023 documented, .Services Provided Exterior Rodent Trap Service, Pest Elimination - Monthly . Target Pests roaches and rodents .
c. An Invoice dated 2/10/2023 documented, .Services Provided .lnspected and treated all patient rooms for pest . Target Pest roaches . There was no mention of service for flies, ants, spiders, or other insects.
d. An Invoice dated 3/28/2023 documented, .Services Provided . provided the monthly interior and exterior fly service . Target Pests flies .
e. An Invoice dated 3/28/2023 documented, .Services Provided . Inspected and treated all patient rooms . Target Pest roaches .
f. An Invoice dated 4/26/2023 documented, .Services Provided . Provided the monthly interior and exterior fly service . Target Pests flies .
g. An Invoice dated 5/18/2023 documented, .Services Provided . Pest Elimination - Monthly . Treated room [ROOM NUMBER] for roaches, will inspect and treat again next week . Target Pests roaches .
h. An Invoice dated 5/22/2023 documented, .Services Provided Fly Service . Provided the monthly interior and exterior fly service . Location .Exterior, common areas, dining room, entry points and kitchen . Target Pest flies .
i. An Invoice dated 5/22/2023 documented, .Services Provided Exterior Rodent Trap Service, Pest Elimination - Monthly . All exterior bait stations were inspected, cleaned, dated and bait was replaced where needed . Target Pests rodents, roaches, ants, beetles, crickets, spiders and wasps .
j. An Invoice dated 5/22/2023 documented, .Services Provided Trouble Call . lnspected and treated all dietary areas. Replaced all monitor boards target pest . Target Pests roaches .
k. An Invoice dated 5/23/2023 documented, .Services Provided Light Trap Service . All 4 light traps were inspected, dated and the glue boards were replaced . Target Pests flies .
l. An Invoice dated 6/7/2023 documented, .Services Provided Trouble Call . Treated the kitchen and room [ROOM NUMBER] for roaches will treat again next week . Target Pests roaches .
m. An Invoice dated 6/19/2023 documented, .Services Provided Trouble Call . lnspected and treated for roaches. Seeing progress and let kitchen staff know what I found . Target Pests roaches .
n. An Invoice dated 6/26/2023 documented, .Services Provided Fly Service . Provided the monthly interior and exterior fly service . Target Pests flies .
o. An Invoice dated 6/26/2023 documented, .Services Provided Exterior Rodent Trap Service, Pest Elimination - Monthly . All exterior bait stations were inspected, cleaned, dated and bait was replaced where needed. No activity was found . Target Pests roaches, ants, beetles, crickets, spiders and wasps, rodents .
p. An Invoice dated 7/26/2023 documented, .Services Provided Fly Service . provided the monthly interior and exterior fly service . Target Pests flies .
q. An Invoice dated 7/26/2023 documented, .Services Provided Exterior Rodent Trap Service, Pest Elimination - Monthly . AII exterior bait Stations were inspected, cleaned, dated and bait was replaced where needed . Target Pests ants, beetles, crickets, spiders and wasps
roaches, rodents .
14. On 08/17/23 at 3:32 PM, the Administrator reported the facility had no policy on Pest Control but provided a Service Agreement and Service Records from (Pest Control Company). The Service Agreement documented, .This agreement covers service to be rendered monthly by [Pest Control Company] . This agreement shall be in effect from June 2008 and stay in effect until the said party calls our company to cancel this agreement .
Based on observation, record review and interview, the facility failed to maintain an effective pest control program to ensure the kitchen service areas and 7 (Rooms 113, 116, 119, 121, 209, 214 and 215) resident rooms and the 400 Hall to ensure the facility was free of insect and spiders. This failed practice had the potential to affect all 43 residents who resided in the facility. The findings are:
1. On 08/14/23 at 12:22 PM, during the noon meal service, one fly was on a bread bag on the counter by the steam table, two flies were on the steam table, 2 flies were at the edges of the food trays and another fly was at the end of the steam table.
2. On 08/15/23 at 1:35 PM, the Surveyor asked Dietary Employee (DE) #3 if they have been having problems with flies. She stated, It was bad yesterday. They come in when the back door is open. I counted about 8 flies, and I kept shooing them away.
Jun 2022
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the most recent federal survey results were readily accessible to residents, family members and/or legal representatives of resident...
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Based on record review and interview, the facility failed to ensure the most recent federal survey results were readily accessible to residents, family members and/or legal representatives of residents. The findings had the potential to effect 42 residents according to the room-bed list provided by the Administrator on 5/31/22 at 10:20 AM The findings are.
1. On 6/2/22 at 10:50 AM, the Administrator was asked the location of the most recent state/federal survey results. The Administrator stated that the results were located in a notebook which is in a metal rack and chained to the nurses' station desk.
2. On 6/2/22 at 11:10 AM, the notebook was attached to the nurses ' station by a chain. The survey results located inside the book were dated 9/20/19 and Desk review dated 11/5/19.
3. On 6/2/22 at 1:23 PM, the Administrator was asked which survey results should be in the notebook available to the residents and their family/representative. She stated, .the last five years. Isn't it the last five year. The Administrator was asked if that would include the most recent survey she stated, Yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure residents were provided with information on their right to formulate an advance directive and/or that their decisions to formulate o...
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Based on record review and interview, the facility failed to ensure residents were provided with information on their right to formulate an advance directive and/or that their decisions to formulate or not formulate advance directives were documented in the clinical record, to ensure residents and/or their responsible parties were able to make advance decisions regarding end-of-life care if they wished to do so for 1 of 1 (Resident #41) sampled resident whose clinical record was reviewed for advanced directive information. The findings are:
Resident #41 had diagnoses of Cerebral Vascular Disease, and Contractures multiple sites. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/22 documented the resident was severely impaired in cognitive skills per a Staff Assessment of Mental Status; was totally dependent with one-person physical assistance for bed mobility, eating and personal hygiene; totally dependent of two- person assistance for transfers; and always incontinent of bowel and bladder.
a. On 6/01/22 at 10:45 AM, the clinical record was reviewed. There was no advance directive in the chart.
b. On 6/02/22 at 10:48 AM, the DON was asked, Is there a reason [Resident #41 ' s] advance directive is not in the chart? She stated, Let me look for it.
c. On 6/2/22 a 1:30 PM, the Administrator stated, I guess we sent the last advance directive to the hospital with her. We have another one in the chart, and we are waiting on her daughter and the doctor to come sign it.
d. On 6/02/22 at 2:50 PM, the Administrator provided a form titled, Advance Directives. that documented, During the admissions procedure, all residents will be informed of their rights concerning Advance Directives. Receipt of this information shall be documented by a signature of the resident or his/her legal guardian, responsible party or family member acting on his/her behalf. Two persons shall witness the signatures .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the Minimum Data Set [MDS] assessments accurately reflected the Care Area Assessment [CAA] to provide accurate information to develo...
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Based on record review and interview, the facility failed to ensure the Minimum Data Set [MDS] assessments accurately reflected the Care Area Assessment [CAA] to provide accurate information to develop a Care Plan to meet the residents' needs for 1 (Resident #38) sampled resident whose MDS assessments were reviewed. The findings are:
Resident #38 had diagnosis of Type 2 Diabetes Mellitus, Congestive Heart Failure [CHF], Angina Pectoris, Chronic Pulmonary Embolism and Osteoporosis w/path Fracture [Fx] (R) [Right] femur. An admission MDS with an Assessment Reference Date [ARD] of 04/27/22 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status [BIMS]; was totally dependent of 2 staff for transfers; totally dependent of 1 staff for dressing, toilet use, personal hygiene and bathing, required extensive assistance of 1 staff for bed mobility; was independent after set up for eating; and always incontinent of bladder and bowel.
a. On 05/31/22 at 11:00 am, the resident asked the Surveyor how she got her chewing tobacco, asking does my family bring it or do ya'll furnish it? There was a Styrofoam cup with napkins stuffed in it sitting on the bedside [bs] table, but no smokeless tobacco observed.
b. On 6/01/22 at 10:51 am, Licensed Practical Nurse [LPN] #1 was asked if she took care of Resident #38. She stated, Yes. The LPN was asks if the resident used smokeless tobacco and she stated, Yes.
c. On 06/01/22 at 02:35 pm, Certified Nursing Assistant [CNA] #3 was asks if she took care of Resident #38. She stated, Yes. The CNA was asks if resident used smokeless tobacco and she stated, Yes, she dips. Her family brings her tobacco.
d. On 06/01/22 at 03:00 pm, the admission MDS under Section J - Health Conditions, documented, .Current Tobacco Use: No.
e. On 06/02/22 at 03:12 pm, the MDS Coordinator was asked if she was aware resident #38 used smokeless tobacco and she stated, No, I was not aware of that. She was advised that interviews with the resident, a Certified Nurses Aid and a Licensed Practical Nurse identified that the resident does use smokeless tobacco. She was asked if that should be listed on the MDS and care plan and she stated, Yes, I will fix that.
f. On 06/02/22 at 03:15 pm, the Administrator stated, The resident does not have an assessment for smokeless tobacco and the facility does not have a policy on smokeless tobacco.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure an assessment was accurately completed to reflect smoking preference to maintain accuracy of data for 1 (Resident #38) of 1 sampled ...
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Based on record review and interview, the facility failed to ensure an assessment was accurately completed to reflect smoking preference to maintain accuracy of data for 1 (Resident #38) of 1 sampled resident who used smokeless tobacco. This failed practice had the potential to affect 1 resident who used smokeless tobacco as identified on a list provided by the Administrator on 06/02/22 at 03:00 pm. The findings are:
Resident #38 had diagnosis of Type 2 Diabetes Mellitus, Congestive Heart Failure [CHF], Angina Pectoris, Chronic Pulmonary Embolism and Osteoporosis w/path Fracture [Fx] (R) [Right] femur. An admission MDS with an Assessment Reference Date [ARD] of 04/27/22 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status [BIMS]; was totally dependent of 2 staff for transfers; totally dependent of 1 staff for dressing, toilet use, personal hygiene and bathing, required extensive assistance of 1 staff for bed mobility; was independent after set up for eating; and always incontinent of bladder and bowel.
a. On 05/31/22 at 11:00 am, the resident asked the Surveyor how she got her chewing tobacco, asking does my family bring it or do ya'll furnish it? There was a Styrofoam cup with napkins stuffed in it sitting on the bedside [bs] table, but no smokeless tobacco observed.
b. On 6/01/22 at 10:51 am, Licensed Practical Nurse [LPN] #1 was asked if she took care of Resident #38. She stated, Yes. The LPN was asks if the resident used smokeless tobacco and she stated, Yes.
c. On 06/01/22 at 02:35 pm, Certified Nursing Assistant [CNA] #3 was asks if she took care of Resident #38. She stated, Yes. The CNA was asks if resident used smokeless tobacco and she stated, Yes, she dips. Her family brings her tobacco.
d. On 06/01/22 at 03:00 pm, the admission MDS under Section J - Health Conditions, documented, .Current Tobacco Use: No.
e. On 06/02/22 at 03:12 pm, the MDS Coordinator was asked if she was aware resident #38 used smokeless tobacco and she stated, No, I was not aware of that. She was advised that interviews with the resident, a Certified Nurses Aid and a Licensed Practical Nurse identified that the resident does use smokeless tobacco. She was asked if that should be listed on the MDS and care plan and she stated, Yes, I will fix that.
f. On 06/02/22 at 03:15 pm, the Administrator stated, The resident does not have an assessment for smokeless tobacco and the facility does not have a policy on smokeless tobacco.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure a care plan addressed a diagnosis of Bipolar for 1 (Resident #28) of 3 (Resident #20, #26, and #28) sample residents that had a diagn...
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Based on interview and record review the facility failed to ensure a care plan addressed a diagnosis of Bipolar for 1 (Resident #28) of 3 (Resident #20, #26, and #28) sample residents that had a diagnosis that required a PASARR screening. The findings are:
Resident #28 had diagnoses of Bipolar Disorder. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/22 documented the resident scored 9 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status. Bipolar checked yes in the active diagnosis section.
a. As of 6/3/2022, there was no documentation on the care plan to address Resident #28 ' s diagnosis of Bipolar.
b. On 6/03/22 at 9:18 AM the MDS coordinator was asked, Can you tell me why the bipolar diagnosis was not care planned for Resident #28? She stated, I just started doing care plans by myself, and I didn't know he had a bipolar diagnosis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a call light was answered in a timely manner i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a call light was answered in a timely manner in order for 1 (Resident #144) of 5 (Resident #24, #3, #4, #41, and #144) sample residents who depended on staff for repositioning. The findings are:
Resident #144 had a diagnosis of Femoral Neck Fracture with repair. An admission 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/27/22/22 documented the resident scored 06 (0-7 indicates severely impaired) on the Brief Interview for Mental Status; required extensive one-person physical assistance with transfers, toilet use, and personal hygiene; had Impairment to lower extremity; and was frequently incontinent of bowel and bladder.
a. A care plan with a review date of 5/27/22 documented, .[Resident #144] is a resident to the facility and currently requires limited to extensive assist with the following ADL's [Activities of Daily Living]: Transfers, Locomotion on and off unit, toileting, personal hygiene, bathing and dressing .
b. An incident report dated 5/21/22 documented, .Confused .Fell out of bed .Called to resident's room, observed resident lying on safety mat beside bed .
c. On 6/01/22 at 10:55 AM, Resident #144 was positioned in the middle of the bed.
d. On 6/01/22 at 10:58 AM Resident #144 stated, I need to be pulled up in bed. They aren't doing anything with me. I can't get any help back here. The resident was asked to turn on her call light.
e. On 6/01/22 at 11:33 AM, Certified Nursing Assistant (CNA) #5 walked down the hall and went in Resident #144 ' s room and turned off the call light. She was asked, Did [Resident #144] tell you what she needed? She stated, No. This surveyor informed CNA #5 that Resident #144 needed to be repositioned in bed. CNA #5 stated I'm not assigned to her, but I'll go ahead and reposition her since I'm down here.
f. On 6/01/22 at 2:24 PM, CNA #6 was asked, Are you assigned to [Resident #144] in room [ROOM NUMBER]? She stated, Yes. She was asked, Can you tell me why it took so long for someone to answer her call light when she turned it on at 10:58 AM today? She stated, I don't know why it took so long. There's a board at the nurse's station that lights up when the light comes on.
g. On 6/3/22 at 8:35 AM, CNA #8 was asked, Did you work with Resident #144 on 6/01/22 on the 6-2 shift? She stated, Yes. She was asked, Can you tell why [Resident #144 ' s] call light was on for 35 minutes before someone came to assist her on 6/01/22? She stated, We probably was getting ready to serve lunch in the dining room. She was asked, How soon should you answer a call light? She stated, Right away, as soon as you hear it. [Resident #144] has a bed alarm and her alarm goes off all the time. She was asked, Should you check the alarm when it goes off? She stated, Yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure an assistive device was provided to prevent further contractures for 1 (Resident #41) of 3 (Resident #20, #24, and #41)...
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Based on observation, interview, and record review the facility failed to ensure an assistive device was provided to prevent further contractures for 1 (Resident #41) of 3 (Resident #20, #24, and #41) sample residents who had contractures. The findings are:
Resident #41 had diagnoses of Cerebral Vascular Accident, and Contractures multiple sites. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/22 documented the resident was severely impaired in cognitive skills per a Staff Assessment of Mental Status; was totally dependent of one-person with assistance for bed mobility and personal hygiene; totally dependent of two- person with assistance for transfers; and always incontinent of bowel and bladder; and had limited range of motion of both upper extremities and one lower extremity.
a. On 5/31/22 at 12:12 PM and 6/1/22 at 8:26 AM, Resident #41 was in bed. Both of her hands were balled up in a fist. Her hands were raised up to her chest. There were no handrolls in her hands.
b. On 6/01/22 at 8:27 AM, Licensed Practical Nurse (LPN) #1 was asked, Can you tell me why [Resident #41] doesn't have any hand rolls in her hands? She stated, They were in here this morning, and [Certified Nursing Assistant (CNA) #4] was getting ready to give her a bath, so we took them out. She was asked, Can you show me where her hand rolls are located? She reached in the drawer on the nightstand and pulled out 2 towels that were rolled up. She was asked, Is there a reason why you didn't wait until she was actually ready for the bath before the hand rolls were removed? She stated, No.
c. On 6/01/22 at 8:44 AM, CNA #4 was asked, Are you the CNA assigned to [Resident #41]? She stated, Yes. She was asked, Can you tell me why she doesn't have her hand rolls in?' She stated, Because they weren't there when I got here this morning.
d. On 6/01/22 at 2:50 PM, the Director of Nursing (DON) was asked, Can you tell me how often [Resident #41] supposed to wear her hand rolls? She stated, Supposed to wear them every day? She was asked, Can you tell me why she didn't have her hand rolls in yesterday, or today? She stated, I cannot tell you why.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure physician orders for cleaning a Percutaneous Endoscopic Gastrostomy (PEG) tube site were followed to prevent a potenti...
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Based on observation, interview, and record review, the facility failed to ensure physician orders for cleaning a Percutaneous Endoscopic Gastrostomy (PEG) tube site were followed to prevent a potential infection for 1 (Resident #41) of 2 (Resident #20, and 41) sample residents who had a peg tube. The findings are:
Resident #41 had diagnoses of Cerebral Vascular Accident, and Contractures multiple sites. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/22 documented the resident was severely impaired in cognitive skills per a Staff Assessment of Mental Status; was totally dependent of one-person with assistance for bed mobility and personal hygiene; totally dependent of two- person with assistance for transfers; and always incontinent of bowel and bladder; and had a feeding tube.
a. A physician order dated 1/1/2020 documented, .Clean peg tube site with W/C [Wound Cleanser] pat dry, apply dry gauze and secure w [with]/tape QD [every day] give at 7-3 .
b. A telephone order dated 5/22/22 documented, .Transport to [emergency room (ER)] per EMS [Emergency Medical Services] to eval [evaluate] and tx [treat] as indicated D/T [due to] feces at peg stoma .
c. On 6/01/22 at 2:59 PM, Licensed Practical Nurse (LPN) #1 removed a gauze dated 5/31/22 from Resident #41 ' s peg site. There was no drainage on the dressing. She applied a clean gauze and secured it with paper tape.
d. On 6/2/22 at 10:01 AM, LPN #1 was asked, How do you clean [Resident #41 ' s] peg site? She stated, I put the gauze on it with paper tape. She was asked, Is there a reason why you didn't clean the site with wound cleanser and pat dry? She stated, When the CNA's give her a bed bath, they clean it with soap and water.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure Medicaid recipient residents and/or their responsible parties were notified when their trust balance was within or approaching $200 ...
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Based on interview and record review, the facility failed to ensure Medicaid recipient residents and/or their responsible parties were notified when their trust balance was within or approaching $200 of the maximum Medicaid recipient cash assets for 5 of 5 (Residents #4, #35, #28, #3, and #37) sampled residents who had a trust fund. The findings are:
1. A Trust Fund Report for April 1 through April 30, 2022 documented the following:
a. On 4/7/21 Resident #4 received a stimulus payment of $1,400.00. Most recent quarterly statement dated 4/30/22 reflected a balance of $2160.65.
b. On 4/7/21 Resident #35 received a stimulus payment of $1,400.00. Most recent quarterly statement dated 4/30/22 reflected a balance of $2140.58.
c. On 4/7/21 Resident #28 received a stimulus payment of $1,400.00. Most recent quarterly statement dated 4/30/22 reflects a balance of $3,80.91.
d. On 4/7/22 Resident #3 received a stimulus payment of $1,400.00. Most recent quarterly statement dated 4/30/22 reflected a balance of $5530.99,
e. On 4/7/22 Resident #37 received a stimulus payment of $1,400.00. Most recent quarterly statement dated 4/30/22 reflected a balance of $4161.46.
2. On 6/2/22 at 3:00 PM, the Administrator was asked how residents and their family or representatives were notified when their balance was within $200 of the maximum Medicaid recipient cash assets. The Administrator stated, .at this point we have just been sending out their statements .Honestly, we didn't think a thing about it until we recently had some training with corporate and we are working with them to get things set up the way they are supposed to be.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to inform residents as soon as possible of a change in their part A services/Medicare Reimbursement for 1 of 1 (Resident #46) sampled resident ...
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Based on interview and record review the facility failed to inform residents as soon as possible of a change in their part A services/Medicare Reimbursement for 1 of 1 (Resident #46) sampled resident who had a change in par A services/Medicare Reimbursement. The findings are:
Resident #46 had a diagnosis of Cellulitis/R lower leg, Type 2 Diabetes mellitus, acute kidney failure and Blindness. The Minimum Data Set with an assessment reference date of 3/10/22 documented the resident scored 13 (13-15 cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assistance of 1 person for bed mobility, and was totally dependent on 1 person physical for transfer, toileting, personal hygiene and bathing.
a. On 6/1/22 the Administrator provided the Notice of Medicare Provider Non-Coverage that documented The effective date coverage of your current services will end as of 3/23/22. The notice was signed by the resident ' s spouse on 3/22/22.
b. On 6/2/22 the Administrator was asked, How long prior to a resident being discharged from Part A services should a resident or their representative be provided with notice of a change in services/reimbursement. She stated, .no sooner than a week before discharge .by the day of discharge .we usually get them to sign it when they pick up the resident's belongings .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
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 air conditioning was working properly to ensure a comfortable ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure air conditioning was working properly to ensure a comfortable temperature in resident rooms and the bathroom was clean and free of odors in one resident room to provide a comfortable, sanitary, and homelike environment. This failed practice had the potential to affect all 42 residents (Census) given by the Administrator on 05/31/22. The findings are:
1. On 05/31/22 at 11:43 am, Resident #26 had 4 osculating fans blowing in her room. She was asks if she was hot. She stated, My air conditioner doesn't work. It's not too bad in here right now but I want it fixed before it gets too hot. I have breathing problems and it gets worse when I get hot. One large vent approximately a foot from the ceiling had lint hanging from it, a smaller vent approximately a foot from the floor was half hidden by a chest of drawers and another small vent approximately a foot from the floor had lint hanging out of it. The resident was asked if she had told anyone her air conditioner wasn't working and she stated, Yes, I told the Maintenance man. She was asked if he had tried to fix it or had someone look at it and she stated, He told me that the unit was froze up. The resident was asked when was the last time he had looked at it or cleaned out the vents and she stated, I don't know, I can't remember.
a. On 06/02/22 at 08:10 am, The Administrator was told the air conditioner was not working in Resident's room. She stated, Let me call someone to get that fixed right away.
b. On 06/02/22 at 01:30 pm The Administrator was asks when did you become aware of the air not working in resident's room? She stated, This morning when I was told was the first time I heard it, and I called [NAME] Heat & Air right away. The earliest they could come is tomorrow. She was asks if she was aware of resident having four fans in her room? She stated, Yes, she has always had 4 fans in her room, that is what she wants.
c. On 06/02/22, the Maintenance staff was not available for interview.
2. On 5/31/22 at 11:37 AM, the bathroom in Resident room [ROOM NUMBER] smelled like urine.
a. On 6/2/22 at 10:26 AM, Housekeeping #2 was asked, Can you tell me why room [ROOM NUMBER] smells like urine? She stated, I cannot answer that.
b. On 6/02/22 at 10:35 AM and 3:19 p.m., the bathroom in Resident room [ROOM NUMBER] smelled like urine. There was a brown substance on the bathroom floor, and around the shower. The shower had white soap scum inside the shower. The shower curtains were dirty with a white substance on them, and spider webs at were at the top of the shower.
c. On 6/02/22 at 3:45 PM, the Administrator was asked, How often should the bathroom be cleaned? She stated, It should be daily. She was asked, Can you tell me why the bathroom in room [ROOM NUMBER] smells like urine, and there is brown substance on the floor? She stated, Housekeeping must have sprayed, and I see what you're saying about it need to be cleaned.
d. On 6/03/22 at 8:53 AM, the Housekeeping Supervisor was asked, Can you tell me why there is a urine smell in room [ROOM NUMBER], a brown substance on the bathroom floor, the shower curtain is dirty, and spider webs are in the shower? She stated, No ma'am, I haven't been down there today. I sent [Housekeeper #4] down there the other day to clean it up when you asked about it. She was asked, How often should the bathrooms be cleaned? She stated, Every day.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
2. Resident #26 had diagnosis: Schizophrenia, Paranoid, Delusions. An Annual Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 04/23/22 documented resident scored 15 (13 to 15 indicate...
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2. Resident #26 had diagnosis: Schizophrenia, Paranoid, Delusions. An Annual Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 04/23/22 documented resident scored 15 (13 to 15 indicates cognitively intact} on the Brief Interview for Mental Status [BIMS]; required extensive assistance of 1 for personal hygiene, assistance of 1 for bathing, limited assistance of 1 for dressing and toilet use, was independent after setup for eating, independent for transfer and bed mobility and was frequently incontinent of bladder and bowel.
a. On 06/02/22 at 08:15 am, the Administrator provided the surveyor with a 3 ring binder which she stated contained all PASARRs. This surveyor could not locate a PASARR for Resident #26. A form entitled [PASARR Agency] dated 08/22/08 documented [Resident #26] has been approved* for 90 days of convalescent care/medical review by OLTC [Office of Long Term Care] and may enter nursing home of his/her choice . Nursing Facilities: You must contact [PASARR Agency] with Clients admission date in order to receive your clients completed PASARR evaluation.
b. On 06/03/22 at 09:28 am, the Administrator was shown PASARR agency documentation (above) in resident's chart and asks if she had a Level I evaluation. She stated, I'm not sure, it should be in her chart if we had one but there may be a copy in the financial office. I'll go look.
c. On 06/03/22 at 09:50 am, the Administrator stated, I did not find a copy of a Level I PASARR. I called [PASARR Agency] and was told that they had mailed the facility one back in 2008. I will have to get them to mail another one.
Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) screening was completed for 2 (Resident #26, and #28) of 3 (Resident #20, #26, and #28) sample residents who had a diagnosis that required a PASARR screening. The findings are:
1. Resident #28 had diagnoses of bipolar disorder. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/22 documented the resident scored 9 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status. Bipolar checked yes in the active diagnosis section.
a. On 6/01/22 at 11:48 AM, the clinical record was reviewed. There was not a PASSAR in the clinical record.
b. On 6/01/22 at 2:30 PM, the DON was asked, Can you tell me where the PASARR is located in the clinical record? She stated, Not sure where they keep it
c. On 6/01/22 at 4:07 PM, the DON was asked, Does [Resident #28] have a PASARR? She stated, I don't know if he has a PASARR. I'll ask the Administrator.
d. On 6/01/22 at 4:15 PM the DON provided a form titled, Diagnosis Report. It documented, .bipolar disorder .Diagnosis Onset Date .9/03/2020 .
e. On 6/02/22 at 8:47 AM, the Administrator was asked, Can you tell me why [Resident #28] doesn't have a PASARR in his clinical record? She stated, Does he have a diagnosis that require a PASARR? She was asked, Can you tell me why the PASARR's aren't kept in the clinical record? She stated, It supposed to be one in the chart and a copy in my book.
f. On 6/02/22 at 9:30 AM, the Administrator provided a form dated 10/09/19. It documented, .This client is a NON-PASARR client .
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 area behind the clothes dryers was clean and free of excess debris which might impede the proper operation of the ...
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Based on observation, record review, and interview, the facility failed to ensure the area behind the clothes dryers was clean and free of excess debris which might impede the proper operation of the dryers and possible fire hazard and failed to ensure the bed rails were secure, and in good working condition to prevent the potential for injury for 1 (Resident #28) of 6 (Resident #194, #24, #3, #20, #41, and #144) sample residents who used their bed rails for bed mobility and transfers. The findings are:
1. On 06/02/22 at 8:36 AM, the laundry staff was asked who was responsible for cleaning the area behind the dryers. Laundry Employee #3 stated, I guess we are supposed to. Laundry Employee #3 was asked when the area was last cleaned and the employee stated, I'm not sure, I think about a month ago. There were two doors leading to the area behind the dryers on the clean side of the laundry facility. Entering through the door located on the right side, the area was covered in a thick layer of dust. The windowsill was covered in dust, cobwebs and littered with dead insects of varying sizes and colors. The natural gas-powered dryer immediately to the left had a metal housing which surrounded the pilot light. The flame associated with the pilot light extended from the top of the metal casing. The metal casing was coated in dust and cobwebs. The metal grating on the back of the dryer was coated in dust, interspersed with lint. The motor of the dryer was encased in dust. Upon entering the left door to the area behind the dryers, a dryer had the metal sheeting removed. The sheeting was meant to cover the moving parts and prevent injury. The moving parts include belts and gears which are now covered in a thick layer of dust approximately 1/8 [(inch) thick. The metal covering was propped against the middle dryer. Laundry Employee #2 was asked why the metal cover was removed from the back of the dryer and she stated, There was someone here working on it about a month or so ago. He must have forgot to put it back.
2. Resident #28 had diagnoses of Morbid Obesity, Personal history of transient Ischemic attack, and End Stage Renal Disease. A Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/20/22 documented the resident scored 8 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status, required extensive one-person physical assistance with bed mobility, totally dependent with two-plus persons assistance for transfers, and always incontinent of bowel and bladder.
a. A care plan with a review date of 5/20/2 documented, .Limited assist with bed mobility .Provide only the amount of assistance/supervision that is needed .
b. On 6/01/22 at 9:42 AM, Resident #3 stated, When I get back from dialysis, I have problems getting in my bed. The staff try to tell me to turn a certain way, but I can't because the rails are loose. The rails on my bed are loose and I'm scared and don't feel safe when I'm holding on to them. Plus, my bed isn't big enough for me to turn over from side to side.
c. On 6/01/22 at 9:50 AM, Resident #3 was asked to show this surveyor what's wrong with her bed rails. Resident #3 grabbed the rail on the left side of her bed. She shook the rail, and the rail easily moved side to side. The rail was hanging and wasn't secured to the bed.
d. On 6/01/22 at 2:47 PM, Certified Nursing Assistant (CNA) #1 was asked, Can you tell me why [Resident #3 ' s] bed rail is loose? CNA #1 walked in Resident #3 ' s room and shook the rail, then she stated, The maintenance supervisor usually tightens it up. CNA #1 twisted the knob on the rail, and then she shook the rail. The rail moved up and down when she shook it. She stated, I can't tighten it, I don't have enough energy.
e. On 6/01/22 at 2:55 PM, the Director of Nursing (DON) was asked, Can you tell me why [Resident #3 ' s] bed rails are loose? She stated, I had no idea. She was asked, Can you tell me why it's important that the bed rails are in good working condition? She stated, She needs to turn and reposition. I've talked to maintenance, and we got her a new mattress.
f. On 6/03/22 at 10:09 AM, the Maintenance Supervisor was asked, Were you aware that [Resident #3 ' s] bed rail was loose? She stated, No I did not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 laundry was not held against staff ' s body to prevent cross-co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure laundry was not held against staff ' s body to prevent cross-contamination and staff were wearing their mask appropriately to prevent the spread of COVID 19 and other infectious diseases. The failed practice had the ability to affect all 42 residents who reside in the facility according to a list provided by the Administrator on [DATE]. The findings are:
1. On [DATE] at 10:10 AM, upon entering the facility, Certified Nursing Assistant (CNA) #2 was in the corridor pushing a resident in a wheelchair. The CNA had her mask below her chin, leaving her mouth and nose exposed. CNA promptly corrected the mask upon seeing this surveyor. CNA, #2 was asked where her mask should be located and she stated, Over my mouth and nose.
2. On [DATE] at 10:00 AM, Laundry Staff #3 was folding clothes. As she folded the clothing items she would hold the items against her person. At one point she held a folded pair of paints under her arm as she turned the shirt right side out and readied it for hanging. Staff was asked if the clothing should be held against her person and she stated, No.
3. On [DATE] at 10:30 AM, the the Laundry Supervisor was asked what was the proper way to process clean laundry and the Supervisor stated with the question, Can I show you?'' Laundry Supervisor then demonstrated how to fold a sheet on the table in front of her taking care to not allow the bed linen to touch her person, clothing or the floor. She continued to describe that the purpose of her technique was to maintain sanitation by not getting it next to me. She was asked why this was important and she stated, To prevent cross contamination.
4. On [DATE] at 10:35 AM, the CNA #1 was in the main dining room with her mask below her chin. She placed the mask over her mouth and nose upon recognizing the surveyor. CNA exited the dining room accompanied by CNA #7. CNA #1 was walking to the break room with her mask below her chin, leaving her mouth and nose exposed. CNA #7 was walking with her mask below her chin, leaving her mouth and nose exposed.
5. On [DATE] at 10:44 AM, Dietary Staff #1 had her mask below her chin, leaving her mouth and nose exposed as she entered the resident dining room. At 10:45 AM, Dietary Staff #1 was sitting in a chair in the resident dining room with her mask below her nose.
6. On [DATE] at 10:50 AM, Housekeeping Staff #1 was in the resident dining room with her mask below her chin, leaving her mouth and nose exposed.
7. On [DATE] at 10:55 AM, Housekeeping Staff #1 was in Resident room [ROOM NUMBER] with her mask pulled down below her chin, leaving her mouth and nose exposed. Housekeeper #2 was standing within 2 feet of a resident who was sitting in his recliner.
8. On [DATE] at 11:00 AM, CNA #1 was exiting Resident room [ROOM NUMBER] with her mask under her chin, leaving her mask and nose exposed.
9. On [DATE] at 11:32 AM, CNA #1 was in the resident dining room, playing dominoes with 2 male residents. CNA #1 had her mask below her chin, leaving her mouth and nose exposed. Staff was approximately 2.5 feet from a resident on her left and 2.5 feet from the resident on her right.
10. On [DATE] at 9:13 AM, the Administrator provided the Infection Control Guidelines for All Nursing Procedures. The Educational Resources section identifies the CDC [Centers for Disease Control] Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes.
11. According to the CDC, .HCP [Health Care Providers] who are up to date with all recommended COVID-19 vaccine doses: Could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen). They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet residents' nutritional needs for 1 of 2 meals obse...
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Based on observation and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet residents' nutritional needs for 1 of 2 meals observed. The failed practice had the potential to affect 40 residents who receive meal trays from 1 of 1 kitchen ( Total Census 42) The findings are:
1. On 5/31/22 at 11:25 a. m., the Assistant Dietary Manager provided a copy of the of the menu for the week. The lunch menu on this day called for Roast Turkey, Mashed Potatoes, Lima Beans, Bread, Margarine Spread, Angle Food Cake with Strawberries & Whipped Topping, Coffee or Tea.
Dietary employees were preparing to serve the lunch meal. The Assistant Dietary Manager instructed the staff that no bread would be served today, as all of the bread was discarded due to being expired.
2. On 6/2/22 at 1:15 p.m., the Administrator was asked if she had been made aware that bread was not served during the lunch meal on 5/31/22. She stated, No.If I had known we would have gone to [store] or somewhere and bought some bread.
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 interview and observation, the facility failed to ensure staff practiced appropriate hand hygiene and glove use during food preparation activities, that food products were discarded on or bef...
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Based on interview and observation, the facility failed to ensure staff practiced appropriate hand hygiene and glove use during food preparation activities, that food products were discarded on or before the expiration date, food was stored properly and off the floor. The failed practice had the ability to affect 40 residents who receive their meals from the kitchen according to a list of residents provided By the Administrator on 6/2/22 at 3:05 PM. The findings are:
1. On 5/31/22 at 10:40 AM, a five-pound container of Parmesan cheese was located on the top shelf of a two-door refrigerator. The use by date was 12/8/21. Located on the same shelf is a one-half gallon container of Buttermilk. The use by date was 5/21/21.
2. On 5/31/22 at 10:44 AM, a five-pound bag of pork chops was in a large zip lock bag, in the freezer. The zip lock was unsealed. The Assistant Dietary Manager was shown the bag and asked what she saw. She stated, They have to be sealed.
3. On 5/31/22 at 10:53 AM, a large plastic tub containing approximately 20 pounds of seasoned corn meal, was located in the dry storage area. The tub had a lid in place and had a large scoop protruding from the dry mixture within the tub. A large plastic tub of flour with the lid in place and a large scoop protruding from the dry mixture. When asked how much flour the container would hold the Assistant Dietary Manager stated, I think, like two 25-pound bags. A large plastic tub labeled; sugar was had a large scoop protruding from the dry ingredient.
4. On 5/31/22 at 10:55 AM, an open cardboard box containing 4 bags of Taco Seasoning Mix was on a shelf in the dry storage area. One bag of seasoning was open to air and other contaminants.
5. On 5/31/22 at 10:57 AM, four large trays used to house packaged bread were sitting directly on the floor. Located on one tray was 3 bags of Texas Toast with a use by date of 5/15/22. One bag of Texas toast containing 17 slices had a use by date of 4/26/22. One bag of hamburger buns with a use by date of 5/3/22 was covered with a green/brown powdery substance. Two bags of Hamburger buns, each containing 12 buns had a use by date of 5/9/22. One bag containing 9 hamburger buns had a use by date of 5/3/22. Five, 1 pound, 8 ounce loafs of white bread had a use by date of 5/25/22. Eight, 1 pound, 4-ounce loaves of Honey Wheat bread had a use by date of 5/23/22.
6. On 5/31/22 at 11:05 AM, twenty-one, 15 ounce boxes of Raisins were located on a shelf in the dry storage area. The raisins had a use by date of 4/22/22.
7. On 5/31/22 at 11:15 AM, a one-pound box of cornstarch and a one-pound box of confectioners ' sugar were sitting on a shelf in the kitchen. The boxes were open and had not been placed in a sealed container.
8. On 5/31/22 at 11:17 AM above the ice machine, was a thick layer of dust adhered to the ceiling. The same grime and dust substance was covering the wall and the side of the refrigerator. The windowsill was covered in a thick layer of dust and multiple dead insects of varying sizes and colors.
9. On 5/31/22 at 12:05 AM., Dietary Employee #2 was serving lunch trays. The employee was wearing gloves. The employee removed her gloves and replaced them with a second pair without washing her hands. Dietary Employee #3 served lunch trays, moving multiple trays with her gloved hands. The employee was wearing the same contaminated gloves when she used her hands to transfer cake from disposable, individual serving tray to the covered lunch tray. Dietary employee #2, wearing the same gloves, used the thumb and forefinger to remove a piece of turkey which had dropped onto the top of a serving of potatoes. The potatoes were located on a tray which was being served to a resident.
10. On 6/1/22 at 11:11 AM, Dietary Employee #1 pureed the polish sausage for the day's lunch. The employee had a white hair covering that was positioned over the back half of her head, the elastic was even with her ears. The positioning left the front of her head including her bangs, which reached her eyebrows, uncovered.
11. On 6/2/22 at 3:46 PM, the Administrator provided a copy of the Handwashing/Hand Hygiene policy. The policy stated that all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors.
12. On 6/3/22 at 8:45 AM, Dietary Employee #1 had a white hair covering that was positioned over the back half of her head, the elastic even with her ears. The positioning left the front of her head including her bangs, which reach her eyebrows, uncovered.
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.
- • 23% annual turnover. Excellent stability, 25 points below Arkansas's 48% average. Staff who stay learn residents' needs.
Concerns
- • 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (55/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.
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About This Facility
What is Crestpark Forrest City, Llc's CMS Rating?
CMS assigns CRESTPARK FORREST CITY, LLC an overall rating of 2 out of 5 stars, which is considered 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 Crestpark Forrest City, Llc Staffed?
CMS rates CRESTPARK FORREST CITY, LLC's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 23%, compared to the Arkansas average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Crestpark Forrest City, Llc?
State health inspectors documented 33 deficiencies at CRESTPARK FORREST CITY, LLC during 2022 to 2024. These included: 33 with potential for harm.
Who Owns and Operates Crestpark Forrest City, Llc?
CRESTPARK FORREST CITY, LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CRESTPARK, a chain that manages multiple nursing homes. With 100 certified beds and approximately 40 residents (about 40% occupancy), it is a mid-sized facility located in FORREST CITY, Arkansas.
How Does Crestpark Forrest City, Llc Compare to Other Arkansas Nursing Homes?
Compared to the 100 nursing homes in Arkansas, CRESTPARK FORREST CITY, LLC's overall rating (2 stars) is below the state average of 3.1, staff turnover (23%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Crestpark Forrest City, Llc?
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 Crestpark Forrest City, Llc Safe?
Based on CMS inspection data, CRESTPARK FORREST CITY, LLC 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 2-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 Crestpark Forrest City, Llc Stick Around?
Staff at CRESTPARK FORREST CITY, LLC tend to stick around. With a turnover rate of 23%, the facility is 23 percentage points below the Arkansas average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was Crestpark Forrest City, Llc Ever Fined?
CRESTPARK FORREST CITY, LLC 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 Crestpark Forrest City, Llc on Any Federal Watch List?
CRESTPARK FORREST CITY, LLC 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.