Does THE SPRINGS OF RED OAK have any serious inspection findings?

Yes, THE SPRINGS OF RED OAK has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 24 total deficiencies from recent inspections.

What are the staffing levels at THE SPRINGS OF RED OAK?

THE SPRINGS OF RED OAK has a three-star staffing rating from CMS with 0.45 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is THE SPRINGS OF RED OAK located?

THE SPRINGS OF RED OAK is located in HOT SPRINGS, AR. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does THE SPRINGS OF RED OAK have?

THE SPRINGS OF RED OAK has 80 certified beds.

Who owns THE SPRINGS OF RED OAK?

THE SPRINGS OF RED OAK is a for profit - limited liability company facility and is part of the THE SPRINGS ARKANSAS chain.

What questions should families ask when visiting THE SPRINGS OF RED OAK?

Families visiting THE SPRINGS OF RED OAK should ask about staff retention and training programs, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does THE SPRINGS OF RED OAK compare to other nursing homes?

THE SPRINGS OF RED OAK has a 3-star overall rating, which is average compared to other nursing homes in AR. Consider visiting multiple facilities before making a decision.

THE SPRINGS OF RED OAK

Name: THE SPRINGS OF RED OAK
Address: 260 LAKEPARK DRIVE, HOT SPRINGS, AR, 71901, US
Telephone: (501) 262-1920
Rating: 3.0

260 LAKEPARK DRIVE, HOT SPRINGS, AR 71901 · (501) 262-1920

For profit - Limited Liability company 80 Beds THE SPRINGS ARKANSAS Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

41/100

#134 of 218 in AR

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THE SPRINGS OF RED OAK nursing home in HOT SPRINGS, AR - Photo 1 of 2

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Last Inspection: January 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

The Springs of Red Oak has a Trust Grade of D, which indicates below-average performance and raises some concerns about the facility. It ranks #134 out of 218 nursing homes in Arkansas, placing it in the bottom half of all facilities in the state, and #6 out of 9 in Garland County, meaning only two local options are worse. The facility's trend is stable, with 8 reported issues in both 2024 and 2025, but it has a concerning staffing turnover rate of 66%, significantly higher than the state average of 50%. Additionally, the facility has incurred $14,935 in fines, which is higher than 85% of similar facilities, suggesting ongoing compliance issues. Specific incidents include a critical failure to safely off-load a resident in a wheelchair, resulting in a back injury, and a lack of proper water management practices that could expose residents to waterborne infections. While the nursing home has average RN coverage, these deficiencies highlight the need for improvement in resident safety and care standards.

Trust Score: D
In Arkansas: #134/218
Safety Record: High Risk
Inspections: Holding Steady
Staff Stability: 66% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $14,935 in fines. Higher than 72% of Arkansas facilities. Some compliance issues.
Skilled Nurses: Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for Arkansas. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 24 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★☆☆

3.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2024: 8 issues

2025: 8 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

3-Star Overall Rating

Near Arkansas average (3.1)

Meets federal standards, typical of most facilities

Staff Turnover: 66%

20pts above Arkansas avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $14,935

Below median ($33,413)

Minor penalties assessed

Chain: THE SPRINGS ARKANSAS

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (66%)

18 points above Arkansas average of 48%

The Ugly 24 deficiencies on record

1 life-threatening

Jan 2025 8 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observations, interview, record review, and facility policy review the facility failed to ensure dignity was maintained for 1(Resident #21) of 1 sampled resident reviewed for dignity. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/2024, revealed Resident #21 had a Brief Interview of Mental Status (BIMS) score 10 indicating moderately impaired cognition. Review of a Plan of Care for Resident #21 initiated 08/07/2024, revealed Resident #21 had an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) needing assistance with ADLs. On 1/08/25 at 11:17 AM, this surveyor observed Certified Nursing Assistant (CNA) #2 push Resident #21 past the nurse's station in a shower chair. This surveyor noted Resident #21 was not fully covered. On 1/08/25 at 12:54 PM, during an interview CNA #2 stated Resident #21 was not fully covered while being transported through a common area which could be a dignity issue. On 01/09/25 at 8:40 AM, during an interview the Director of Nursing (DON) stated staff should ensure residents are fully covered prior to transporting, to maintain dignity and keep the resident warm. A policy titled Dignity noted residents are always treated with dignity and respect.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review the facility failed to ensure confidentiality of personal and medical information was protected for 1 (Resident #21) of 1 sampled resident reviewed for personal and medical information confidentiality. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #21 had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition. Review of a Plan of Care for Resident #21 initiated [DATE], revealed Resident #21 requested that no cardiopulmonary resuscitation (CPR) measures be performed. On [DATE] at 11:50 AM, this surveyor observed an unattended, unlocked tablet which displayed Resident #21 ' s personal and medical information. This surveyor was able to visualize Resident 21's name, date of birth , code status, and physician's order on the unlocked tablet. On [DATE] at 12:00 PM, during an observation and interview the Nursing Consultant stated the tablet should be locked to protect the resident's personal and medical information. On [DATE] at 8:40 AM, during an interview, the Director of Nursing (DON) stated nurses should lock unattended tablets and/or computers to ensure the resident's personal and medical information was protected. A policy titled Confidentiality of Information and Personal Privacy noted the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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Based on record review, interview, and facility policy review the facility failed to coordinate with state authority to determine if placement in the facility was appropriate or incorporate the Pre-admission Screening and Resident Review (PASARR) assessment with if any recommendations from the level II determination and the PASARR evaluation report into the resident assessment, care planning, and transition of care for 1 (Resident #46) of 1 sampled resident reviewed. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/2024, revealed Resident #46 had a Brief Interview of Mental Status (BIMS) score of 06 indicating severely impaired cognition. Resident #46 had diagnoses of anxiety, bipolar disorder, and Schizophrenia. A review of a Plan of Care revised 10/28/2024, for Resident #46 revealed Resident #46 received antipsychotic medication related to (r/t) bipolar disorder and behaviors. On 01/07/25 at 2:20 PM, this surveyor requested the level II evaluation report for Resident #46 from the Director of Nursing (DON). On 01/07/25 at 3:3 PM, the Administrator Consultant stated the facility was unable to locate the level II evaluation report for Resident #46. The Administrator Consultant stated without the level II evaluation report the facility would not know if the resident required any specialized services or had any recommendation from the state authority. On 01/08/25 at 9:34 AM, the Director of Nursing (DON) provided a level II evaluation dated 01/08/2025. On 01/09/25 at 9:48 AM, the DON stated she was unaware Resident #46 was considered by the state as PASARR level II. On 01/08/25 at 10:00 AM, the Nurse Consultant stated we knew we would still get a tag, because the facility failed to follow through with the state on the resident PASARR status until now. On 01/09/25 at 8:40 AM, the DON stated the facility was not aware Resident #46 was considered by the state as PASARR level II, therefore the facility did not have the level II evaluation report readily available. The DON stated this failure could have potentially affected Resident #46 ' s care. A policy titled admission Criteria noted all new admissions and re-admissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. Upon completion of the level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interviews, the facility failed to ensure a comprehensive care plan was developed to address the necessary monitoring and precautions related to the use of tobacco products to meet the needs of the resident and minimize the potential for complications for 1 (Resident #55) of 1 sampled resident who was reviewed for tobacco use. The findings are: 1.Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/2024, indicated Resident #55 had diagnoses of heart failure, stroke, and tobacco use, scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and was a current tobacco user. a. On 01/07/25 at 1:40 PM, Resident #55 was observed in the facility ' s designated smoking area, sitting in their wheelchair with a smoking apron on, smoking a cigarette. A staff member was present supervising the residents that were smoking. b. A form titled Smoking Safety Screen dated 11/13/2024, indicated Resident #55 was safe to smoke with a smoking apron and staff supervision. c. Resident #55 ' sCare Plan with an initiation date of 11/13/2024, did not address that Resident #55 smoked tobacco products. d. On 01/08/2025 at 1:15 PM, the Minimum Data Set Coordinator (MDS) confirmed during interview that Resident #55 smoked tobacco products and Resident #55 ' s Care Plan did not address the resident was a current smoker who required supervision and a smoking apron when smoking. The MDS coordinator stated Residents #55's Care Plan should have addressed smoking due to safety, as well as so the resident could be monitored for possible side effects to smoking. e. 01/08/25 at 1:25 PM, the Director of Nursing (DON) confirmed during interview that Resident #55 smoked and required supervision when smoking. The DON stated Resident #55's Care Plan should have addressed that Resident #55 smoked since resident care plans should be individualized to meet the resident's needs. f. On 01/08/25 at 3:15 PM, the Director of Nursing was asked if the facility had a policy on care plans. The DON stated she would check and see. g. On 01/08/25 at 3:35 PM, the policy titled Care Planning - Interdisciplinary Team (Revised March 2022), provided by the Assistant Director of Nursing (ADON) indicated that the interdisciplinary team was responsible for the development of resident care plans that are comprehensive, and person-centered based on the resident assessment.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

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Based on record review, interview, and facility policy review the facility failed to develop a discharge summary which included a recapitalization of the resident's stay, a final summary of the resident's status, and reconciliation of all pre and post discharge medications for 1 (Resident #111) of 3 sampled residents. The findings include: A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/20/2024, revealed Resident #111 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderately impaired cognition. Review of a Plan of Care for Resident #111 initiated 10/17/2024, revealed Resident #111 or representative wished to be discharged home with home health and durable medical equipment (DME) as needed. A review of the Discharge Note dated 11/01/2024, indicated Resident #111 was discharged home with home health. On 01/09/25 at 8:40 AM, during an interview the Director of Nursing (DON) stated the discharge summary was not completed for Resident #111. A policy titled Discharge Summary and Plan indicated when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on record review, interview, and facility policy review the facility failed to ensure 1 (Resident #39) of 1 sampled resident received wound care according to the physician's order. The findings include: A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2024, revealed Resident #39 had a Brief Interview of Mental Status (BIMS) score of 04 indicating severely impaired cognition. A review of a Plan of Care for Resident #39, revised 11/20/2024, revealed Resident #39 had a pressure ulcer to left heel. According to the Treatment Administration Record (TAR), Resident #39 had a physician's order for treatment for left heel. The order noted, clean heel with wound cleanser, pat dry, apply collagen and hydrogel, then cover with dry dressing daily until wound is resolved. The TAR noted treatment was completed on 1/01/2025 and 1/05/2025. On 1/08/2025 at 12:53 PM, during an interview the Director of Nursing (DON) stated treatment to Resident #39 ' s left foot should be done daily, but it was not signed off on the TAR indicating completion. The DON stated if it was not documented it was not done. On 1/09/2025 at 8:40 AM, the DON stated no, there was not documentation to show that the treatment was done daily. A policy titled Pressure Injuries Overview did not contain any pertinent information related to the deficient practice.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

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Based on document review, observations, interviews, and facility policy review, the facility failed to post the nurse staffing information on a daily basis, to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. The deficient practice had the potential to affect all residents. The findings are: a. On 01/07/25 at 8:30 AM, this surveyor noted nursing staffing posted for Monday 1/6 at the beginning of the shift which included facility name, date, and the total number and actual hours worked per shift for RNs, LPN, CNAs who are responsible for resident care. b. On 01/08/25 at 11:30 AM, this surveyor noted nursing staffing posted for Monday 1/6. c. On 01/08/25 at 4:45 PM, this surveyor noted nursing staffing posted remained Monday 1/6. d. During an interview on 01/09/25 at 8:16 AM, with the Administrator regarding nursing staff posting remained Monday 1/6. The Administrator stated Human Resources does that and she was not present, and she forgot. e. During an interview on 01/09/25 at 9:01 AM, with the Director of Nursing (DON) and the Administrator regarding posting of staffing schedule not being updated, the Administrator responded she, Human Resources forgot, however, the DON updated and posted. f. During an interview on 01/09/25 at 9:32 AM, this surveyor asked the Administrator for a policy regarding posting of nurse staffing daily. g. On 01/09/25 at 9:45 AM, this surveyor received the facility policy provided by the Administrator titled Staffing. It did not have any pertinent information related to the deficient practice.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on record review, interview, and facility policy review the facility failed to ensure gradual psychotropic (anti-anxiety) dose reductions (GDR) were attempted in the absence of a physician's documented evaluation of the specific risks versus benefits of continuing the as needed (PRN) medication past 14 days and a documented explanation as to why a dose reduction attempt would be contraindicated, in order to ascertain the smallest effective dose and minimize the potential for adverse drug effects for 1(Resident # 43) of 1 sampled resident. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/2024, revealed Resident #43 had a Staff Assessment of Mental Status (SAMS) which indicated memory problems. A review of a Plan of Care for Resident #43 initiated 11/05/2024, revealed Resident #43 used anti-anxiety medications related to anxiety disorder. A review of the Pharmacy [ Medication Regimen Review] MRR - Nursing Recommendation dated 06/17/2024, indicated Resident #43 had an order for [name brand anti-anxiety medication] (a medication used to treat anxiety disorders) injection solution 2 milligram (MG)/milliliter (ML) inject 1 milligram intramuscularly every 24 hours as needed for increased behaviors and PRN orders for psychotropic medications are limited to 14 days. On 01/08/25 at 11:16 AM, the Director of Nursing (DON) stated the facility does not have any documentation completed by the Medical Doctor (MD) to continue the [name brand anti-anxiety medication] past 14 days. On 01/09/25 at 8:40 AM, the DON stated there should be documentation completed by the MD in place for regulation purposes. The DON stated the facility should not administer as needed psychotropic drugs past the 14 days without documentation and regulation. A policy titled Medication Therapy indicated, the physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example: when a medication is being given in excessive dose, for excessive periods of time, without adequate monitoring, or in the absence of a valid clinical rationale.

Feb 2024 5 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview, the facility failed to ensure parameters were put in place to ensure the correct dosage of oxygen was administered to enable the Physician to determine the dosage needed for 1 (Resident #4) sampled resident. The findings are: 1. On 02/20/24 at 10:16 AM, Resident #4 was lying in the bed receiving oxygen via nasal cannula (NC) at 3 liters per minute (LPM). 2. On 02/20/24 at 03:16 PM, Resident #4 was lying in bed receiving oxygen at 3 LPM via N/C. 3. On 02/21/24 at 08:27 AM, Resident #4 was lying in bed receiving oxygen at 2 LPM via N/C. 4. A Physicians Order dated 2/19/24 documented, O2 [oxygen] @ [at] 2L [liters] /NC. Titrate to remain > [greater than] 90% every shift related to SHORTNESS OF BREATH Titrate to remain >90% . 5. A Care Plan documented, The resident has oxygen therapy r/t [related to] ineffective gas exchange Promote lung expansion Date Initiated: 02/20/2024: OXYGEN SETTINGS: O2 via nasal cannula @ 2L titrate [adjust rate] to remain >90% Revision on: 02/20/2024 . 6. The Medication Administration Record (MAR) contained no documentation of pulse oximetry results to follow for correct dosage of oxygen administration. 7. On 02/21/24 at 10:27 AM, Licensed Practical Nurse (LPN) #2 was asked, how do you know when to increase or decrease the oxygen on Resident #4. LPN #2 stated, We check [Resident #4's] pulse ox [pulse oximeter, or Pulse Ox, is an electronic device that measures the saturation of oxygen carried in your red blood cells]. LPN #2 was asked if she could verify when the liter flow rate should be titrated. LPN #2 stated, It should be on the MAR, let me look. It's not on there but it should be so we can alert the Physician that [Resident #4's] needing more oxygen or that [Resident #4's] oxygen is dropping. LPN #2 was asked if there was any other place it could be documented LPN #2 stated, On my notebook. LPN #2 was asked what was documented yesterday for Resident #4's oxygen saturation. LPN #4 looked at the notebook and stated, I forgot. 8. On 2/22/24 at 3:22 PM, the Director of Nursing (DON) was asked to explain how he/she expected the nurses to determine what an oxygen flow rate should be. The DON said that the physician's orders should be followed. The DON was asked to look at the electronic record and read the current physician's order. The DON stated, We would check the pulse ox. The Surveyor asked how often it should be checked and where it would be documented. The DON stated, The order would need to be clarified and parameters be set up. The DON was asked the importance in setting parameters. The DON stated, To alert the nurses and doctor the need to increase or decrease the amount of oxygen needed. 9. On 2/22/24 at 2:16 PM, the DON provided a policy titled, Oxygen Administration, which documented, The purpose of this procedure is to provide guidelines for safe oxygen administration . 1. Review the Physicians order . Before administering oxygen, Assessment 6 .oxygen saturation . Documentation 6. All assessment data obtained before .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure Pneumococcal immunizations were administered to eligible residents and the immunization records were updated in the electronic health records (EHR) for 1 (Resident #22) of 5 (Residents #4, #5, #21, #22 and #32) sampled residents whose immunization information was reviewed. The findings are: 1. On 2/22/23 at 3:00 PM, review of Resident #22's immunization information in the electronic health record revealed no documentation that a pneumonia immunization was offered, administered, or if the Resident or Resident's Representative consented or declined the immunization. a. A Physician's order dated 11/07/23 documented, May have Pneumococcal Vaccine per consent . b. A Care Plan with a revision date of 1/18/24 documented the resident smokes. c. A review of Resident #22's November 2023 electronic Medication Administration Record (eMAR) revealed no documentation regarding administration of the pneumonia vaccine. d. On 2/22/24, the Director of Nursing (DON) was asked for information to show if Resident #22 received a pneumonia vaccine. At 4:08 PM, the DON confirmed there was no information pertaining to this resident receiving or declining the pneumonia vaccine or any education offered in the EHR. e. On 2/23/24 at 2:25 PM, the DON confirmed after reviewing Resident #22's EHR that Resident #22 did sign the consent that he wanted to receive the pneumonia vaccination in November 2023, but she could not see where it was administered. f. A Pneumococcal Vaccine Policy, provided by the Administrator on 2/21/24, documented, Policy Statement All residents are offered Pneumococcal vaccines to aid in preventing pneumonia/Pneumococcal infections . 4. Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved Pneumococcal vaccination protocol .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

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Based on record review, observation, and interview, the facility failed to ensure the indwelling catheter tubing was anchored to prevent trauma and positioned to allow the urine to flow down away from the bladder for 1 (Resident #30) of 1 sampled resident and failed to ensure a catheter bag was not touching the floor to decrease the potential for infection for 2 (Residents #4 and #30) of 2 sampled residents who had a physician's order for an indwelling catheter. The findings are: 1. Resident #30 had a diagnosis of Flaccid (Not Firm) Neuropathic (Nerve Problem) Bladder. a. A Physician's Order with a start date of 9/29/23 documented, .Change [Brand of indwelling catheters] . catheter monthly on the 5th, every day shift . b. A Care Plan with a revision date of 12/20/23 documented, .The resident has indwelling Catheter: Neurogenic bladder . Monitor/document for pain/discomfort due to catheter . c. On 2/20/24 at 10:22 AM, Resident #30 was lying in bed awake and the door was open. A catheter bag with a privacy cover and tubing was visible from the doorway and the resident's top cover was down and the right leg was exposed. The catheter tubing was coming from the right side of the resident's brief, looped over the right upper thigh and the end of the catheter that connects to the tubing was visible at this time and not secured to (Resident #30's) leg. This surveyor asked Resident #30 if there was anything on Resident #30's left leg and the resident exposed the upper leg and there was nothing to secure the catheter tubing. d. On 2/22/24 at 9:14 AM, Resident #30 was lying in bed with the head of bed up and eyes closed. The catheter bag was hooked on the right side of bed frame and sitting directly on the floor. e. On 2/22/24 at 9:16 AM, Certified Nursing Assistant (CNA) #1 was asked to accompany this Surveyor to Resident #30's room. The Surveyor asked where (Resident #30's) catheter bag was. CNA #1 confirmed that it was on the floor and should not have been. The Surveyor asked why it should be off the floor. CNA #1 stated, Because it could get dirty or stepped on, or it could get a hole in it, and [Resident #30's] urine flow should flow down so it should be below the leg, but not on the floor. CNA #1 was asked to remove [Resident #30]'s covers, with the resident's consent first, so this Surveyor could check it. She pulled the covers back and a stat lock was in place to the right inner lower thigh just above Resident 30's knee, but it was not dated to reflect the date it was placed. CNA #1 said the nurses places the stat locks to the residents. f. On 2/23/24 at 2:12 PM, Licensed Practical Nurse (LPN) #2, was asked, When a resident has an indwelling catheter in place, how is it secured? LPN #2 stated, With a stat lock. So, we put the stat lock on the leg, and clean it with the pad they provide in the package, and we snap the tubing into the stat lock. LPN #2 was asked who was responsible for performing that task. LPN #2 confirmed it was the nurses. LPN #2 was asked, When should this be done? LPN #2 stated, As soon as the patient arrives with a catheter, we need to make sure it's secured and throughout their stay. LPN #2 was asked, What if the catheter is placed at this facility, when should it be secured? LPN #2 confirmed after it's inserted. LPN #2 was asked, Is this documented anywhere? LPN #2 stated, It should be on the MAR [Medication Administration Record] to secure placement of the catheter. LPN #2 confirmed there should be a physician's order for it. g. On 2/22/24 at 2:18 PM, the Director of Nursing (DON) was asked, Should there be a Physician's order for an indwelling catheter to be secured? The DON stated, Yes. The Surveyor asked, Tell me why a catheter bag should not on the floor? The DON stated, Well it has a chance of getting punctured and it could be a risk of being pulled out. The Surveyor asked, Does that cause a potential risk for infections? The DON stated, Yes. The Surveyor asked, Tell me where the tubing should be for an indwelling catheter? The DON stated, It should've been down more mid-thigh a stat lock. The Surveyor asked, Tell me why? The DON stated, To prevent the urine from backing up to allow it to drain appropriately. 2.Resident #4 had a diagnosis of Neuromuscular dysfunction of bladder, unspecified. a. On 02/20/24 at 10:18 AM, Resident #4 was lying in bed with a catheter bag lying on the floor wedged under the bed with the bed on top of it. b. On 02/20/24 at 03:24 PM, Resident #4 was lying in bed with the catheter bag folded and lying on the floor. c. On 02/21/24 at 08:25 AM, Resident # 4 was eating in bed. The head of the bed was rolled up. One third of the catheter was lying on the floor. d. A Physicians Order dated 2/6/24 documented, Change [Brand of indwelling catheters] . Catheter q [every] 15th of month and prn [as needed]. e. A Care Plan dated 2/6/24 documented, The resident has INDWELLING FOLEY Catheter: Neurogenic bladder Date Initiated: 02/06/2024 Revision on: 2/22/24 . f. On 2/22/24 at 3:18 PM, the DON was asked to look at the position of the catheter bag was in, folded under the bed with the bed lying on the catheter bag. The DON stated, That's unacceptable. The DON was asked to explain why it was unacceptable. The DON stated, It can crush the catheter tubing and urine will backflow into the bladder. g. A Policy titled, Catheter Care, Urinary provided by the DON on 2/22/24 documented, Purpose .prevent catheter-associated urinary tract infections .Maintaining Unobstructed Urine Flow 1. Check the resident frequently to be sure he or she is not lying on the catheter .Infection Control 1.b. Be sure the catheter tubing and drainage bag are kept of the floor .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to ensure multi-dose insulin vials were dated when opened and discontinued or expired medications were removed and placed into an area for destruction to prevent potential administration to residents. The findings are: On 02/21/2024 at 10:50 AM, the following observations were made on the 100/200 Halls medication cart with Licensed Practical Nurse (LPN) #1: a) An open multi-dose vial of (rapid acting insulin) with an open date of 01/12/2024. b) An open multi-dose vial of (short acting insulin) with no open date. c) An open multi-dose vial of (long acting insulin) with an expiration date of 01/31/2024. d) A partially used (long acting) insulin pen with an expiration date of 02/02/2024. On 02/21/2024 at 11:10 AM, the Surveyor asked LPN #1, What is your process when opening a new insulin vial? LPN #1 replied, Open the vial and date. LPN #1 was asked, What is the importance of dating an open vial? LPN #1 replied, To make sure the medication is still effective and to reorder in a timely manner. The Surveyor asked, What is the process for checking the medication cart for expired medications and how often? LPN #1 replied, The pharmacy rep [representative] does sometimes. The Assistant Director of Nursing (ADON) did weekly when still here. I don't check for the dates. LPN #1 was asked, What is the importance of checking for expired medications? LPN #1 replied, They are not as effective. On 02/21/2024 at 11:30 AM, the Surveyor asked the Director of Nursing (DON), What is the process once a multi-dose vial has been opened? The DON stated, It needs to be dated? The DON was asked, What is the reason for dating an open multi-dose vial? The DON stated, It is for the timeframe of use depending on the manufacture guidelines. The Surveyor asked, How often are the medication carts checked for expired medications? The DON replied, We do match back every thirty days. On 02/22/2024 at 2:17 PM, the DON provided a policy titled, Storage of Medications, which documented, .4.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . On 02/22/2024 at 04:09 PM, the DON stated there was no policy on multi-dose vials.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and/or implement a water management program with measures to minimize the risk for Legionella and other waterborne opportunistic pathogens to reduce the risk for potential infections. This failed practice had the potential to affect 38 residents who resided in the facility. The findings are: 1. On 2/22/24 at 2:06 PM, the Maintenance Supervisor was asked, Do you handle water management here? The Maintenance Supervisor stated, No, I'm not sure what you mean. The Surveyor asked, If the water system has to be tested or checked here, would you be the one doing that? The Maintenance Supervisor stated, Well I'm sure I would be involved in that. The Surveyor asked, Have you assessed the water system regarding Legionella and other water borne opportunistic pathogens since you've been here? The Maintenance Supervisor stated, No, I've never done that. The Surveyor asked, Do you know if there are measures in place to prevent growth of Legionella and other opportunistic water borne pathogens? The Maintenance Supervisor stated, Not that I'm aware of. 2. On 2/22/24 at 2:08 PM, the Administrator handed the Maintenance Supervisor information regarding Legionella (Legionella Surveillance Policy and Water Management Program to Reduce Legionella Growth & [and] Spread from the CDC (Centers for Disease Control)). The Maintenance Supervisor stated, Let me see what it is that she just gave me. While looking down at the paper the Maintenance Supervisor stated, Oh, you can breathe it in. The Maintenance Supervisor confirmed he was not familiar with the information. 3. On 2/22/24 at 4:26 PM, the Administrator was asked, How have you been monitoring the water system for waterborne pathogens or Legionella? The Administrator stated, We would have to listen to the city. We're not testing as of right now because it's so new and it's so expensive. The company, [Name], is in the process of coming up with an active policy and testing kits. 4. A Legionella Surveillance Policy, provided by the Administrator on 2/22/24 at 2:08 PM documented, .It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections . Definitions: .Legionella is a bacteria found in water that can cause a serious type of pneumonia, Legionnaires' disease .

Feb 2024 3 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure transportation provider safely off-loaded a resident in a wheelchair from the facility transportation van to prevent potential injury for 1 (Resident #1) of 2 (Residents #1 and #2) sampled residents who required transport in a wheelchair on the transportation provider's van. The failed practice had the potential to affect 46 residents that resided in the facility per census received 2/7/2024. This failed practice resulted past Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who rolled out of the van in a manual wheelchair and fell on the lift that was ground level resulting in a back injury. The facility was notified of the past Immediate Jeopardy on 2/8/2024 at 2:00 pm. The findings are: 1. Resident #1's was admitted on [DATE] with diagnoses of Multiple Sclerosis, Muscle Wasting and Atrophy. The admission Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2023 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required the use of a wheelchair for mobility. a. On 2/7/2024 at 9:15 am, the Surveyor asked Resident #1 to recall the incident that occurred 12/4/2023 during the off-loading from the van. Resident #1 stated, I was in a manual wheelchair and the aide was trying to do something with the attachments on the floor of the van or something and when she was doing that, I rolled out of the van and hit the concrete. I was in the chair. I had to go to the hospital and had surgery the next day on my back. b. On 2/7/2024 at 12:45 pm, a Progress Note dated 12/4/23 at 3:43 pm by Licensed Practical Nurse (LPN) #1 stated, . CNA [Certified Nursing Assistant] called out for a nurse outside in front, Patient was lying on the lift to the van on right side in fetal position c/o [complaint of] back pain. Pt [Patient] was alert and talking MD [Medical Doctor] [Name] notified, Administrator [Name] Nursing consultant [Name], ADON [Assistant Director of Nursing] [Name], pt was sent to [Hospital] via ambulance for eval [evaluation] and tx [treatment] per v/o [verbal order] MD [Name]. CNA stated I was getting him off the van in the chair when i went to push w/c [wheelchair] on the lift the patient fell out of the chair onto the lift . c. On 2/8/2024 at 8:00 am, the Surveyor asked the Director of Nursing (DON) for the investigation information regarding Resident #1's fall on 12/4/23 during the off-loading from the facility van. She replied, They should be in the reportable. Oh, that's right one was not done on the fall. The Surveyor asked for the incident report if available. The DON replied, I will get that for you. At 10:20 am, an Incident Report dated 12/4/23 at 2:33 pm completed by LPN #1 documented, .Type Fall . Incident Location Grounds . Activity Transfer . Witness [CNA #1] . d. On 2/8/2024 at 10:20 pm, the Auto Accident Report form completed on 12/4/23 at 2:37 pm stated under Accident Details, .Van driver [CNA #1] was getting the resident off the van, went to push the wheelchair to the ramp and patient fell backwards out of the wheelchair and fell on the lift that was lowered . e. On 2/8/2024 at 10:55 am, a Witness Statement form dated 12/4/23 at 3:10 pm completed by CNA #1 stated, .Job Title CNA/Van Driver .I picked up [Resident #1] from the mall, got to the facility. I got the electric wheelchair off first, I got back on the van to get [Resident #1] off, had him already unhooked from everything he started rolling himself backward toward the lift. I was telling him to keep it straight when I heard the alarm going off. I told him to stop and grabbed the wheelchair. I thought the lift was up, but unfortunately it was not so his wheelchair fell off the van, he landed on his side on the lift . This happened about 2:35pm . f. On 2/8/2024 at 12:10 pm, the Surveyor asked the Administrator to recall the incident regarding Resident #1 on 12/4/2023. The Administrator stated, I did not witness the actual incident. I was in my office, and I heard the commotion occur, and when I looked out the window, I seen the facility van sitting in the drive under the awning and I could see a little of [CNA #1] and [Resident #1] at the back of the van. [CNA #1] said she had taken the residents electric wheelchair off the van using the lift and moved it to the side of the van because they take it with them on the trip so [Resident #1] will be able to use it at the mall, but he has to sit in the facility manual wheelchair during the transport on the van. [CNA #1] had walked around to the side of the van and was getting up in the van and noticed the resident rolling himself backwards toward the back of the van. She started screaming at him to stop and she seen him roll out of the back of the van. He had thought the lift was up, but it was not. It was ground level and he rolled out backwards and fell from van level to ground level on the lift on the ground in the wheelchair. g. On 2/8/2024 at 12:45 pm, the Surveyor asked the Administrator, Has there been any other incidents of falls or issues with transport since the incident on 12/4/23. The Administrator stated, No we have not had any other issues or falls/incidents. I did what I knew I needed to do. I did the investigation and the in-services. h. On 2/8/2024 at 1:50 pm, the surveyor asked the MDS Nurse to recall the incident on 12/4/23 regarding Resident #1. The MDS Nurse replied, I was standing at the nurse's station desk when [CNA #1] came in and said [MDS Nurse's name], I need your help right now. I went out front with [CNA #1] and found [Resident #1] lying on his right side on the lift that was down, ground level. [Resident #1] kept saying he was sorry, he was sorry. We assessed him and kept him still until the ambulance could arrive because he was complaining of pain in his back. The ambulance came and he went to the hospital. i. On 2/8/2024 at 2:00 pm, Surveyor notified the Administrator of the Past Immediate Jeopardy for Accidents/Supervision related to Resident #1's 12/4/2023 fall from the facility van during offloading by staff. The following Inservices were provided: 12/4/2023: by the Administrator and Corporate Maintenance and Safety Officer documented, No one is to drive the facility van without FIRST being trained and checked off by someone that is fully trained to do so . 1/30/24: Correct Lift Operation/Properly Securing Residents. Items Covered: correct operation of the lift; correct procedure for loading/unloading resident on lift; correctly securing resident with proper tie down procedures; manual operation of the lift.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all alleged violations involving a fall with major injury was reported immediately, but not later than 2 hours after major injury was discovered for 1 (Resident #1) of 1 sampled resident who had a report for fall during off-loading from facility transport van since December 2023. The findings are: 1. Resident #1's was admitted on [DATE] with diagnoses of Multiple Sclerosis, Muscle Wasting and Atrophy. The admission Minimum Data Set with an Assessment Reference Date of 12/28/2023 documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status and required the use of a wheelchair for mobility. a. On 2/7/2024 at 11:30 am, received 5 reportable files for the last 3 months that were sent in to report any incident by the facility. No reportable regarding Resident #1 found. b. On 2/7/2024 at 12:45 pm, a Progress Note dated 12/4/23 at 3:43 pm by Licensed Practical Nurse (LPN) #1 stated, . CNA [Certified Nursing Assistant] called out for a nurse outside in front, Patient was lying on the lift to the van on right side in fetal position c/o [complaint of] back pain. Pt [Patient] was alert and talking MD [Medical Doctor] [Name] notified, Administrator [Name] Nursing consultant [Name], ADON [Assistant Director of Nursing] [Name], pt was sent to [Hospital] via ambulance for eval [evaluation] and tx [treatment] per v/o [verbal order] MD [Name]. CNA stated I was getting him off the van in the chair when i went to push w/c [wheelchair] on the lift the patient fell out of the chair onto the lift . c. On 2/8/2024 at 8:00 am, the Surveyor asked the Director of Nursing (DON) for the investigation information regarding Resident #1's fall on 12/4/23 during the off-loading from the facility van. She replied, They should be in the reportable. Oh, that's right, one was not done on the fall. d. On 2/8/2024 at 12:45 pm, the Surveyor asked the Administrator for the witness statements and reportable information for 12/4/2023 on Resident #1. The Administrator replied, I did the investigation and the in-services, and had started the information for the reportable and I was told by the regional team that I did not need to send in a reportable due to we know how the resident got hurt. It was a witnessed incident. I can give you my van incident protocol information I have my notes on to show you.

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

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Based on record review and interview, the facility failed to review and revise the care plan and reassess the effectiveness of interventions to meet the resident needs for 2 (Residents #1 and #3) of 3 sampled residents. The findings are: 1. On 2/7/2024 at 10:20 am, Resident #1's Physicians Orders and Treatment Record documented, .TX [Treatment]: skin tear to left hand. Clean with wound cleanser. Pat dry. Apply [Fine mesh gauze occlusive dressing] Gauze. Cover with border foam dressing. one time a day every 3 day(s) for skin tear . ordered dated 1/20/24 and start date 1/21/24. The Treatment Record documented the treatment was done by a nurse starting 1/21/2024 and every three days through 2/8/2024. a. On 2/7/2024 at 2:30 pm, review of the Care Plan with a revision date of 12/11/23 did not address Resident #1's skin tear or the treatment every three days. 2. On 2/7/2024 at 2:30 pm, Resident #3's Physicians Orders and Treatment Record documented, .TX: Clean buttocks affected area with wound cleanser. Apply border foam dressing for protection. May change as needed if dressing becomes soiled. three times a day for Skin breakdown ., order dated 1/20/2024 and start date 1/20/2024. Treatment Record documented treatment was done by a nurse starting 1/20/24 through 2/8/2024. a. On 2/7/2024 at 2:30 pm, review of the Care Plan with a revision date of 02/02/24 did not address Resident #3's wound care to the buttocks. 3. On 2/8/2024 at 12:00 pm, the Surveyor asked the Director of Nursing (DON), Who is responsible for a resident's care plan revisions and when should a residents care plan be revised? She replied, Any change in condition, any new therapy or orders for medications, or wound care. The MDS [Minimum Data Set] nurse is doing the revisions right now. We have a treatment nurse that will officially start in that position this Monday. The Surveyor asked if anyone else could revise a care plan. The DON stated, Well I guess I can, and the Social can, and therapy, but we are trying to keep it to a select few, not all the nurses can do it. The Surveyor asked if a resident has orders for wound care, new wound care orders on the 20th of January, should the care plan reflect a revision for that care ordered by this time, February 8th. The DON replied, Yes it should, I would think. 4. On 2/8/2024 at 2:20 pm, the Surveyor asked the MDS Nurse Who was responsible for revision of care plans in the facility, and when should residents care plans be revised? The MDS Nurse replied, I do the revisions and I have not gotten some of them done lately. We have a treatment nurse that starts Monday, really anyone can revise them, like the therapy, social, the dietician, and the nurses. They should be revised, when there is a change in condition, a new treatment, as needed and quarterly, I know. The Surveyor asked if a resident has an order for wound care, should the care plan be revised within 5 to 10 days after the wound care is ordered? The MDS Nurse replied, Yes, it should reflect the change. 5. On 2/8/2024 at 2:39 pm, the DON provided a policy titled Care Plans, Comprehensive Person-Centered. The Policy stated, .Assessments of resident are ongoing and care plans are revised as information about the resident and the residents' conditions change .

Jun 2023 1 deficiency

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure the presence of a feeding tube was accurately coded on the Minimum Data Set (MDS) for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents. The findings are: 1. The Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2019 documented, .FEEDING TUBE: Presence of any type of tube that can deliver food/nutritional substances/ fluids/medications directly into the gastrointestinal system. Examples include, but are not limited to, nasogastric tubes, gastrostomy tubes, jejunostomy tubes, percutaneous endoscopic gastrostomy (PEG) tubes . 2. On 06/06/23 at 9:50 a.m., the Surveyor reviewed the facility's Roster Matrix. According to the Roster Matrix, Resident #1 did not have a feeding tube. 2. On 06/06/23 at 1:00 p.m., the Assistant Director of Nursing (ADON) was asked, Do you have any residents with a feeding tube in the facility? She answered, Just one. The MDS Coordinator asked, Are you talking about [Resident #1]? 3. Resident #1's admission MDS with an Assessment Reference Date (ARD) of 02/27/23 did not document the presence of a feeding tube while not a resident or while a resident. The Discharge Return Anticipated MDS dated [DATE], 03/01/23 and 05/15/23 did not document the presence of a feeding tube while not a resident or while a resident. 4. On 06/06/23 at 2:00 p.m., Resident #1's User Defined Assessments titled, Nursing Admit Readmit, dated 02/16/23, 02/22/23, 03/17/23 and 05/30/23 did not document the presence of a feeding tube. 6. On 06/06/23 at 2:45 p.m., the Surveyor asked Licensed Practical Nurse (LPN) #1, Are you familiar with [Resident #1]? She answered, Not really. The other nurse works on that hall. The Surveyor asked, Do you know if he has a feeding tube? She answered, Yes he does. 7. On 06/06/23 at 2:55 p.m., the Surveyor asked LPN #2, Are you familiar with [Resident #1]? She answered, Yes. The Surveyor asked, Does he have a feeding tube? She answered, Yes. The Surveyor asked, Did he have it when he admitted ? She answered, Yes. 8. On 6/6/23 at 3:00 p.m., the Surveyor asked Registered Nurse (RN) #1, Are you familiar with [Resident #1]? She answered, Yes. The Surveyor asked, Does he have a feeding tube? She answered, Yes he was admitted with it. He doesn't get feedings though. He gets meds [medications] and flushes only. 9. On 06/06/23 at 3:30 p.m., the Surveyor asked the MDS Coordinator, Are you familiar with [Resident #1]? He answered, Yes. The Surveyor asked, Does he have a feeding tube? He answered, Yes. The Surveyor asked, Is the presence of a feeding tube documented on the MDS? He answered, No. But the reason why I didn't put it was because Section K is all about nutrition in the last 7 days. He does not use his for nutrition. Only meds and flushes. The Surveyor asked, What instruction does the RAI manual give in regard to feeding tubes? He reviewed the RAI manual and stated, Presence of any type of tube that can deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system. The Surveyor asked, Should [Resident #1's] MDS document the presence of a feeding tube? He answered, Yes. I will have to change this.

Apr 2023 1 deficiency

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) within 14 days of determining the status change was significant for 1 (Resident #3) sampled resident in the facility who received Hospice Care. This failed practice had the potential to affect 10 residents who received Hospice Care, as documented on a list provided by the MDS Coordinator on 04/24/23 at 12:04 p.m. The findings are: 1. Resident #3 had a diagnosis of Dementia. The Quarterly MDS with an Assessment Reference Date (ARD) of 03/08/23 documented a score of 1 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). The resident had 1 fall with minor injury since the last assessment. The MDS did not document Hospice Care. a. The Physician's Order with an order date of 03/08/23 documented, Consult [named] . Hospice . b. On 04/24/23 at 10:31 a.m., Resident #3's Care Plan did not address Hospice Care. c. On 04/24/23 at 10:32 a.m., Resident #3 did not have a Significant Change MDS completed after 03/08/23. d. Resident #3's Pay Source Page in the Electronic Record provided by the Business Office Manager on 04/24/23 at 12:04 p.m. documented his Pay source as Hospice Medicaid effective 03/09/23. e. On 04/24/23 at 11:55 a.m., the Surveyor asked the MDS Coordinator Is Resident #3 on Hospice care? He answered, Yes. The Surveyor asked, What date did he go on Hospice Care? He answered, 03/09/23. The Surveyor asked, Did you do a Significant Change in Status MDS when he went on Hospice Care? He answered, No. I did a Quarterly on 03/08/23. The Surveyor asked, Are you aware that you should do a Significant Change MDS when a resident goes on Hospice Care? He answered, Yes I did know that. I just wasn't made aware of the change. f. On 04/24/23 at 12:25 p.m., the Director of Nursing (DON) provided a document which read, [Named facility] follows the RAI guidance for all MDS change of conditions. The Surveyor asked the DON, Should a Significant Change MDS be completed when a resident goes on Hospice Care? She answered, Yes. g. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 October 2019 (RAI Manual) documented, . Significant Change in Status (SCSA) . Assessment Reference Date . 14th [fourteenth] calendar day after determination that significant change in resident's status occurred . An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election .

Dec 2022 6 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to provide privacy by not covering a urinary catheter and leaving it exposed to the resident population for 1 resident (R #36) of 5 (R #19, R #23, R #27, R #36, R #38) sampled residents according to a list provided by the Director of Nursing (DON) on 12/8/22 at 11:15am. The failed practice had the potential to affect (how many) residents. The Findings are: 1.Resident 36 had a diagnoses of Unspecified Fracture of the Left Femur with Routine Healing, Alzheimer's Disease with late onset, Difficulty Walking, Gastro-Esophageal Reflux disease without Esophagitis. The Discharge Return Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/22 documented a score of 2 (2 indicates moderately impaired) on the Staff Assessment for Mental Status (SAMS). a. On 12/07/22 at 10:00am, R #36's catheter bag was observed from the [named] hall hanging on the bedside. The catheter bag was not in a privacy bag and was in clear view of the hall. b. On 12/07/22 at 12:05pm, R #36's catheter bag that contained urine was observed from the [named] hall hanging on the bedside. The catheter bag was not covered or in a privacy bag. c. On 12/07/22 at 1:15pm, The Surveyor asked the DON, Should a resident's catheter bag be visible from the hallway? The DON stated, No, the catheter bags we use have a flap that covers the bag providing privacy. The Surveyor asked, Do all the residents with a catheter have the same type of bag? The DON stated, They should all be the same. The Surveyor asked, What would be a reason that a resident would have a different type of catheter bag? The DON stated, If a resident came from the hospital, they probably would have a different one and it should have been changed to the one we use. d. On 12/8/22 at 8:30am, The Surveyor asked Licensed Practical Nurse (LPN) #1, Should a catheter bag be exposed to the staff and resident population? LPN #1 stated, No, it should be covered. The Surveyor asked LPN #1, Why should a catheter bag be covered? LPN #1 stated, It's a privacy issue. Sometimes the hospital will send a resident here with one of the bags they use, and it (catheter bag) will not be in a privacy bag. The Surveyor asked, If the hospital sends a resident with a catheter and the catheter bag is exposed what should you do? LPN #1 stated, Place the catheter bag inside a privacy bag. c. On 12/8/22 at 8:48am, The Surveyor asked LPN #2, , Should a catheter bag be exposed to the staff and resident population? LPN #2 stated, No, it should be covered or be in a privacy bag. The Surveyor asked, Why should a catheter bag be covered? LPN #2 stated, It's a privacy and dignity issue if someone can see the catheter bag. The Surveyor asked, If a resident with a catheter and the catheter bag is exposed what should you do? LPN #2 stated, Place the catheter bag inside a privacy bag or get one with the flap that covers the bag.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to ensure fingernails were clean, groomed, and free from jagged edges to promote good personal hygiene and grooming for 1 (Resident #24) (R #1, R #2, R #3, R #4, R #5, R #6, R #7, R #10, R #11, R #12, R #13, R #14, R #15, R #16, R #17, R #18, R #19, R #20, R #21, R #22, R #23, R #24, R #25, R #26, R #27, R #28, R #29, R #31, R #32, R #33, R #34, R #35, R #36, R #37, R #38, and R #192.) of 36 sampled residents that were dependent on staff for fingernail care. This failed practice had the potential to affect 36 residents that were dependent on staff for nail care according to a list provided by Director of Nursing (DON) on 12/08/22 at 10:15 A.M. The findings are: 1. Resident #24 had diagnoses of Alzheimer, Parkinson's, and Macular Degeneration. The Minimum Data Set (MDS) an Annual Assessment Reference Date (ARD) of 10/5/22 documented the resident scored a 3 (3 Severe Cognitive Impairment) on a Staff Assessment Mental Status (SAMS). The resident required extensive assist of 1 person with personal hygiene. a. The Care Plan with an initiated date of 5/16/19 and a revision date of 6/27/22 documented, . PERSONAL HYGIENE . The resident requires extensive assist of 1 with personal hygiene and has an (ADL) Activities of Daily Living Self-Care performance deficit r/t [related to] impaired cognition. Date Initiated: 05/16/2019 Revision on: 10/01/2019 . b. On 12/07/22 at 09:49 AM, the resident was lying in bed with long jagged fingernails, 1/4 inch above fingertip with dirty dark substance under her nails. c. On 12/07/22 12:12 PM, the Surveyor asked Certified Nursing Assistant (CNA)#1, Do you bathe the resident? CNA #1 said, Yes, I do, sometimes. The Surveyor asked, Do you clean her nails and cut them when you bathe her? CNA #1 said, I will clean them, I do not cut them. The resident is a digger, you can clean her nails and they get dirty again. The Surveyor asked CNA #1, Does she eat with her dirty fingernails? CNA #1 said, She is a feeder, she is fed her meals in the dining room.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 7 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 12/8/22. The findings are: a. On 12/07/22 at 4:40 PM, the Dietary Supervisor used a 4 oz [ounce] spoon and placed 6 servings of ground beef into a blender, added broth and pureed. At 4:42 PM She poured the pureed ground beef in a pan and placed it on the steam table. The consistency of the pureed meat was gritty, not smooth. b. On 12/07/22 at 4:45 PM, the Dietary Supervisor used a 4 oz spoon and placed 7 servings of corn into a blender and pureed. At 4:47 PM, She poured the pureed corn in a pan. She covered the pan with foil and placed it on the steam table. The consistency of the pureed corn was lumpy, not smooth. There were pieces of corn skin visible in the mixture. c. On 12/07/22 at 4:50 PM, the Dietary Supervisor used a #8 scoop and placed 7 servings of refried beans into a blender and pureed. At 4:53 PM, she poured the pureed refried beans in a pan and placed it on the steam table. The consistency of the pureed refried beans was lumpy, not smooth. There were pieces of beans in the mixture. d. On 12/07/22 at 5:06 PM, the Surveyor asked the Regional Consultant to describe the consistency of the pureed refried beans. She stated, It was lumpy, and it has pieces of beans in it. She took it out of the steam table and pureed it some more. e. On 12/07/22 at 5:22 PM, the Dietary Supervisor portioned out pureed corn and pureed ground meat to serve to the residents. The Surveyor asked the Dietary Supervisor to describe the consistency of the pureed corn and ground meat ready to be sent out to the residents on pureed diets. She stated, They needed to be smooth. The Regional Consultant stated, Pureed corn was lumpy and pureed ground beef was gritty.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to ensure maintenance and housekeeping services were provided to maintain a sanitary, orderly and comfortable interior and improve the quality of life for the residents, as evidenced by failure to ensure window blinds, window sills, thermostat wall mount were free of jagged edges in occupied rooms on 4 (100 Hall, 200 Hall, 300 Hall, and 400 Hall) of 4 (100, 200, 300 and 400) Halls, a broken picture frame on the 400 Hall with loose edges next to glass, and missing floor tile with built up brown gritty substance on the floor. These failed practices had the potential to affect all 37 residents who resided in the facility, as documented on the census and condition provided by the Director of Nursing (DON) on 12/06/22 at 2:45 PM. The findings are: a. On 12/06/22 at 4:12 P.M, the Surveyor entered [named] room. There was missing floor tile with build and up a brown gritty substance on the floor. b. On 12/07/22 at 9:23 A.M, the Surveyor entered [named] room. There was missing floor tile with a built up brown gritty substance on the floor. c. On 12/08/22 at 11:42 A.M, the Surveyor entered [named] room. There was missing floor tile with a buildup brown gritty substance on the floor. The Surveyor asked Certified Nursing Assistant (CNA) #4, What happened to the floor, why is there not any tile in this room? The CNA said, She has been here for two years, and she has wondered the same, it looks bad. It has been there like that for 2 years. d. On 12/08/22 at 11:44 A.M, the Surveyor asked the Director or Nursing (DON) Office (DON) anything about the floor tile missing in [named] Room. The DON said, No. The Administrator said, We were just talking about the floor in that room, we have only been here for three weeks. The Surveyor asked them does the floor have missing tile? The DON and Administrator (Admin) said, They didn't know, but they were just talking about the floor in the [named] Room. e. On 12/08/22 at 11:51 A.M, the Surveyor and the Maintenance Director went to [named] Room. The Surveyor asked him, What do you think of the floor? He said, He thought it was ok, it is easier to clean. The Surveyor said, It does not look clean. The Surveyor asked the Maintenance Director if he had noticed the broken blinds and if he thought it was, ok? He said, No, it is broken. The DON asked the Maintenance Director if the facility has any spares to replace it? He said Yes, he would change it. f. On 12/08/22 at 12:03 P.M, there were broken window blinds with jagged edges in (named) rooms the Maintenance Director agreed the blinds should be replaced. g. On 12/08/22 at 12:06 P.M, there were broken blinds in (named) rooms. There was a sunken portion of the wall approximately 6 inches on the wall with the trimming not attached in the bathroom of (named) room. The Maintenance Director said, I didn't fix it, that was before me. h. On 12/08/22 at 12:11 P.M, there were broken blinds in (named) rooms. The Surveyor asked the Maintenance Director, What could happen with the broken blinds? The Maintenance Director said, You could get cut. i. On 12/08/22 at 12:12 P.M, the handrail was loose from the wall approximately 1/4 inch from the wall on (named) Hall. The Surveyor asked the Maintenance Director if he thought the handrail was loose? He pulled on the rail. The rail almost came completely came out of the wall. The Surveyor asked him, What could happen with loose handrails? He said, You could fall. j. On 12/08/22 at 12:15 P.M, a broken thermostat cover with a sharp plastic edge, and 2 double AA batteries exposed was on the (Named) hall. The Surveyor asked the Maintenance Director, What could happen with this broken cover? The Maintenance Director said, Someone could be cut. k. On 12/08/22 at 12:22 P.M, there was a broken picture frame with exposed glass on the (Named) Hall. The picture was next to [named] room. l. On 12/08/22 at 12:24 P.M, The Surveyor asked the Maintenance Director for a policy on Maintenance and housekeeping. The Maintenance Director said, they do not have one. The Surveyor asked, What happens if the CNA or LPN has an environmental issue, he/she needs to report? The Maintenance Director showed us a binder at the nurse's station that the employees could put in a request and report environmental issues and hazards that were identified.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to review and revise the Care Plan and reassess the effectiveness of interventions to meet the resident needs for 1 (Resident #2) of 1 sampled resident who used a seat belt when up in her electric wheelchair to promote independence and safety. The findings are: Resident #2 had diagnoses of Other Cerebral Palsy, Dysphagia, Unspecified, Cerebrovascular Disease, Hypertension. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/22 documented a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). The MDS documented the resident required extensive assistance with toileting, bed mobility, transferring and ambulation on unit. a. On 12/6/22 at 4:45pm, R #2 utilized a seat belt. The Surveyor asked R #2 if she could release the seat belt. R #2 stated, I can but due to my condition I would rather not. I wear the seat belt because I have Cerebral Palsy. The seat belt helps me feel safe and independent. b. On 12/7/22 (time?) (and what is the date on the Care Plan?) c. On 12/8/22 at 10:25am, The Surveyor asked the Minimum Data Set MDS Nurse, Why does a resident have a care pan? The MDS Nurse stated, It shows staff how to provide the care needed for a particular resident. The Surveyor asked, When should a care plan be updated or revised? The MDS Nurse stated, Whenever there is a change in the care for the resident and quarterly. The Surveyor asked, Should a resident that uses a seat belt when up in an electric wheelchair be on the care plan? The MDS Nurse stated, Yes, it should be. d. On 12/8/22 at 1:00pm, The Director of Nursing (DON) provided a document titled, The Care Plan Policy and Procedure. Online number 3 stated, The Resident's care plan will be updated quarterly and as needed .

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

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Based on observation, record review and interview, dietary staff (failed to) wash their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; the facility failed to ensure foods 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 dry food products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; and failed to ensure 1 of 2 ice machines was maintained in a clean and sanitary condition to prevent potential contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect residents who received meals from the kitchen (total census: 37) as documented on a list provided by Dietary Supervisor. The findings are: 1. On 12/07/22 at 2:22 PM, the following observations were made during the initial tour of the kitchen: a. On 12/07/22 at 2:23 PM, Dietary Employee (DE) #1 pushed can goods on the counter out of the way. He placed gloves on his unwashed hands, which contaminated the gloves. He opened a bag of mixed greens, removed them from the bag and placed them on the cutting board, chopped and placed them in a pan to be served to the residents at the supper meal. b. On 12/07/22 at 2:30 PM, an opened zip lock bag that contained slices of cheese was stored on a shelf in the refrigerator. The bag was not sealed. c. On 12/07/22 at 2:38 PM, DE #1removed the fresh tomatoes from the refrigerator and placed them on the cutting board, he did not rinse them. He cut them in small pieces, was ready to place them in a pan that contained chopped mixed greens. The Surveyor stopped him and asked, What should you do with tomato before slicing it? He stated, Washed them. d. On 12/7/22 at 2:39 PM, there were five bags of Belgian waffle mix on a shelf in the storage room that had expiration date of 4/27/22. e. On 12/07/22 at 3:06 PM, there was a wet orange/pink residue on the interior surfaces of the ice machine in the kitchen. The Surveyor asked the Dietary Supervisor to wipe off what was observed on the ice machine panel. She did so, and the orange and pinkish residue easily transferred to the tissue. The Surveyor asked her to describe what was wiped off. She stated, It was pinkish/orange residue. f. On 12/07/22 at 3:08 PM, The Surveyor asked Certified Nursing Assistant (CNA) #2 What do you do with the ice from the ice machine in the dining room? She stated, We use it for the water pitchers in the residents' rooms. g. On12/07/22 at 3:15 PM, The Surveyor asked CNA #3 What do you do with the ice from the ice machine in the dining room? She stated, We use it for the water pitchers in the residents' rooms. h. On 12/07/22 at 3:18 PM, DE #2 opened the door with tissue paper in his hands. He used the tissue to dry his hands. He picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents. i. The facility policy on hand washing provided by the Regional Consultant on 12/08/22 at 10:09 AM documented, All employees will wash hands upon entering the kitchen from any other location, after all breaks and between all tasks. Hand washing should occur at a minimum of every hour.

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

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
• 24 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $14,935 in fines. Above average for Arkansas. Some compliance problems on record.
• Grade D (41/100). Below average facility with significant concerns.

Bottom line: Trust Score of 41/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is The Springs Of Red Oak's CMS Rating?

CMS assigns THE SPRINGS OF RED OAK an overall rating of 3 out of 5 stars, which is considered average nationally. Within Arkansas, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is The Springs Of Red Oak Staffed?

CMS rates THE SPRINGS OF RED OAK's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 66%, which is 20 percentage points above the Arkansas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at The Springs Of Red Oak?

State health inspectors documented 24 deficiencies at THE SPRINGS OF RED OAK during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 23 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates The Springs Of Red Oak?

THE SPRINGS OF RED OAK 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 THE SPRINGS ARKANSAS, a chain that manages multiple nursing homes. With 80 certified beds and approximately 53 residents (about 66% occupancy), it is a smaller facility located in HOT SPRINGS, Arkansas.

How Does The Springs Of Red Oak Compare to Other Arkansas Nursing Homes?

Compared to the 100 nursing homes in Arkansas, THE SPRINGS OF RED OAK's overall rating (3 stars) is below the state average of 3.1, staff turnover (66%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting The Springs Of Red Oak?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.

Is The Springs Of Red Oak Safe?

Based on CMS inspection data, THE SPRINGS OF RED OAK has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Arkansas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at The Springs Of Red Oak Stick Around?

Staff turnover at THE SPRINGS OF RED OAK is high. At 66%, the facility is 20 percentage points above the Arkansas average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was The Springs Of Red Oak Ever Fined?

THE SPRINGS OF RED OAK has been fined $14,935 across 1 penalty action. This is below the Arkansas average of $33,228. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is The Springs Of Red Oak on Any Federal Watch List?

THE SPRINGS OF RED OAK 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.

Facility Details

Beds: 80
Avg. Residents: 53
Occupancy: 66.4%
Ownership: For profit - Limited Liability company
Chain: THE SPRINGS ARKANSAS
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
3-Star Rating: +20
High Turnover: -5
1 Immediate Jeopardy citation: -12
24 Deficiencies: -10
Fines ($14,935): -2
Final Score: 41/100

Nearby Alternatives

THE BLOSSOMS AT HOT SPRINGS RE... 4-star THE SPRINGS OF PARK AVE 4-star QUAPAW CARE AND REHABILITATION... 4-star

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 045404