PRAIRIE GROVE HEALTH AND REHABILITATION, LLC
For profit - Limited Liability company
70 Beds
STEIN LTC
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
61/100
#74 of 218 in AR
Photo by Google Maps
Photo by Prairie Grove Health & Rehab
Photo by Google Maps
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Prairie Grove Health and Rehabilitation, LLC has a Trust Grade of C+, which means it is slightly above average but not exceptional. It ranks #74 out of 218 facilities in Arkansas, placing it in the top half of the state, and #4 out of 12 in Washington County, indicating there are only three local options that perform better. The facility is improving, having reduced its issues from four in 2023 to three in 2024. Staffing is a relative strength with a 3 out of 5-star rating and a turnover rate of 41%, which is lower than the state average of 50%, suggesting that staff tend to stay longer and build rapport with residents. However, the facility has concerning fines of $7,446, higher than 77% of Arkansas facilities, and significantly less RN coverage than 99% of state facilities, which raises questions about medical oversight. Specific incidents that raise concerns include a critical finding where a resident at risk of elopement left the facility unsupervised, potentially putting themselves and others in harm's way. Additionally, there were issues with sanitation in the kitchen, such as unclean equipment and improper food handling, which could lead to health risks for residents. Overall, while Prairie Grove Health and Rehabilitation has some strengths, these serious deficiencies underscore the need for careful consideration by families researching nursing home options.
- Trust Score
- C+
- In Arkansas
- #74/218
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 41% turnover. Near Arkansas's 48% average. Typical for the industry.
- Penalties ○ Average
- $7,446 in fines. Higher than 74% of Arkansas facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 8 minutes of Registered Nurse (RN) attention daily — below average for Arkansas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 14 deficiencies on record. Higher than average. Multiple issues found across inspections.
61/100
Top 33%
Review needed
4 → 3 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 4 issues
2024: 3 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (41%)
7 points below Arkansas average of 48%
Facility shows strength in fire safety.
The Bad
Staff Turnover: 41%
Near Arkansas avg (46%)
Typical for the industry
Federal Fines: $7,446
Below median ($33,413)
Minor penalties assessed
Chain: STEIN LTC
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 14 deficiencies on record
1 life-threatening
Jun 2024
3 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
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record review, and facility document review, the facility failed to ensure the call light system was functioning for 1 (Resident # 39) of 1 sampled resident reviewed...
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Based on observations, interviews, record review, and facility document review, the facility failed to ensure the call light system was functioning for 1 (Resident # 39) of 1 sampled resident reviewed for call light function.
Findings include:
During a concurrent observation and interview on 06/18/2024 at 8:32 AM, Resident #39 was asked about his room for function, comfort, and available supplies. Resident #39 stated his only complaint was his call light was broken. Resident stated it quit functioning last week and he told the girl at the time. When asked who he told, Resident #39 stated he couldn't remember her name, but it was one of the Certified Nursing Assistants (CNAs). This Surveyor asked the resident to press the call light. When the button was pushed, the light on the wall behind the Resident lit up. The light in the hallway above Resident #39's room did not light up from either direction in the hall. This Surveyor waited 2 minutes then walked to the nurse's station. Transporter #1 confirmed Resident #39's call light was not going off at the central call light screen.
During an interview on 06/18/2024 at 9:20 AM, this Surveyor spoke with Maintenance Personnel #2 about procedures for work orders. Maintenance Personnel #2 handed me a binder and explained staff write any issues with the date and time in the binder and maintenance checks it each day and follows up. Maintenance Personnel #2 confirmed no issue with Resident #39's call light was documented in the binder prior to 06/18/2024 after it was identified by the Surveyor.
During an interview on 06/20/2024 at 8:28 AM, CNA #4 verbalized the procedure for reporting maintenance issues; report it to the maintenance personnel and write it in the maintenance logbook that is kept in the slot on the outside of the maintenance door.
During an interview 06/20/2024 at 11:40 AM, the Administrator was asked for the policy and procedures for call lights. The Administrator stated there was not a policy in place, but facility procedure was to do a monthly check on each resident's call light. The Administrator reported no recent operational issues with the call light system, and stated in the event there was a downtime of an individual call light or the system itself they have squeaky toys and bells in the disaster room. The Administrator also stated if a resident's call light was not functioning it should be written on the maintenance log for repair and in the event it occurs on the weekend, the staff should call and notify her or maintenance personnel. The Administrator confirmed no issue with Resident #39's call light was documented in the maintenance log prior to 06/18/2024.
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, and record review, it was determined that the facility failed to ensure kitchen equipment and surfaces were clean and clean dishes were stored properly.
Findings incl...
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Based on observation, interview, and record review, it was determined that the facility failed to ensure kitchen equipment and surfaces were clean and clean dishes were stored properly.
Findings include:
1. On 06/17/2024 at 11:15 AM, during the initial tour of the facility's kitchen, the Surveyor looked to the right of the kitchen door and saw there was a food blender sitting on a table. The table the blender was sitting on had a light brown runny substance that covered a 4 inch by 6 inch area. There was a metal kitchen ladle sitting on the table. The Dietary Aide (DA) brought over bread slices and a gallon of milk and began putting the bread and milk in the processor. The DA then turned the machine on to blend the food.
2. On 06/17/2024 at 11:20 AM, during an initial brief tour of the facility's kitchen, the Surveyor asked the Dietary Manager (DM) to slide the grease traps out. The DM slid the left side out and it had a piece of aluminum foil over it. On the top of the foil was mostly black in color with clumps of brown and black substance all over the top. The DM immediately took the foil off and discarded it stating, That needs to be cleaned.
3. On 06/17/2024 at 11:24 AM, the Surveyor walked to the right of the stove where dishes were stacked. The bowls were stored in an upright position instead of inverted. The Surveyor asked the DM if the dishes were clean. The DM stated, Yes, those are clean.
4. On 06/19/2024 at 11:33 AM, just before observing food puree, the Dietary Aide (DA) placed a barrier down for scoop and lid on the left of the blender. To the right side of the blender, there were light brown clumps or crumbs of an unknown substance. The DA then brought the food and placed it in the blender and began to blend. Once the DA finished blending the food, the DA washed the blender in preparation for another food to puree. While the DA was washing the blender, another dietary aide came over and wiped the clumps off that were on the right side of the blender.
5. On 06/19/2024 at 11:40 AM, a bread toaster was observed on a shelf underneath the blender. The toaster was covered in tiny light colored clumps or crumbs. There were also two skillets observed on the top of the stove being stored upright instead of inverted.
a. On 06/19/2024 at 2:20 PM, the Surveyor asked the DM why it is important to keep grease traps on the stove clean. The DM stated to keep the stove from catching on fire. The DM was asked how often the grease trap is checked and cleaned. The DM stated that it is supposed to be checked at the end of each day.
b. On 06/19/2024 at 2:22 PM, the Surveyor asked the DM why it is important to keep clean dishes stored upside down. The DM said to keep from contaminating them. The DM was asked why it's important to keep kitchen equipment clean. The DM said for infection control.
c. On 06/19/2024 at 2:30 PM, the DM provided a copy of the in-service staff were provided on 5/15/2024 regarding coffee maker, food temperatures, proper thawing methods, labeling and dating, and utensil usage.
d. On 06/19/2024 at 2:49 PM, the Administrator provided a copy of the policy for kitchen equipment cleaning, Policy 027. The policy stated, .1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-foods contact equipment will be clean and free of debris. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 6. The Dining Services Director will notify the Administrator when repairs are completed. 7. Copies of service repairs and preventative maintenance reports will be submitted monthly.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of a facility-initiated discharge for 1 (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of a facility-initiated discharge for 1 (Resident #111) of 2 sampled residents reviewed for discharge.
The findings are:
Review of Resident #111's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of traumatic brain bleed and dementia with psychotic disturbance. According to the admission Minimum Data Set with an Assessment Reference Date of 01/08/2024, the resident scored 8 on a Brief Interview for Mental Status indicating moderate cognitive impairment.
Review of the Final Discharge Summary dated 02/29/2024, revealed Resident #111 was transferred to an inpatient psychiatric facility for treatment and from that facility was discharged home.
During an interview on 06/20/2024 at 11:55 PM, the Administrator reported the facility was unable to keep Resident #111 safe due to continued suicidal ideations and repeated attempts of self-harm even after inpatient psychiatric stay. The Administrator stated the resident representative was informed verbally that the facility could not keep the resident safe and would not be able to readmit to the facility. The Administrator confirmed the facility provided a written transfer to the hospital notification to the resident representative but failed to notify the resident representative in writing of facility-initiated discharge due to not being able to meet the resident's safety needs.
On 06/20/2024 at 1:57 PM, the Administrator provided a policy titled, Discharge/Transfer Letter. Upon review, the policy contained a statement and instructions for items to be included in the written notice of transfer or discharge, the reason for transfer or discharge, the effective date of transfer or discharge, and the location to which the resident is transferred or discharged .
Jun 2023
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure Physician's Orders were followed for medication administration for 1 (Resident #43) of 2 (#8 and #43) sampled resident...
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Based on observation, interview, and record review, the facility failed to ensure Physician's Orders were followed for medication administration for 1 (Resident #43) of 2 (#8 and #43) sampled residents residing on the secure unit who utilized inhalers for respiratory treatment, and failed to ensure a beverage provided by staff belonged to the correct resident to prevent potential cross contamination for 1 (Resident #43) of 3 (#8, #14, and #43) sampled residents residing on the secure unit who had Physician Orders for thickened liquids as documented on the list provided by the DON on 06/22/23 at 8:49 AM. The findings are:
1. Resident #43 had diagnoses of Lobar Pneumonia, Emphysema, and Shortness of Breath.
a. The Physician Order with a start date of 07/30/22 documented, .Resident to use a spacer with Albuterol and other Pulmonary Inhalers .every shift .
b. The Physician Order with a start date of 06/05/23 documented, .Albuterol Sulfate HFA [Hydrofluoroalkane] Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale every 6 hours as needed for SOB [Shortness of Breath] .
c. The Physician Order with a start date of 12/05/22 documented, .diet .Nectar consistency .
d. On 06/19/23 at 1:40 PM, Resident #43 was sitting in a wheelchair near the Day Room and was coughing. The surveyor heard Licensed Practical Nurse (LPN) #1 ask Certified Nursing Assistant (CNA) #4, Do you know if the thickened water PT [Physical Therapy] brought back is for Resident #43? I can't remember what she said CNA #4 stated, I don't know if it's hers. The surveyor observed LPN #1 take the half full, uncovered, plastic cup of thickened water and handed it to Resident #43 and stated to the Resident, Either way, it will be fine. LPN #1 stated to Resident #43, This should help.
e. On 06/19/23 at 1:52 PM, Resident #43 continued sitting in her wheelchair near the Day Room coughing. LPN #1 obtained an inhaler from the medication cart and explained to Resident #43 that the medication was Albuterol. LPN #1 explained to Resident #43 to blow out then she would place the inhaler in her mouth, and that she needed to breathe in. LPN #1 failed to utilize a spacer to administer the inhaler to Resident #43. The Surveyor observed some of the mist of the medication exited out of the top of the inhaler around the canister. LPN #1 immediately gave Resident #43 a 2nd [second] puff. LPN #1 stated, I don't think you got any of that one. I need you to breathe in. LPN #1 gave Resident #43 a 3rd [third] puff and the Surveyor observed some of the mist spray out of the top of the inhaler. LPN #1 then administered a 4th [fourth] puff and stated, I think we got at least one good one.
f. On 06/21/23 at 8:10 AM, the Surveyor asked LPN #4, If a thickened beverage is unlabeled and uncovered should it be served to a resident? LPN #4 stated, No. The Surveyor asked, If staff are unsure who a thickened beverage is made for, and has been sitting out, should it be given? The LPN #4 stated, No, never. A new one should be made. The Surveyor asked what the possible outcomes would be if a resident was given a beverage that was not theirs. LPN #4 stated, Sickness, infection, choking if it is not the right consistency, and spreading of germs.
g. On 06/21/23 at 8:15 AM, the Surveyor asked the DON, If a thickened beverage is unlabeled and uncovered should it be served to a resident? The DON stated, Uncovered, No. The Surveyor asked, If staff were unsure of who the thickened beverage was made for, and if it has been sitting out, should it be given? The DON stated, No. The Surveyor asked what the possible outcomes would be if a resident was given a beverage that was not theirs. The DON stated, Spread of germs.
h. On 06/21/23 at 9:34 AM, the Surveyor asked LPN #2, If the Physician's Order for an Albuterol inhaler was for 2 puffs, how many should be administered? LPN #2 stated, Two. The Surveyor asked, What is the purpose of the spacer? LPN #2 stated, So they can get more of it in. The Surveyor asked, What could happen if too many puffs were given? LPN #2 stated, They can get nauseous, and their heart rate can speed up. The Surveyor asked, What could happen if a spacer was not utilized? LPN #2 stated, They might not get enough of the medicine.
i. On 06/21/23 at 9:39 AM, the Surveyor asked LPN #3 If the Physicians Order for an Albuterol inhaler was for 2 puffs, how many should be administered? LPN #3 stated, Two. The Surveyor asked, What is the purpose of the spacer? LPN #3 stated, To allow them to inhale all of the medication effectively and to prevent it from sticking in their mouth and causing thrush. The Surveyor asked, What could happen if too many puffs were given? LPN #3 stated, Could cause jitteriness, an increase in heart rate, and a med (medication) error. The Surveyor asked, What could happen if a spacer was not utilized? LPN #3 stated, They might not inhale all of the medication and not be effective.
j. On 06/21/23 at 9:43 AM, the Surveyor asked the DON, If the Physician Order for an Albuterol inhaler was for 2 puffs, how many should be administered? The DON stated, Two. The Surveyor asked, What is the purpose of the spacer? The DON stated, To ensure they are getting all of the medication. The Surveyor asked, What could happen if too many puffs were given? The DON stated, An increase in heart rate. The Surveyor asked, What could happen if a spacer was not utilized? The DON stated, There is a chance that she does not get all of the medication.
k. The facility policy titled, Administering Medications through a Metered Dose Inhaler, provided by the DON on 06/21/23 at 11:09 AM documented, .Preparation .6. Check the label on the inhaler and confirm the medication name and dose with the MAR [Medication Administration Record] .14. c. If the inhaler has a spacer, pull it away from the inhaler until it clocks into place .15 .Allow at least one (1) minute between inhalations of the same medication .
l. The facility policy titled, Personal Competency Review, provided by the DON on 06/21/23 at 11:22 AM documented, .Competency: Med Pass (Nurse) dated 06/08/23 for LPN #1 .Number of previous observations: 1 . and was marked Pass next to Correct dose is administered.
m. The facility policy titled, Therapeutic Diets, provided by the Administrator on 06/22/23 at 9:52 AM documented, .All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending Physician .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat 3 (Residents #13, #25, #30) of 5 (#13, #15, #25...
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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 treat 3 (Residents #13, #25, #30) of 5 (#13, #15, #25, #30, #33) sampled residents with dignity and respect while assisting with feeding the residents. The findings are:
1. Resident #13 had a diagnosis of Alzheimer's Disease, Unspecified, Dysphagia, Oropharyngeal Phase, other reduced Mobility.
a. The Quarterly Minimum Data Set (MDS) dated [DATE] shows Resident #13 requires total dependence with one-person assistance for meals.
b. On 06/19/23 at 1:53 PM, Certified Nursing Assistant (CNA) #2 was feeding Resident #13 applesauce while standing over him. On 06/19/23 at 2:08 PM, She sat down and continued to feed him.
c. On 06/21/23 at 8:17 AM, the Surveyor asked CNA #2 what the procedures were for feeding the residents, and why Resident #13 was fed applesauce from a standing position. CNA #2 said, It was my first day working this shift. I normally work 2nd [second] shift and did not know. Someone had to come over and remind me. The Surveyor asked if there was any possible consequence from feeding residents from a standing position. CNA #2 said, It is like you are looming over them. It might make them feel inferior.
2. Resident #25 had a diagnosis of Multiple Sclerosis, and Paraplegia, Unspecified.
a. The Quarterly MDS dated [DATE] showed Resident #25 is independent with set up assistance for meals.
b. On 06/20/23 at 12:53 PM, CNA #1 was standing above Resident #25, assisting her with scooping food in her spoon. She took Resident #25 by the right hand and scooped the food onto the spoon.
c. On 06/20/23 at 1:00 PM, the Surveyor asked CNA #1 about her process for feeding residents. CNA #1 said, I forgot we do not feed residents while standing above them.
3. Resident #30 had a diagnosis of Alzheimer's Disease with late onset, and Legal Blindness.
a. The Quarterly MDS dated [DATE] showed Resident #30 requires limited one-person assistance for meals.
b. On 06/20/23 at 8:22 AM, CNA #3 was standing over Resident #30 while feeding her cereal and assisting her with a nectar thick house shake.
c. On 06/20/23 at 8:24 AM, CNA #3 said, I have to sit down. I'm getting old. CNA #3 sat down and assisted Resident #30 with the spout cup of house shake.
d. On 06/21/23 at 8:23 AM, the Surveyor asked the Director of Nursing (DON) if it was appropriate to stand over the residents while assisting them to eat. The DON said, No, if they are having trouble, we tell them to go to the other side of the table to assist the resident with their meal. The Surveyor asked, Why we do not stand over residents to feed them? The DON said, It is a dignity issue.
e. On 06/21/23 at 10:40 AM, the Surveyor asked CNA #3 if Resident #30 had any special accommodations that would require feeding while standing above her. CNA #3 said, No, I should have fed her from a sitting position. I did get a chair and moved to her side to finish feeding her. She is blind, and I can get her to eat better than others. The Surveyor asked if feeding a blind resident from across the table was an issue with assisting her to eat. CNA #3 said, No, but she does better when you sit to her side. That is why I did get a chair and sit to the side and feed her.
f. The facility policy titled, Assistance with the Meals Policy, provided by the DON on 06/21/23 at 11:49 AM documented, Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity.
g. The facility policy titled, Residents Rights, provided by the RN Consultant on 06/21/23 at 12:17 PM documented, The nurse consultant provided the Residents Rights policy stating our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #30 has a diagnosis of Alzheimer's Disease with late onset, and Legal Blindness.
a. The Quarterly MDS dated [DATE] r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #30 has a diagnosis of Alzheimer's Disease with late onset, and Legal Blindness.
a. The Quarterly MDS dated [DATE] reveals Resident #30 requires limited one-person assistance for meals.
b. On 06/19/23 at 12:31 PM, Dietary Employee #1 exited the kitchen door and went into the Dining Area, used her hands to unlock the ice machine and scooped the ice into a silver bowl. The scoop rested on the ice machine door.
c. On 06/19/23 at 12:33 PM, the Surveyor asked DE #1 if she performed hand hygiene before getting ice from the machine. DE #1 said, I washed my hands before I left the kitchen. The Surveyor asked what did she touch from the time she washed her hands in the kitchen. DE #1 said, I should have washed or re-sanitized my hands. The Surveyor asked about the possible outcome of not using hand hygiene, and the scoop touching the ice machine door. DE #1 said, Cross contamination.
d. On 06/20/23 at 12:53 PM, CNA #1 was standing above Resident #25, taking her by the right hand and scooping food onto the spoon and feeding her. CNA #1 walked around the table and assisted Resident #30 by supporting a two handled spout cup. She placed her hands over Resident #30's hands and lifted the cup up to her mouth. She then rubbed Resident #30's left hand with her right hand. CNA #1 did not sanitize her hands between feeding the residents.
e. On 06/20/23 at 1:00 PM, the Surveyor asked CNA #1 about her process for hand hygiene between Residents #25 and #30. CNA #1 said, I forgot we do not feed the residents while standing above them, and we use hand sanitizer. I usually have sanitizer in my pocket, but I did not have any sanitizer today. The Surveyor asked CNA #1 what the possible consequences were of not using hand hygiene between the residents. CNA #1 said, Cross contamination.
f. On 06/21/23 at 8:25 AM, the Surveyor asked the Director of Nursing (DON) if it was appropriate for staff to place their hands on another resident hands to assist with eating, and to assist another resident with eating without washing their hands or using hand sanitizer. The DON said, No, they should probably get hand sanitizer between residents, The Surveyor asked if there are any possible consequences when not using hand hygiene between feeding the residents. The DON said, They are spreading germs. The Surveyor asked if it was appropriate to scoop ice from the ice machine after resting the scoop on the ice machine, and without performing hand hygiene. The DON said, No it is not. It spreads germs.
g. The facility policy titled, Handwashing/hand Hygiene, provided by the DON on 06/22/23 at 8:41 AM, documented, All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections, all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sink, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Use an alcohol-based hand rub containing .before and after direct contact with residents .
Based on observation, record review, and interview, the facility failed to ensure Dietary Staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen; ensure food items stored in the refrigerator, freezer and dry storage areas were covered or sealed and expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen; and to ensure frozen food items were kept frozen to prevent the potential for bacteria growth for residents who received meals from 1 of 1 kitchen, and the facility failed to ensure that the ice machine scoop was handled in a sanitary manner. These failed practices had the potential to affect 56 residents who received meals from the kitchen (total census: 56), as documented on a list provided by the Dietary Supervisor on 06/20/23. The findings are:
a. On 06/19/23 at 11:16 AM, Dietary Employee (DE) #1 turned on the hand washing sink's faucet and washed her hands. She then turned off the sink's faucet with her bare hands, contaminating them. She removed tissue from the tissue dispenser and dried her hands. Without washing them, she picked up a pan with her thumb inside of it and placed it on the counter. She emptied 2 cans of apple slices into a bowl. She held a box of gloves and removed gloves from the glove box into her hands, contaminating them. She added sugar to the apple, mixed it and transferred it into a pan. She also mixed the oatmeal and brown sugar and sprinkled the mixture on top of the apple, then placed the pan of apple crisp in the oven to be baked and served to the residents for lunch.
b. On 06/19/23 at 11:29 AM, DE #2 held the box of gloves and removed gloves from the box, contaminating the gloves. Without changing the gloves, she used the same contaminated gloved hands to pick up the clean utensils by their tips and placed them in the condiment dispenser and holder for the residents to be used in eating their lunch.
c. On 06/19/23 at 11:41 AM, DE #2 turned on the food preparation sink's faucet, picked up a glass by the rim, and obtained the water. She turned off the faucet and placed the glass of water on the counter, added thickener and mixed it to be served to the resident on a nectar thickened liquid diet.
d. On 06/19/23 at 11:44 AM, the following food items on the counter in the kitchen were not covered or sealed:
1. An opened bag of [named mashed potatoes].
2. An opened box of cornstarch.
e. On 06/19/23 at 11:59 AM, DE #1 picked up a rag from the floor and placed it in a dirty container. Without washing her hands, she picked up a measuring cup with her fingers inside the cup and placed it on the counter. She poured the Italian dressing in the cup and poured it on the crushed tomatoes in a pan on the counter to be served to the residents for their lunch.
f. On 06/19/23 at 12:02 PM, DE #1 turned on the hand washing sink's faucet and washed her hands. She removed the tissue and used them to turn off the faucet. She then used the same tissue to dry her hands. She placed the gloves on her hands, contaminating them. She removed the slices of cheese from the bag and placed them in a container to be used in the sandwiches to be served to the residents for their lunch.
g. On 06/19/23 at 12:13 PM, DE #2 pushed a cart that contained glasses close to the ice machine in the Dining Room. She emptied the packets of sugar into 2 of the glasses that contained ice cubes. Without washing her hands, she picked up the glasses by their rims and poured tea to be served to the residents for their lunch.
h. On 06/19/23 at 12:20 PM, DE #1 turned on the hand washing sink's faucet, washed her hands, and placed on her gloves. She unzipped a packet that contained slices of turkey. Without changing gloves and washing her hands, she removed a slice of turkey and placed it on the cutting board.
i. On 06/19/23 at 12:23 PM, DE #1 turned on the hand washing sink's faucet and washed her hands. She removed the tissue and used them to turn off the faucet. She then used the same tissue to dry off her hands. She placed the gloves on her hands, contaminating them. She removed the slices of cheese from the bag to place them in a container to use in the sandwich to be served to the residents for their lunch.
j. On 06/19/23 at 12:33 PM, DE #2 opened the refrigerator door and removed a pan that contained the beverages and placed it on the counter. Without washing her hands, she picked up the glasses by their rims and placed them on the pan of ice on the cold side of the steam table. The Surveyor asked DE #2, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands.
k. On 06/19/23 at 12:47 PM, DE #1 opened a bag of shredded lettuce and placed it on the counter. She placed gloves on her hands, contaminating them. Without changing gloves and washing her hands, she removed the shredded cheese from the bag and placed them in a bowl. She picked up the diced tomatoes and placed them on the shredded lettuce. At 12:50 PM, DE #1 sliced the turkey into pieces and placed it on the lettuce and tomatoes to be served to the residents who requested salad. The Surveyor asked DE #1, What should you have done after touching dirty objects and before handling clean equipment? DE #1 stated, I should have changed gloves and washed my hands.
l. On 06/19/23 at 2:52 PM, DE #2 was putting up cartons of supplements and ice cream that was left over from lunch in the freezer. The Surveyor asked DE #2 to check the temperature on the chocolate milk. DE #2 stated, It was 58 degrees Fahrenheit. The Surveyor asked DE #2 if the ice cream was still frozen. She lifted the lid from the ice cream and stated, It melted.
m. On 06/20/23 at 10:07 AM, there was an opened, uncovered box of bacon on the shelf in the refrigerator.
n. On 06/20/23 at 10:14 AM, there was an opened, unsealed box of biscuits on the shelf in the freezer.
o. On 06/20/23 at 10:18 AM, the following expired canned goods were on a shelf in the Storage Room.
1. Three of 3 cans of beets were on a shelf in the Storage Room with an expiration date of 12/22.
2. Five of 5 cans of chocolate pudding with an expiration date of 02/23.
3. Five of 5 cans of chili con carne [with meat] and with beans with an expiration date of 03/23.
p. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on 06/20/23 at 3:32 PM documented, Handwashing with soap and water is required in a Dining Services Setting in the following situations: In between glove changes. For example, when changing tasks. After removing gloves. When beginning your shift, after handling dirty dishes or trash. When you take one step away from your workstation and Between tasks.
Jun 2023
1 deficiency
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility was in past non-compliance and failed to ensure adequate supervision and mon...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility was in past non-compliance and failed to ensure adequate supervision and monitoring was provided to prevent an elopement for 1 (Resident #1) of 3 (#1, #2 and #3) sampled residents who were at risk for elopement. These failed practices resulted in non-compliance at the level of Immediate Jeopardy, which had the potential to cause injury, harm, and impairment for Resident #1, who eloped from the facility out the front door using the door code, was missing for approximately 2 hours, traversed over a mile from the facility, with access to a busy streets ,and had the potential to cause more than minimal harm to 11 residents who were at risk for elopement, as documented on a list provided by the Administrator on 06/06/23 at 9:54 AM. The Administrator was informed of the Past Immediate Jeopardy on 06/06/23 at 2:45 PM. The findings are:
1. Resident #1 was admitted to the facility's 200 Hall secure unit on 04/07/23 and had diagnoses of Unspecified Dementia. The admission Minimum Data Set (MDS) with an Assessment Reference Date of 04/11/23 documented a score of 15 (indicates cognitively intact) on the Brief Interview of Mental Status (BIMS), required limited physical assistance of one person for locomotion on unit and locomotion off unit, Not steady, only able to stabilize with staff assistance.
a. The Wandering assessment dated [DATE] documented a score of, .11 .high risk for wandering .known wanderer/hx [history] of wandering .
b. The Care Plan with an initiated date of 04/10/23 documented, .has a diagnosis of Dementia .remains at risk for elopement, direction and cueing from staff . is a high risk for falls r/t [related to] deconditioning . confusion .increased risk of falls and fractures, dizziness
c. The facility's Electronic Health Records documented on 04/27/23 that Resident #1 was moved from the 200 Hall secure unit to general population on the 500 Hall.
d. The Witness Statement written by Nursing Assistant (NA)#1 on 05/13/23 documented .It was dinner time, we just started serving. I noticed she [Resident #1] wasn't out in the dining room, so I went in her room to go find her and she was not in there. I proceeded to let the nurse/CNAs know she was not anywhere around.
e. The Progress Note dated 05/14/23 at 22:00 [10:00] documented, . resident was noted to not be in her room when staff went to get her for dinner. Resident was looked for in the day room, and staff was not able to find her. Staff notified this nurse and this nurse activated EOP for Elopement, called staff to search for the resident in the facility and outside. This nurse called the Director of Nurses (DON). The Resident had not been found so facility and outside was searched a second time. CNAs tried calling resident's cell phone several times, but the resident continued to hang up. DON and Social Services Director (SSD) arrived at facility and made contact with family who then called resident themselves and made contact. Family then notified DON resident's location, the DON then retrieved resident and escorted safely back to facility. Resident then moved to secure unit per family request. Q [every] 15-minute checks initiated along with body audit.
f. On 06/06/23 at 10:30 AM, Resident #1 was sitting on the side of the bed in her room. The Surveyor asked, Tell me about when you left the facility and walked home to get some clothes and your electric wheelchair. Resident #1 replied, I wanted to go home, I live 5 blocks from here, to get some clothes and my electric wheelchair. The Surveyor asked, How did you know the code to get out of the front door? Resident #1 replied, I had watched someone else put the code in and remembered it. The Surveyor asked, Did you tell anyone you were leaving the facility? Resident #1 replied, No, I did not tell anyone I left, I got some clothes, and I was tired, so I got my electric wheelchair and rode back. She stated, I had put my address in my maps on my phone, but I got lost on the way back, I took a wrong turn, and my battery was low. I was missing a couple of hours before they noticed I was gone. The Surveyor asked, Have you always been on 200 Hall? Resident #1 replied, No, I was on 200 Hall, then they put me on 500 Hall, and after I left, they put me back on 200 Hall and I was [expletive], but I understand because I left without telling anyone. The Surveyor asked, Did you get hurt while you were out of the building? Resident #1 replied, No, I was sore from the walking, but didn't get hurt. Resident #1 stated, I called my [family member], then my [family member] called and said they were looking for me.
g. On 06/06/23 at 1:05 PM, the Surveyor asked the SSD what occurred on 05/13/23 regarding Resident #1. The SSD stated, The DON called me. When I got here, I directed the staff to do another search. I called Resident #1's [family member], and she happened to be with Resident #1's [family member]. Resident #1's [family member] called Resident #1, and I could hear in the background that he reached her. I told the DON to get in the vehicle and Resident #1 was on the electric wheelchair down there. The Surveyor asked, Where was Resident #1? The SSD stated, They said she was at the water park. [named Resident #1] had told [named family member] she wanted clothes and her electric wheelchair, and she was on her way back. The Surveyor asked when she was notified of Resident #1 being missing. The SSD stated, the DON called me at 5:28 PM. The Surveyor asked if she saw Resident #1 leave. The SSD stated, I did not, No. The Surveyor asked the reason the DON was called and not the Administrator. The SSD stated, The staff had tried to call the Administrator first and then they called the DON, and the DON called me.
h. On 06/06/23 at 1:05 PM, a telephone interview was conducted with Certified Nursing Assistant (CNA) #1. The Surveyor asked, Were you working with Resident #1 on 05/13/23? CNA #1 replied, I was working with Resident #1. The Surveyor asked, Did Resident #1 tell you she was leaving the building? CNA#1 replied, No, I had no idea. The Surveyor asked, When was the last time you saw Resident #1? CNA#1 replied, Around 4-4:30 PM, she was sitting on the bed crocheting. The Surveyor asked, When did you notice Resident #1 was gone? CNA#1 replied, We were getting ready for supper around 4-4:30 PM, I was passing room trays and the other CNA went to get Resident #1, and she wasn't in the room, I stopped and looked in the Bathroom and the Day Room, I couldn't find her, I told the Licensed Practical Nurse (LPN) #1. LPN #1 couldn't find Resident #1, so I went back to passing trays and LPN #1 called the Code for elopement and they started looking for her. The Surveyor asked, What time was it when Resident #1 was found? CNA#1 replied, Between 5:30 PM and 6:00 PM. The Surveyor asked, Had Resident #1 ever eloped before? CNA#1 replied, No. The Surveyor asked, Did Resident #1 have exit seeking behaviors prior to exiting the facility on 05/23/23? CNA#1 replied, No. The Surveyor asked, Did Resident #1 sustain any injuries? CNA#1 replied, Not that I know of. The Surveyor asked, Did Resident #1 see a Physician after returning to the facility? CNA#1 replied, Not sure, they moved her to the unit after that.
i. On 06/06/23 at 1:13 PM, the Surveyor asked the Administrator, What occurred on 05/13/23 regarding Resident #1? The Administrator stated, They called me and notified me they could not find her. They had done a search of the grounds. [named SSD] had called family. I watched the cameras after and [named Resident #1] put in codes, fluffed her hair, and went out. I gave orders for audits and new Wander Assessments. She [Resident #1] had never had exit seeking before. The Surveyor asked, Who notified you and at what time? The Administrator stated, [named DON] called me. I was out of service when they 1st [first] called me. The first call was from [named LPN #2] the nurse at 5:20 PM and then from [named DON] at 5:31 PM. The Surveyor asked if she saw Resident #1 leave. The Administrator stated, I saw her leave the cameras at 3:30 pm. The Surveyor asked if any other residents eloped recently. The Administrator stated, No, the last one was a year ago.
j. On 06/06/23 at 1:16 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) #1. The Surveyor asked, Did Resident #1 ever elope or have any exit seeking behaviors prior to 05/13/23? LPN #1 replied, No. The Surveyor asked, Did Resident #1 tell you or anyone she was leaving? LPN #1 replied, No. The Surveyor asked, When was the last time you saw Resident #1 that day? LPN #1 replied, On the 500 Halls, in the hallway talking to another resident, that was after 3 PM. The Surveyor asked, When did you find out Resident #1 was missing or couldn't be found. LPN #1 replied, Around dinner time, the assistants asked if I had seen Resident #1, they said she wasn't in the room, we looked in other residents' rooms, we couldn't find her, I called the code for elopement. The Surveyor asked, What time was the code called? LPN #1 replied, After 5:00 PM. The Surveyor asked, When you call the code for elopement, who do you notify? LPN #1 replied, We tried to call the Administrator and the DON, it took a couple of tries to get them, I think [named SSD] came in with the DON, and they notified the police, they looked inside and outside a couple of times. The Surveyor asked, Where was Resident #1 found? LPN #1 replied, The DON found Resident #1 at her old house, where she used to live, 5 blocks away. The Surveyor asked, How did Resident #1 get back to the facility? LPN #1 replied, The DON brought her back to the facility. The Surveyor asked, was Resident #1 seen by a doctor? LPN #1 replied, The in-facility doctor checked her out. The Surveyor asked, Did Resident #1 have any injuries? The LPN #1 replied, No. The Surveyor asked, What interventions were put in place after the elopement? LPN #1 replied, Resident #1 was moved from 500 Hall to 200 Hall, the secure unit, every 15-minute checks were done for maybe a day or two, not sure. The Surveyor asked, Has Resident #1 had any exiting seeking behaviors or eloped since the incident on 05/13/23? LPN #1 replied, No.
k. On 06/06/23 at 1:19 PM, the Surveyor asked the DON, What occurred on 05/13/23 regarding Resident #1? The DON stated, [named LPN #1] called me and said they initiated a search and could not find her. The Surveyor asked what time she was notified. The DON stated, 5:26 PM. I live 3 min away. I called [named SSD] and she called the daughter in law [named]. Staff told me they had been calling [named Resident #1] for a while. The Surveyor asked what time she called the SSD. The DON stated, 5:28 PM I called [named SSD] and tried to call [named Administrator]. [named LPN #1] told me she had tried to call [named Administrator] but could not reach her. The Surveyor asked what time she called the Administrator. The DON stated, 5:29 PM. The [named SSD] told me the family told her that they knew where she was, and I went and followed her back here. The Surveyor asked what time she arrived at Resident #1 and where she was located. The DON stated, Honestly about 5:30 or so. She was on a side street, [named street], and she was on the phone with her [family member] when I pulled up. I escorted her back. The Surveyor asked how long she was missing. The DON stated, [named Administrator] stated she went out about 3:30 PM, so about 2 hours. The Surveyor asked if staff are responsible for knowing where residents are at all times. The DON stated, Yes.
l. On 06/06/23 at 2:26 PM, the Surveyor asked the Administrator about the afternoon temperature on 05/13/23. The Administrator stated, 83 degrees. The Surveyor asked what she utilized to determine this. The Administrator stated, [named internet search engine]. The Surveyor asked if the address on Resident #1's face sheet was correct. The Administrator stated, Yes. The Surveyor asked what the distance was to Resident #1's home where she obtained the electric wheelchair. The Administrator stated, Exactly 1 mile. The Surveyor asked one way or total distance. The Administrator stated, One way. The Surveyor asked what she utilized to determine the distance. The Administrator stated, [named Map and location application]. The Surveyor asked what hazards were between the facility and Resident #1's home. The Administrator stated, Traffic is all I know of for sure. The Surveyor asked how the facility ensured door codes were not obtained by the residents. The Administrator stated, We change them monthly, and staff are trained to know they are kept confidential. Families know them, so that cannot be controlled. If we find out someone knows the code that should not, we immediately change them.
m. The facility's policy titled, Elopements, provided by the Administrator at 9:54 AM documented, .4. If an employee discovers that a resident is missing from the facility, he/she shall .b. initiates a search of the building(s) and premises .c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials .
Mar 2022
7 deficiencies
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 interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the use of an anticoagulant medication for 1 (Resident #36) of sampled r...
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Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the use of an anticoagulant medication for 1 (Resident #36) of sampled resident who had a physician order for anticoagulant. This failed practice had the potential to affect 10 (R#32, R30, R33, R49, R#41, R#11, R#36, R#36, R#23, R#44) sampled residents who had Physician order for anticoagulant per list provided by the DON (Director of Nursing) on 3/25/22. The findings are:
Resident #36 had diagnoses of Chronic Atrial Fibrillation. The Quarterly MDS with an Assessment Reference Date of 2/10/22 documented the resident scored 4 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status and did not take an anticoagulant.
a. On 03/22/22 at 02:43 PM, the physician's orders documented, .Eliquis Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day related to CHRONIC ATRIAL FIBRILLATION, UNSPECIFIED .start date 1.21.22 .
b. The February Medication Administration Record (MAR) documented the resident received Eliquis twice a day.
c. The Care Plan with a recent review date of 2/22/22 documented, .[R36] is on Anticoagulant therapy r/t [related to]: Atrial fibrillation .[R36] will be free from
discomfort or adverse reactions related to anticoagulant use through the review
date.
6. On 3/24/22 at 12:09 PM, the MDS Coordinator was asked, Is [R36] receiving Eliquis? She stated, Let me check .yes. She was asked, When did she start taking Eliquis? She stated, The order date was 1/21/22. She was asked, What is the classification of Eliquis? She stated, Anticoagulant. She was asked, When was her last MDS completed? She stated, 2/10/22. She was asked, Does her MDS document that she was receiving the anticoagulant? She stated, No, it is not. She was asked, Should it have documented that she was receiving an anticoagulant? She stated, Yes, It should have been. I don't know I how I missed that .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to ensure facial was removed to promote good personal hygiene for 1 (Resident #24) of 16 (Residents #R#31, R#3, R#27, R#30, R#25,...
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Based on observation, record review and interview, the facility failed to ensure facial was removed to promote good personal hygiene for 1 (Resident #24) of 16 (Residents #R#31, R#3, R#27, R#30, R#25, R#16, R#13, R#24, R#41, R#37, R#11, R#2, R#51, R#44, R#5, and R#56) sampled residents who required their face to be shaved. This failed practice had the potential to affect 16 (Residents #R#31, R#3, R#27, R#30, R#25, R#16, R#13, R#24, R#41, R#37, R#11, R#2, R#51, R#44, R#5, and R#56) who required their face to be shaved as documented on a list provided by the DON (Director of Nursing) on 3/25/22. The findings are:
Resident #24 had diagnoses of Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/26/22 documented the resident scored 15 (indicates cognitively intact) on a Brief Interview for Mental Status and required 2 plus persons assistance with personal hygiene, bed mobility and dressing.
a. A Care Plan, with a problem dated 1/24/22 that documented, [Resident (R) #24] has an ADL [Activities of Daily Living] Self Care Performance Deficit r/t [related to] Dementia . Interventions . PERSONAL HYGIENE/ORAL CARE: [Resident #24] requires staff participation with personal hygiene .
b. On 03/22/22 at 08:02 AM, there were multiple gray hairs under R24's chin.
c. On 03/23/22 at 08:32 AM, Resident #24 was asked, Do the staff assist you with grooming? R24 rubbed her chin and stated, .They are going to go to the dollar store as soon as they get somebody to do it to get some razors . That's my picture up there on my wall . That's how I always looked before.
d. On 3/24/22 at 10:20 AM, Certified Nursing Assistant (CNA) #1 was asked, Do you have razors available to shave the residents? She stated, yes. She was asked, Who is responsible for providing [R24's] ADLs/ hygiene care? She stated, She has a hospice aide that comes. She was asked, [R24] told me you all were out of razors, and she hasn't gotten her chin hairs shaved. CNA #1 stated, I will shave them today.
e. On 3/24/22 at 12:39 PM, the DON was asked, Who is responsible for ensuring the female residents do not have facial hair unless they want it? She stated, The aides. She was asked, Who is responsible for ensuring the facility has razors available? She stated, I do. She was asked, Do you have razors available now for the residents? She stated, Yes. She was asked, Should [R24] have multiple short chin hairs? She stated, Not if she doesn't want them.
f. A policy titled Shaving Residents that was provided by the DON on 3/25/22 documented, The purpose of this procedure is to provided cleanliness and provide skin care . The policy did not address unwanted facial hair on a female resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written, and posted menu to meet the nutritional needs ...
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Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written, and posted menu to meet the nutritional needs of the residents for 1 of 2 meals observed. This failed practice had the potential to affect 57 (total census 59) who received meals from the kitchen. The findings are:
1. On 3/21/22 at 11:40 AM, the food observed on the steam table was tater tot casserole, green beans, & garlic toast for all diets.
2. The Menu received from Dietary Manager (DM) #1 stated Lunch for Monday was:
a. REGULAR: Thin Crust Cheese Pizza, Garlic [NAME] Beans, Breadstick, Margarine, and Lemon Cake with Lemon icing
b. DYS ADV (Dysphasia Advanced): Cheese Ravioli w/Sauce, Garlic [NAME] Beans, Dinner Roll/bread, Margarine, & Lemon cake with lemon icing
c. PUREED: Cheese Ravioli w/sauce, Garlic [NAME] Beans, Breadstick, Margarine, & lemon cake with lemon icing
3. On 03/22/22 at 2:10 PM, DM #1 was asked for documentation of dietician approving change in menu for 3/21/22. DM #1 stated she did not have documentation. DM #1 showed the surveyor a log for previously dated changes approved by Dietician but not changes made on 3/21/22.
4. At 2:12 PM the Surveyor stated bread sticks and pizza were on menu but toast and tater tot casserole were served. DM #1 stated the residents complained about bread sticks and pizza. DM #1 was asked where the menu was posted. DM #1 stated it was posted in the dining room. DM #1 was asked if the changes were posted, and DM #1 stated they did not post the change. DM #1 stated the residents would find out the change when they received the menu cards to choose their choices for the meal.
5. On 3/23/22 at 10:55 AM, Resident Council President R#49 and R#32 & R#56, who attend meetings regularly, were asked if they liked pizza and breadsticks and if they would like to see that served. R32 & R56 stated they liked pizza and would like that on the menu and R49 stated he also likes pizza but was tube fed.
6. On 3/24/22 at 10:39 AM, the Menu policy received from DM #1 documented, 5. A registered Dietician/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus . 6. Menus will be served as written, unless a substitution is provided in response to a preference, unavailability of an item, or a special meal . 8. Menus will be posted in the Dining Services department, dining rooms, and resident/patient care areas.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to ensure kitchen lighting was in good repair and a hole in the laundry room was repaired to maintain a sanitary, comfortable, an...
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Based on observation, record review and interview, the facility failed to ensure kitchen lighting was in good repair and a hole in the laundry room was repaired to maintain a sanitary, comfortable, and home-like environment. Findings are:
1. On 03/21/22 at 11:40 AM, there were 5 partial-working ceiling lighting fixtures in the areas of dish cleaning, clean dish storage, and food storage in the kitchen. One metal light bar holder above the serving area had a duct tape covered end and one light tube was not working. Dietary Manager #1 (DM) was asked who takes care of repairing and replacing the lights and she stated maintenance. She was asked if maintenance had been notified to the lack of lighting, she stated, Not sure. I really hadn't noticed lately. I guess we just get used to it being this way.
2. On
3/22/22 at 2:27 PM, in the dryer room of the laundry room was a hole above the air conditioner 2 feet wide by 3 inches tall with dry, white spray foam dripping from the air conditioner. There were numerous pieces of dry spray foam on blankets folded under air conditioner. Laundry manager (LM) #1 was asked who was responsible for the repair, and he stated maintenance was. He was asked if maintenance was notified and LM #1 stated he was not sure.
3. On 3/24/22 at 8:35 AM, Laundry staff #2 asked how long the hole had been above air conditioner had been there. She stated Ever since I have worked here, Laundry Staff #2 was asked how long she had worked at facility, and she stated about 2 years. She was asked if she had ever noticed an issue with bugs or rodents and she stated she had not. She was asked if she felt the space above the air conditioner could allow bugs or rodents in and she stated No, she has not seen any.
On 3/24/22 at 10:12 AM, Maintenance Manager #1 (MM) was asked when he was notified about the opening, and he stated about 2-2 1/2 months ago. MM #1 stated he had tried to fill area with spray white stuff about 2 ½ months ago but it didn't work. MM #1 was asked to show logbook mentioned. MM #1 stated there was not much in it because he throws them away when he is done with them.
4. On 3/24/22 at 8:59 AM, Staff #4 was washing dishes and there were no lights above work area working.
5. On 3/24/22 at 9:59 AM, Dry goods food storage policy received from DM #1 stated, .4. The Dining Services Director or designee regularly inspects the dry goods storage area to ensure it is well lit DM #1 was asked her title and she stated Dietary Manager. She was asked who was the Dining Services Director, and DM #1 stated she guessed that was her.
6. On 3/24/22 at 10:12 AM, Maintenance Manager #1 (MM) was asked how often lighting was evaluated and non-working bulbs changed. MM #1 stated the CNAs (Certified Nursing Assistants) write it in his logbook on his door or if he sees lights out, he changes them. MM #1 was asked about the non-working bulbs and lights in the dining room and kitchen. MM #1 stated he was not aware of bulbs out in the dining room, but he was replacing a light in the kitchen today and re-wiring two others.
At 10:17 AM, MM #1 provided copies of logs he had. Maintenance logs dated 2/28/22 to 3/22/22 stated no reports of dining room or kitchen light maintenance requests.
7. On 3/24/22 at 10:20 AM, the Administrator was asked if she was aware of the non-working bulbs and lights in the dining room and kitchen and the hole to the outside in the laundry room. The Administrator stated she was aware of the kitchen lighting issue that happened yesterday afternoon because maintenance had accidentally cut a wire and now needed to install a new light and wrap wiring. Administrator was asked what she felt would possibly happen with the hole to the outside above the air conditioning unit in the laundry room. Administrator stated possible that insects or rodents and pests could come in. The Administrator was asked how staff reported concerns and how she monitored what the maintenance manager completed. The Administrator stated she performed rounds to check on what he completed and was not aware until today that he threw away all of the maintenance logs when he is finished. The Administrator was asked to provide maintenance policy.
At 12:52 PM, the Administrator sent and email stating the facility did not have a maintenance policy
8. On 3/23/22 at 8:35 AM, Environment policy received from DM #1 stated 1. Dietary Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including .lighting .
CONCERN
(E)
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 observations, record reviews, and interviews the facility failed to ensure physician orders were implemented to prevent further complications for 1 of 1 (Resident #15) who had a physician or ...
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Based on observations, record reviews, and interviews the facility failed to ensure physician orders were implemented to prevent further complications for 1 of 1 (Resident #15) who had a physician or for TED (Thrombo-Embolus Deterrent) stocking and Geri Sleeves. The findings are:
Resident #15 had diagnoses of Heart Failure, Hypertension, Non-Alzheimer's Dementia, Anxiety Disorder and Psychotic Disorder. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/22 documented the resident scored 5 (0-7 indicated severe cognitive impact) on a Brief Interview for Mental Status (BIMS) and required no set up or physical help from staff for dressing, and one person assist for toileting.
a. A physician's order documented, .Geri-sleeves or long sleeves at all times every shift . with a start date of 1/6/2020 . TED stockings to BLE [bilateral lower extremities] Q [every] AM [morning] before getting out of bed and remove qhs [every hour of sleep] two times a day . With a start date of 9/10/2019.
b. On 03/22/22 at 8:00 AM, Resident #15 was sitting in a chair in her room wearing a short-sleeved t-shirt. She was not wearing Geri- sleeves or long sleeves. The TED stockings were not on her lower extremities.
c. On 03/23/22 01:32 PM, the resident was sitting in her room. The resident pulled up her pant legs and was wearing yellow nonskid socks. She did not have on TED stockings. She stated, Why am I here? . Where am I at?
d. On 3/23/22 a current Care Plan documented, [R15] is on Diuretic therapy r/t [related to] : hypertension . Staff will encourage [R15] to allow TED stockings to be applied in am and off at hs [hour of sleep] . [R15] is at risk for impairment to skin integrity . The Care Plan did not mention Geri- sleeves nor that the resident ever refused to wear the TED stockings.
e. On 3/24/22 at 10:22 am, Certified Nursing Assistant (CNA) #2 was asked, What area of the facility do you work in? She stated she worked in the secured unit. She was asked, Who is responsible for assisting [R15] with putting on her Geri sleeves? She stated, She doesn't have any that I know of. She was asked, Who is responsible for ensuring [R30] has her TED stockings on while she is up? She stated, She dresses herself, but sometimes she refuses them. She was asked, Has she had them on this week? She stated, To be honest I don't know . She is usually pretty good about putting them on herself .
f. On 3/24/22 at 10:29 am, CNA #3 was asked, What area do you work in? She stated, I've worked back here [secured unit] first shift for 4 years . She was asked, Has [R15] had her Geri -sleeves on or her TED stockings on this week? She stated, Can't say for sure .she usually dresses herself .I don't think she has Geri sleeves .sometimes she refuses the TED stockings .
g. On 3/24/22 at 12:39 pm, the Director of Nursing (DON) was asked, What is [R15's] orientation? She stated, She knows her name. She was asked, Who is responsible for ensuring her physician's orders are being followed? She stated, The nurses. She was asked, What is the physicians order for [R15's] TED stockings and Geri-sleeves or long sleeves? She stated, She should be wearing them during the day. She was asked, Why does she require TED stockings? She stated, She has some edema She was asked, Why does she require Geri sleeves? She stated, She was bumping her arms into random things.
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 medication were not stored at 32 degrees Fahrenheit or below to maintain the integrity of the medications stored in 1 o...
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Based on observation, record review and interview, the facility failed to ensure medication were not stored at 32 degrees Fahrenheit or below to maintain the integrity of the medications stored in 1 of 1 refrigerator.
On 03/24/22 at 08:02 a.m., the facility's medication room and refrigerator was inspected with Director of Nursing (DON). The refrigerator temperature was noted to be 32 degrees. The DON was asked, At what temperature does liquid freeze? She stated, 32 degrees.
a. The refrigerator contained, Glatapa 40mg 7 syringes, Hep B 4 vials, Pneumovax 23 syringe -11,Prevnar 20 syringe -3, Lantus 100 units - 4 pens, Trulicity 0.75 mg 3 pens, Lantus 100 units - 4 pens, Levemir 100 units - 3 pens ,Novolog - 2 pens, Levemir flextouch - 4 pens, Victoza 18 mg/3 ml - 2 pens, Novolog 100 mg/ml - 1 vial. All medication listed had a red sticker that documented, DO NOT FREEZE, keep in refrigerator.
b. On 03/24/22 at 9:57 a.m., review of refrigerator temperature logs show that on March 1, 2, 3, and 4th. the temperature of the refrigerator was 32 degrees or below. On March 7, 8 and 9th was also 32 degrees or below. The dates of the 12th thru the 17th of the month were 32 degrees or below. The 19th thru 23rd were below acceptable temperature.
c. On 03/24/22 at 09:57 a.m., the Director of Nursing was asked, When should staff report abnormal temperatures of the refrigerator? She stated, They should have reported it immediately.
d. On 03/24/22 at 11:00 a.m., the Administrator was asked, Who is responsible for checking the refrigerator temperature logs? She stated, We all should be.
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, and record review the facility failed to ensure equipment was clean and dry between uses; staff used sanitary procedures when serving food; the walls, lights, sprinkle...
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Based on observation, interview, and record review the facility failed to ensure equipment was clean and dry between uses; staff used sanitary procedures when serving food; the walls, lights, sprinkler heads, and stove were clean; staff washed the hands prior to preparing food; outdated and spoiled food were removed from use; and staff were hair nets and covered all of their hair to provide a sanitary environment and prevent the potential for food borne illness. The findings are:
1. On 03/21/22, the following observations were made:
a. At 11:40 AM, [NAME] #2 obtained small pans for pureed foods with his fingers, non-gloved, down inside pans. After [NAME] #2 pureed the casserole he wiped his hand on his chest. [NAME] #2 cleaned the food processor and left 1-2 tablespoons of sanitation water in processor bowl. DM #1 was asked to check the container and see how much water was in bowl. DM stated there was still 2 teaspoons of liquid in bowl and dumped it out in the sink. The [NAME] was not wearing gloves and picked up 5 slice of bread out of bag to puree and laid bread slices against food remnant covered chest, while he twist-tied the bread bag closed. The food processor parts were dripping with water between uses.
Kitchen staff #3 was observed putting thumb on plates while holding and placed a piece of cake partially on thumb and then pulled thumb from under cake piece and covered with plastic wrap.
b. At 11:56 AM, the paint was peeling and flaking off the wall near the dish washer and onto stainless area where dishes were sitting. There was brown and gray fuzzy build up hanging off of the sprinkler heads in the kitchen.
c. At 12:08 PM, there was a dirt buildup hanging from edge of the light and around light on ceiling. There was brown and gray fuzzy build up hanging from a vent and brown box mounted above the steam table where food was halfway covered with lids. There was an opening in the ceiling to attic/crawl space above storage area for clean dishes, with no door or cover noted, with grayish fuzzy substance hanging from edges
d. At 12:10 PM, while re-pureeing food, [NAME] #2 began coughing and exited area quickly out of sight of and was heard making gagging sounds. DM #1 began re-pureeing and [NAME] #2 joined. There was no observation of [NAME] #2 washing his hands upon return.
d. At 12:14 PM, on the stove were food particles and blackish brown, thick, shiny build up around burners. DM #1 reported a new oven/stove was ordered today and should be arriving in the next few days due to burners not lighting appropriately. DM #1 had to light stove burner with handheld lighter.
e. At 12:30 PM, onions on the dry food storage shelves had black, soft, mold-like areas and 3 inch long green growths on them.
f. At 12:35 PM. in the single door freezer there were ice cream sandwiches dated as received 5/26 (21). There were grayish, iridescent, leathery ice crystals formed on sandwiches. DM #1 stated one could be opened to check. Some of the dark brown chocolate parts of the sandwich had lighter brownish-gray patches. DM #1 stated she should probably throw them away.
g. At 12:39 PM, the triple door freezer contained:
1) Loose hamburger patty with grayish, iridescent, leathery ice crystals in box outside of bag that held other patties.
2) A box of peas with grayish, iridescent, leathery ice crystals dated opened 3/16 in open bag not tied.
3) Venom energy drink found in freezer on shelf not dated. DM #1 stated it was an employee's drink.
4) A box of French toast with grayish, iridescent, leathery ice crystals dated 3/16 found open in a bag not tied.
5) A box of cookie dough with grayish, iridescent, leathery ice crystals dated 3/16 found open not tied.
h. At 12:41 PM, DM #1's hair net had hair in back hanging out and kitchen staff #3 had hair hanging out in the back and 4-5 inches out on the sides.
3. On 03/22/22 at 2:10 PM, DM #1 was asked to describe what she saw on the ceiling and around the lights and she stated, it looks like cobwebs, dirt, and well, just filthy and needs cleaned. DM #1 was asked how often the walls, vents, ceiling are cleaned the DM #1 stated monthly, but has not been done this month yet. Policies for storage and cleaning requested from DM #1.
2. On 3/23/22 at 8:35 AM Policy for Cold Food storage stated, 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
The Environment policy received from DM #1 stated, 1. Dietary Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.
Equipment cleaning received from DM #1 stated, 2. All staff members will be properly trained in the cleaning and maintenance of all equipment . 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or maintenance Director as needed . 6. The Dining Services Director will notify the Administrator when repairs are completed.
3. On 3/24/22 at 8:59 AM, DM #1 was in the kitchen without hair net.
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?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 41% turnover. Below Arkansas's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 14 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
Bottom line: Mixed indicators with Trust Score of 61/100. Visit in person and ask pointed questions.
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About This Facility
What is Prairie Grove, Llc's CMS Rating?
CMS assigns PRAIRIE GROVE HEALTH AND REHABILITATION, LLC an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Arkansas, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Prairie Grove, Llc Staffed?
CMS rates PRAIRIE GROVE HEALTH AND REHABILITATION, LLC's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 41%, compared to the Arkansas average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Prairie Grove, Llc?
State health inspectors documented 14 deficiencies at PRAIRIE GROVE HEALTH AND REHABILITATION, LLC during 2022 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 12 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Prairie Grove, Llc?
PRAIRIE GROVE HEALTH AND REHABILITATION, 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 STEIN LTC, a chain that manages multiple nursing homes. With 70 certified beds and approximately 62 residents (about 89% occupancy), it is a smaller facility located in PRAIRIE GROVE, Arkansas.
How Does Prairie Grove, Llc Compare to Other Arkansas Nursing Homes?
Compared to the 100 nursing homes in Arkansas, PRAIRIE GROVE HEALTH AND REHABILITATION, LLC's overall rating (4 stars) is above the state average of 3.1, staff turnover (41%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Prairie Grove, Llc?
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?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Prairie Grove, Llc Safe?
Based on CMS inspection data, PRAIRIE GROVE HEALTH AND REHABILITATION, LLC 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 4-star overall rating and ranks #1 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 Prairie Grove, Llc Stick Around?
PRAIRIE GROVE HEALTH AND REHABILITATION, LLC has a staff turnover rate of 41%, which is about average for Arkansas nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Prairie Grove, Llc Ever Fined?
PRAIRIE GROVE HEALTH AND REHABILITATION, LLC has been fined $7,446 across 1 penalty action. This is below the Arkansas average of $33,153. 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 Prairie Grove, Llc on Any Federal Watch List?
PRAIRIE GROVE HEALTH AND REHABILITATION, 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.