Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Premier At The Springs during CMS and state inspections, most recent first.
The facility did not complete a thorough facility assessment to determine appropriate staffing and resource needs for all shifts, nor did it develop a plan for staff recruitment and retention. The assessment team lacked input from direct care staff and residents, and staffing decisions were based on census and minimal requirements rather than resident acuity or needs. Leadership interviews confirmed the facility assessment was not used to guide staffing or operational planning.
Staff failed to follow infection control protocols during wound care for a resident with a surgical wound, including not using barriers, reusing gauze, and improper glove changes. Additionally, two glucometers used for blood sugar checks on multiple residents were not disinfected according to manufacturer guidelines, as an LPN used alcohol pads instead of the required germicidal wipes.
Two residents did not receive necessary assistance with personal hygiene and nail care, despite being unable to perform these activities independently. One resident, with a recent amputation and diabetes, was not assisted with shaving as requested, resulting in significant facial hair growth. Another resident, with paralysis and chronic illness, had long, curled, and discolored toenails that were not addressed despite repeated reports to staff. Facility policies and staff interviews confirmed the expectation for such care, but it was not provided in these cases.
A resident with severe cognitive impairment and on hospice care was the subject of an abuse allegation that was not reported to law enforcement as required by facility policy. Despite internal investigation procedures, there was no evidence of a police report or incident number, and interviews confirmed that the required notification to law enforcement did not occur.
A resident with severe cognitive impairment and limited mobility was observed using a wheelchair that remained visibly dirty over several days, with staff interviews confirming that cleaning was a night shift CNA responsibility. The facility lacked policies or in-service training for wheelchair cleaning, contributing to the failure to maintain necessary equipment in a clean and sanitary state.
The facility did not consistently post all required daily nurse staffing information, specifically omitting the actual hours worked by licensed personnel and, at times, the facility census. Observations confirmed that only staff assignments and numbers by category were displayed, and interviews with the DON and Administrator indicated the postings were intended for staff assignment purposes rather than full regulatory compliance.
A facility failed to accurately complete the MDS for a resident on hospice care. The resident, admitted with Moderate Protein-Calorie Malnutrition, had elected hospice services, but the MDS inaccurately indicated no prognosis of less than six months to live. The error was identified during a review with the MDS Coordinator, who confirmed the mistake.
A resident with respiratory failure and sleep apnea had a physician's order for oxygen therapy, but the care plan did not reflect this need. The MDS indicated the resident received oxygen, yet the care plan was not updated to include this treatment, contrary to facility policy.
The facility failed to ensure proper food storage and sanitation practices, including uncovered food items, improper refrigerator temperatures, expired food, unsanitary kitchen conditions, and inadequate hand hygiene and glove use by staff. These deficiencies had the potential to affect 108 residents.
The facility failed to maintain privacy and dignity for two residents. One resident was exposed during incontinence care without the privacy curtain being pulled, and another was transported uncovered on a shower bed. The CNAs involved acknowledged the lapses, and the DON confirmed the need for privacy measures.
The facility failed to accurately assess the comprehensive assessments for two residents. One resident with bipolar disorder was not correctly documented as PASSAR level II, and another resident with COPD was not accurately coded as a smoker in the MDS. The DON confirmed these inaccuracies, and the facility did not provide the surveyor with an MDS coding policy.
A resident with severe cognitive impairment and a Stage 4 Pressure Ulcer did not receive proper nail care and shaving as per the care plan. Observations and interviews confirmed that the resident's nails were dirty, and his beard was untrimmed, despite facility policies and care plans specifying regular maintenance.
The facility failed to ensure hydration was available at all times for a resident with a diagnosis of constipation. The resident reported not having water all day and often lacking water on weekends. Observations confirmed the absence of water, and a CNA admitted being too busy to pass water that day. The DON confirmed that residents should always have water available.
The facility failed to provide clean oxygen tubing and proper storage for oxygen tubing for two residents on oxygen therapy. Oxygen tubing was observed lying on the floor in one resident's room and not stored in a storage bag for another resident. Staff confirmed that the tubing should be replaced if found on the floor and stored in a bag when not in use.
The facility failed to conduct a side rail assessment for a resident with a Stage 4 Pressure Ulcer, despite the resident being observed with bed rails up on multiple occasions. Staff confirmed the use of side rails without proper assessment, contrary to the facility's 'Bed Safety' policy.
The facility failed to reduce a resident's Sertraline dosage from 125 mg to 100 mg as recommended by the physician. Despite the DON signing the recommendation, the resident continued to receive the higher dosage, and the DON could not explain the oversight.
The facility failed to serve meals according to the planned menu, resulting in residents on mechanical soft diets receiving incorrect portions of pork chili Verde and blackened chicken breast. This affected the nutritional intake of 27 residents on mechanical soft diets and 7 residents on pureed diets.
The facility failed to maintain an effective pest control program, resulting in multiple flies being observed in various areas of the kitchen during meal preparation and serving. Despite regular pest control services, the issue was not addressed, leading to the observed deficiency.
The facility failed to ensure call lights were within reach for several residents, including those with severe cognitive impairments and incontinence issues. Observations showed call lights on the floor, out of reach, despite staff acknowledging the importance of accessibility. This deficiency highlights a lapse in accommodating residents' needs for assistance.
A facility failed to complete a self-administration safety screen for a resident with multiple diagnoses, allowing the resident to have undocumented over-the-counter medications on their nightstand. The medications were observed multiple times over several days, and a self-administration assessment was only completed after the surveyor's observations.
The facility failed to update a resident's care plan to reflect the presence of an indwelling catheter, despite the resident's history of urinary issues and a physician's order for the catheter. The MDS assessment confirmed the catheter's presence, but the care plan was not revised accordingly.
A resident with an indwelling urinary catheter received improper peri care, including incorrect wiping and lack of catheter securing, leading to potential risks of dislodging and trauma. The DON confirmed the correct procedures were not followed, and the facility's policy did not address the specific deficient practice.
Failure to Conduct Comprehensive Facility Assessment for Staffing and Resource Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not specify staffing requirements for day, evening, night, or weekend shifts based on the needs of the resident population. There was no documented plan for staff recruitment or retention, and the assessment team did not include direct care staff or resident representatives. The assessment relied on census numbers and minimal state requirements rather than a detailed analysis of resident acuity or specific care needs. Additionally, the assessment was not referenced by staff responsible for scheduling or staffing decisions. Interviews with facility leadership revealed a lack of understanding and utilization of the facility assessment in staffing and operational planning. The ADON and DON indicated that staffing decisions were based on corporate direction and minimal state formulas, without reference to the facility's own assessment. The Administrator also did not use the assessment to determine staffing needs, instead relying on general federal requirements. The facility's policy required a detailed review of resident acuity and available resources, but this was not reflected in the actual assessment or in practice.
Infection Control Deficiencies in Wound Care and Glucometer Cleaning
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care and blood glucose monitoring. During wound care for a resident with a surgical wound and wound vacuum on the left foot, the LPN did not follow established infection control protocols. Supplies were placed directly on an un-sanitized over-bed table without a barrier, and no protective barrier was placed under the resident's foot, resulting in purulent drainage contaminating the bed linen. The LPN reused gauze pads to clean the wound, did not change gloves between removing the old dressing and cleaning the wound, and used scissors that had been placed on an un-sanitized surface to cut wound care materials. After the procedure, items such as the skin prep spray and scissors were handled with ungloved hands and placed on the treatment cart without immediate sanitization. Additionally, the facility failed to ensure that glucometers were cleansed according to the manufacturer's guidelines between resident uses. An LPN was observed performing fingerstick blood sugar checks on multiple residents using two glucometers, but did not properly disinfect the devices between uses. Instead of using a registered disinfectant or germicidal wipe as required by the manufacturer, the LPN used alcohol pads to clean the glucometers and only did so after multiple uses. The LPN stated that she had been instructed by management to use alcohol wipes, although the DON was unaware of this change and confirmed that germicidal wipes were the expected method. Facility policy for wound care required establishing a clean field, using barriers to protect linens, performing hand hygiene, changing gloves appropriately, and sanitizing reusable items before returning them to the treatment cart. The policy for glucometer cleaning aligned with the manufacturer's guidelines, which specified the use of a registered disinfectant or bleach solution. These protocols were not followed during the observed incidents, resulting in deficiencies in infection prevention and control.
Failure to Provide Personal Hygiene and Nail Care Assistance
Penalty
Summary
The facility failed to provide necessary personal care and assistance with activities of daily living for two residents who were unable to perform these tasks independently. One resident, admitted with multiple diagnoses including a recent amputation, diabetes, and vascular disease, was documented as requiring moderate assistance with personal hygiene. Despite being cognitively intact and expressing a clear preference to remain clean-shaven, the resident reported only receiving a shave once in the facility's barber shop, for which they had to pay. Over several days of observation, the resident continued to have a significant growth of facial hair, and staff interviews confirmed that CNAs were responsible for assisting with shaving but had not consistently provided this care as requested by the resident. Another resident, admitted with a history of stroke, paralysis, and chronic illnesses, was identified as having a self-care deficit and required assistance with nail care. Although records indicated that the resident's nails were checked regularly, direct observation revealed that the resident's toenails were long, curled, discolored, and jagged. The resident confirmed that the condition of their toenails was bothersome and had been reported to nursing staff multiple times. Interviews with CNAs and nursing staff revealed that there was an established process for nail care, particularly for residents with diabetes or other complicating conditions, but the process was not followed in this case. The resident was not listed for podiatry care, despite the need for professional attention to their toenails. Facility policies required that residents unable to perform activities of daily living independently receive necessary services to maintain grooming and hygiene, and that foot care be provided in accordance with professional standards. Staff interviews confirmed awareness of these policies and the procedures for providing or escalating care needs. However, the failure to provide timely and appropriate assistance with shaving and toenail care for these two residents resulted in unmet personal care needs, as directly observed and reported during the survey.
Failure to Report Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to ensure that an abuse allegation involving a resident with severe cognitive impairment was reported to law enforcement as required by facility policy. The resident, who was receiving hospice care and had significant cognitive and communication deficits, was the subject of an internal abuse investigation initiated after an allegation was reported. Upon review of the facility’s investigation records, there was no evidence of a police report or incident number related to the allegation. Interviews with the Administrator and DON confirmed that reporting abuse allegations to law enforcement was part of the facility’s established process. However, the police officer identified by the Administrator as having received the report stated that no such report was made on the specified day, nor was there any record of a report for the entire month in question. The facility’s policy explicitly required immediate notification of law enforcement officials in cases of suspected abuse, neglect, exploitation, or misappropriation.
Failure to Maintain Resident Wheelchair in Clean and Sanitary Condition
Penalty
Summary
The facility failed to ensure that necessary equipment, specifically a resident’s wheelchair, was maintained in a clean and sanitary condition. Over multiple days of observation, the wheelchair assigned to a resident with severe cognitive impairment and limited mobility was found to have visible dirt, white and brown flakes, and crumbs caked on the seat cushion and frame. The resident, who had diagnoses including hypertensive heart disease, vascular dementia, and acute kidney failure, reported that the wheelchair had been dirty for a long time. Staff interviews confirmed that it was the responsibility of night shift CNAs to check and clean wheelchairs, but the resident’s wheelchair remained unclean over several days. Further review revealed that the facility did not have any policies or in-service training related to environmental or wheelchair cleaning. Multiple staff members, including CNAs, LPNs, and the DON, acknowledged that cleaning wheelchairs was part of the night shift CNAs’ duties, but the lack of a formal policy or training contributed to the ongoing issue. The deficiency was identified through direct observation, resident and staff interviews, and review of facility records.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information as mandated. Observations on two consecutive days revealed that while the facility posted staff assignments and the number of licensed staff by category (RN, LPN, CNA), they did not consistently post the facility census or the actual hours worked by licensed personnel. On one day, the census was missing, and on the next, although the census was posted, the actual hours worked were still not displayed. Interviews with the Director of Nursing and the Administrator confirmed that the posted information was intended to show staff assignments and numbers, but did not include all required elements such as actual hours worked.
Inaccurate MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the Minimum Data Set (MDS) for a resident, which is essential for planning and providing necessary care and services. The resident was admitted with a diagnosis of Moderate Protein-Calorie Malnutrition and had elected hospice services. However, the significant change MDS assessment inaccurately marked section J1400 as 'No,' indicating the resident did not have a prognosis of less than six months to live, despite being on hospice care. This error was identified during a review of the MDS with the MDS Coordinator, who acknowledged the mistake and confirmed that section J1400 should have been marked 'Yes' to reflect the resident's hospice status and prognosis.
Failure to Include Oxygen Therapy in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for a resident who was admitted with diagnoses of respiratory failure and sleep apnea. The resident had a physician's order for oxygen at two liters per minute as needed, which was documented in the Order Summary Report. However, the care plan dated October 21, 2024, did not reflect that the resident received oxygen as needed, despite the Minimum Data Set (MDS) indicating that the resident was receiving oxygen while in the facility. Interviews with the MDS Coordinator and the Director of Nursing confirmed that they were aware of the physician's order for oxygen and that the MDS indicated the resident received oxygen. Both acknowledged that the care plan should have included this information but did not. The facility's policy on comprehensive, person-centered care plans requires that they include measurable objectives and timeframes and describe the services to be furnished to meet the resident's needs, which was not adhered to in this case.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices in the kitchen and pantry areas. Observations revealed that food items in the refrigerator and freezer were not covered or sealed, including Parmesan cheese, sausage patties, chicken, cobbler crust dough sheets, dinner dough, egg rolls, broccoli, leftover spaghetti, and mixed vegetables. Additionally, the temperature of the upright refrigerator was found to be 51.8 degrees Fahrenheit, which is above the recommended storage temperature. Expired food items, such as vanilla med pass 2.0, were also found in the pantry and medication rooms, and the ice machines in various locations had wet sage-colored residues, indicating inadequate cleaning practices. The kitchen environment was unsanitary, with peeling paint, rust, dirt, and lint accumulation on walls, air vents, and light fixtures. The floor in the storage room had stains, and the baseboard was loose, exposing the cement underneath. Staff members were observed not following proper hand hygiene and glove use protocols, such as not washing hands before handling clean equipment or food items, and contaminating gloves before food preparation. These deficiencies had the potential to affect 108 residents who received food from the kitchen.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain privacy and dignity for two residents. Resident #9, who had a history of urinary tract infection, overactive bladder, retention of urine, and acute cystitis, was observed with her blanket pulled back and incontinence brief detached without the privacy curtain being pulled. This exposed the resident to her roommate and anyone entering the room. The CNA involved acknowledged that the privacy curtain should have been pulled before providing care. Resident #13, diagnosed with paraplegia and quadriplegia, was observed being transported on a shower bed down the hall wearing only a hospital gown, without any covering. The CNAs involved admitted they were aware the resident should have been covered but cited reasons such as lack of available blankets and time constraints. The Director of Nursing confirmed that residents should be covered during transport to maintain privacy and dignity. The facility's policy on Resident Rights mandates that all residents be treated with kindness, respect, and dignity, including the right to privacy and confidentiality.
Inaccurate Comprehensive Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess the comprehensive assessment for two residents, leading to deficiencies in their care plans. Resident #52, diagnosed with bipolar disorder, depression, and anxiety disorder, was documented as having severe cognitive impairment on the Brief Interview of Mental Status (BIMS). However, the Minimum Data Set (MDS) Coordinator was unaware that Resident #52 was considered by the state as PASSAR level II, and this information was not reflected in the electronic records. The Director of Nursing (DON) confirmed that the comprehensive assessment did not accurately reflect Resident #52's PASSAR level II status. Resident #90, diagnosed with depression, old myocardial infarction, and chronic obstructive pulmonary disease (COPD), was documented as a smoker in the Smoking Safety Screen and care plan. However, the Significant Change Minimum Data Set (MDS) did not indicate that Resident #90 was a smoker. The MDS Coordinator confirmed that this information was not coded correctly in the comprehensive assessment. The DON also confirmed the inaccuracy, and the facility did not provide the surveyor with an MDS coding policy or the relevant section of the Resident Assessment Instrument manual used for coding.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to ensure that Resident #104 received proper care for activities of daily living, specifically in maintaining clean nails and providing regular shaves. Resident #104, who has a diagnosis of a Stage 4 Pressure Ulcer in the sacral region and severe cognitive impairment, required substantial assistance with bathing. Despite this, observations on multiple occasions revealed that the resident's nails had a black substance underneath, and his beard was approximately 2 inches long. The resident confirmed that he had not been shaved since his admission and that staff did not clean his nails. Facility policies dated 05/08/2024 for shaving and nail care were reviewed, indicating the importance of cleanliness and infection prevention. However, interviews with staff, including a Certified Nurse Aid (CNA) and the Director of Nursing (DON), confirmed that the resident's nails and beard were not being maintained as per the care plan, which specified nail cleaning and shaving on Tuesdays, Thursdays, and Saturdays. The CNA acknowledged the need for nail cleaning and shaving, and the DON confirmed the expected frequency of these tasks, highlighting a clear lapse in the execution of the resident's care plan.
Failure to Ensure Hydration Availability
Penalty
Summary
The facility failed to ensure hydration was available at all times for Resident #69, who had a diagnosis of constipation and was cognitively intact with a BIMS score of 15. On 5/05/24 at 11:58 AM, Resident #69 informed the surveyor that they had not had any water all day and often lacked water on weekends. At 12:30 PM and 1:40 PM on the same day, it was observed that Resident #69 still did not have water available. Certified Nurse Aide #11 admitted that she had not had a chance to pass water that day due to being busy, although she usually did so twice a day. The Director of Nursing confirmed that residents should have water available at all times.
Failure to Provide Clean and Properly Stored Oxygen Tubing
Penalty
Summary
The facility failed to provide clean oxygen tubing and proper storage for oxygen tubing for two residents on oxygen therapy. On multiple occasions, a surveyor observed oxygen tubing lying on the floor in Resident #32's room. When questioned, a CNA stated that the appropriate action would be to notify the nurse, and the DON confirmed that the tubing should be immediately replaced if found on the floor. Additionally, the facility's oxygen administration policy was provided by the DON. For Resident #97, who had a diagnosis of Moderate Persistent Asthma and a severe cognitive impairment as indicated by a BIMs score of 00, the surveyor observed the oxygen tubing not being stored in a storage bag when not in use. The tubing was found on top of the oxygen machine on multiple occasions. Both RN #1 and the DON confirmed that the tubing should be stored in a storage bag when not in use. These observations indicate a failure to adhere to proper respiratory care protocols for residents on oxygen therapy.
Failure to Conduct Side Rail Assessment for Resident
Penalty
Summary
The facility failed to ensure bed rails were not used for Resident #104 without a side rail assessment to prevent potential accidents. Resident #104, who had a diagnosis of Pressure Ulcer Sacral Region Stage 4, was observed with bed rails up on multiple occasions. The Medicare-5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/08/24 did not indicate that Resident #104 used side rails, and a side rail assessment dated [DATE] also indicated no use of bed rails. Despite this, Resident #104 was observed with bed rails up on 5/05/24, 5/06/24, and 5/07/24. Certified Nurse Aide (CNA) #11 confirmed that Resident #104 had been using side rails since admission. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the use of side rails without a proper assessment. The facility's policy titled 'Bed Safety' requires an interdisciplinary assessment, consultation with the attending physician, and input from the resident or legal representative if side rails are used.
Failure to Implement Gradual Dose Reduction for Antidepressant Medication
Penalty
Summary
The facility failed to implement a gradual dose reduction for a resident diagnosed with Major Depressive Disorder. Despite a physician's recommendation to reduce the resident's Sertraline dosage from 125 milligrams to 100 milligrams daily, the reduction was not carried out. The Director of Nursing (DON) signed the recommendation, but the resident continued to receive the original dosage of 125 milligrams as documented in the Medication Administration Records for April and May 2024. Both the Licensed Practical Nurse (LPN) and the DON confirmed that the resident was still receiving the higher dosage, and the DON was unable to explain why the physician's order was not implemented. The deficiency was identified during a review of the resident's records and interviews with the facility staff. The resident, who scored 13 on the Brief Interview for Mental Status (BIMs), indicating cognitive intactness, had been on Sertraline since June 2023. The failure to reduce the dosage as recommended by the physician highlights a lapse in the facility's medication management and order implementation processes. The DON acknowledged the oversight but did not provide a reason for the failure to update the medication order in the system.
Failure to Serve Meals According to Planned Menu
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents. Specifically, for two observed meals, the facility did not provide the correct portions of pork chili Verde and blackened chicken breast to residents on mechanical soft diets. On 05/07/24, the menu indicated that residents on mechanical soft diets should receive 3/4 cup of pork chili Verde. However, the dietary employee used a 6-ounce spoon to prepare the servings, and only 7 servings were prepared instead of the required amount. Additionally, the dietary supervisor confirmed that they ran out of mechanical soft meat during the lunch meal, and the dietary employee could not recall the exact portion sizes served to each resident. On 05/08/24, the menu indicated that residents on mechanical soft diets should receive 4 ounces of blackened chicken breast. However, the dietary employee used a 2-ounce spoon to serve the chicken, providing only one serving to each resident. These actions resulted in the residents not receiving the appropriate portions as per the planned menu, potentially affecting the nutritional intake of 27 residents on mechanical soft diets and 7 residents on pureed diets.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to ensure an effective pest control program was maintained to keep the facility free of pests. During an observation on 05/07/24 at 10:50 AM, multiple flies were seen in various areas of the kitchen during meal preparation and serving. Specifically, flies were observed on a cart by the food preparation sink, on the wall near the dishwashing machine, by the plate warmer, and flying around the food preparation area. Further observations at 11:26 AM and 11:53 AM revealed additional flies on clean dish racks, a box of iodized salt, a window by the food preparation counter, a menu, a microwave, and a refrigerator. The Dietary Supervisor confirmed the presence of flies and noted that the issue had recently started due to warmer weather and flies being outside the back door. The facility's pest control records indicated that monthly pest control services were performed, but flies were not reported in the documentation. The records from 02/22/24, 02/26/24, 03/21/24, and 04/22/24 showed that the pest control service focused on roach activity and exterior bait stations, with no mention of flies. Despite the regular pest control services, the facility did not effectively address the fly infestation in the kitchen, leading to the observed deficiency.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for four out of five residents reviewed for call light accessibility. Observations by the surveyor revealed that multiple residents, including those with severe cognitive impairments and incontinence issues, did not have their call lights within reach. For instance, one resident with a history of repeated falls and severe cognitive impairment was observed multiple times with the call light on the floor, out of reach, despite being awake and in bed. Another resident, who was cognitively intact, expressed frustration over the call light being on the floor and not being answered promptly. Interviews with CNAs and the Director of Nursing confirmed the importance of ensuring call lights are within reach to prevent risks such as falls, dehydration, and skin breakdown. Despite this understanding, the surveyor's observations indicated a consistent failure to adhere to this practice, as evidenced by the repeated instances of call lights being inaccessible to residents. This deficiency highlights a significant lapse in the facility's responsibility to accommodate the needs and preferences of its residents, particularly in ensuring their ability to call for assistance when needed.
Failure to Complete Self-Administration Safety Screen
Penalty
Summary
The facility failed to complete a self-administration safety screen for a resident (Resident #27) to ensure that the resident could safely administer medication. The resident had several diagnoses, including hypertension, chronic kidney disease stage 4, old myocardial infarction, chronic obstructive pulmonary disease, atrial fibrillation, and benign prostatic hyperplasia with lower urinary tract symptoms. Despite these conditions, the resident had multiple over-the-counter medications on their nightstand, including allergy relief medication, lidocaine gel, and antifungal powder, which were not documented in the physician's orders. The resident also had an antacid and cold and flu syrup in the nightstand, which were confirmed by an LPN. The resident's care plan indicated that medications should be administered in accordance with the physician's orders and the resident's ability to safely take them, but no self-administration assessment had been completed until after the surveyor's observations. The surveyor observed the medications on the resident's nightstand multiple times over several days, indicating that the medications were consistently accessible to the resident without proper assessment. The Director of Nursing confirmed that a self-administration assessment was only completed after the surveyor's observations. The facility's policy on self-administration of medications states that residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe, which was not adhered to in this case.
Failure to Update Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that the care plan for a resident was revised to reflect the presence of an indwelling catheter. The resident had a history of urinary tract infection, overactive bladder, retention of urine, and acute cystitis. The physician's order indicated the use of a 16 French indwelling urinary catheter with a 10 cubic centimeter balloon. The Minimum Data Set (MDS) assessment confirmed the resident had an indwelling catheter and was always incontinent of bowel. Despite this, the care plan, last revised on 4/30/24, did not accurately reflect the presence of the indwelling catheter, although it included interventions related to catheter care initiated on 04/04/2024. On 05/08/24, the Minimum Data Set Coordinator and the Director of Nursing confirmed that the care plan was not updated to reflect the resident's current condition. The facility's policy on comprehensive person-centered care planning states that assessments are ongoing and care plans should be revised as the resident's condition changes. This failure to update the care plan was identified during observations, interviews, and record reviews conducted by the surveyors.
Improper Incontinence and Catheter Care
Penalty
Summary
The facility failed to ensure proper incontinence care for a resident with an indwelling urinary catheter, leading to potential risks of dislodging and trauma. Resident #9, who had a history of urinary tract infections and other related conditions, was observed receiving improper peri care from CNA #8. The CNA wiped stool downward, which is incorrect, and did not ensure the catheter was positioned to prevent pulling and strain. Additionally, there was no stat lock in place to secure the catheter, increasing the risk of dislodging and trauma. The Director of Nursing confirmed that peri care should be performed correctly and that the catheter should be disconnected from the bed to prevent pulling. The facility's policy on urinary incontinence did not address the specific deficient practice observed. This failure in care had the potential to affect other residents with indwelling catheters in the same hall.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near North Little Rock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakewood Health And Rehab, Llc | 1.7 mi | ★★★★★ | 2 | 0 |
| Robinson Nursing And Rehabilitation Center Llc | 3.8 mi | ★★★★★ | 0 | 0 |
| Sherwood Nursing & Rehabilitation Center, Inc | 4 mi | ★★★★★ | 4 | 1 |
| The Blossoms At North Little Rock Rehab & Nursing | 4.4 mi | ★★★★★ | 1 | 0 |
| Arkansas State Veterans Home At North Little Rock | 4.4 mi | ★★★★★ | 0 | 0 |
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