Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 The Springs Of Brinkley during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of repeated falls had an unwitnessed fall with a skin tear and STAT x-rays ordered. The Medical Director was notified, but the resident’s representative was not promptly informed of the incident and later reported learning about the fall only after calling the facility back, leading to a grievance for not being notified.
A resident with traumatic brain injury, stroke history, and altered mental status was placed on a secured unit for elopement risk but had only general care plan interventions that were not updated when new wandering, exit‑seeking, and aggressive behaviors emerged. Over time, staff documented that the resident walked the halls at night, entered other residents’ rooms, voiced not living there, stated plans to leave through a window, followed staff through locked doors, and sought ways to get out after a home visit. Despite an elopement assessment and multiple behavior notes, no individualized elopement‑prevention interventions were added to the care plan. Eventually, during a night shift when a CNA reported dozing off and not re‑checking the room, the resident broke a bedroom window with furniture, left the building, and was later found off‑site by police after nearly being hit by a car, confirming that the care plan had not been effectively revised or implemented to address the resident’s exit‑seeking behaviors.
A resident with traumatic brain injury, altered mental status, and a history of wandering was housed on a locked unit with a care plan identifying elopement risk but focused mainly on therapeutic activities and medication monitoring. After returning from a home visit, the resident exhibited escalating behaviors over several days, including being up all night walking halls, entering other residents’ rooms, standing at locked exits, following staff out locked doors, voicing a desire to leave, and stating a plan to escape through a window. On the night of the incident, camera footage showed the resident moving between the room, day room, and bathroom until entering the room and not re-emerging, while the CNA on duty did not perform checks, reported that staff did not usually re-check the resident once in the room, and admitted to dozing off. The resident broke the bedroom window with furniture, left the building unnoticed, and was later found by police nearly two miles away after a citizen reported almost hitting the resident with a car, demonstrating that the facility failed to provide adequate supervision and monitoring during a period of increased exit-seeking.
Two residents with severe cognitive and behavioral impairments were involved in separate incidents where one was physically assaulted while crawling into another's room, and another sustained a head injury after an unwitnessed altercation involving a razor. In both cases, inadequate supervision, insufficient staffing, and lack of effective interventions or documentation contributed to the failure to prevent resident-to-resident abuse.
A facility failed to implement Enhanced Barrier Precautions (EBP) and proper hand hygiene for a resident with a pressure ulcer and skin graft infection. The resident's care plan required EBP, but an LPN provided wound care without a gown and did not perform hand hygiene between glove changes. There was confusion about the identification of residents on EBP and the location of PPE supplies, with inconsistent practices observed. The facility's infection control policy was not effectively implemented, as PPE was not readily available near residents' rooms.
The facility failed to repair or replace a leaking water heater in a timely manner, affecting two residents on the North Hall. Wet linens and water were observed on the floor, and staff interviews indicated the leak had persisted for weeks. The maintenance log lacked documentation of the issue, and the Administrator provided plumbing estimates from previous months. The facility's policy mandates maintaining a safe and operational environment.
The facility failed to update care plans for two residents, one with a feeding tube and another with seizures. A resident's care plan did not reflect updated tube feeding orders, while another's lacked specific seizure precautions and medication details. The facility's policy did not address care plan revisions.
The facility failed to ensure safety in the North Hall, where water and wet linens posed fall risks, and the shower room was left unlocked with open razors. A resident with respiratory issues was observed smoking unsupervised, against their care plan. Additionally, missing tiles in the 200 Hallway created an uneven surface, and an aerosol insect spray was found in a resident's room, posing a risk.
The facility failed to follow proper food storage and handling guidelines, risking food spoilage and bacterial growth. Observations included unrefrigerated lemon juice, improper sealing of food items, and inadequate cleaning of steam table pans. Dietary staff did not consistently wash hands or change gloves during meal prep, violating the facility's handwashing policy.
A facility failed to return a deceased resident's personal funds within the required 30-day period. A resident passed away, but months later, the facility's financial records still showed an active balance of $94.08. The Business Office Manager delayed returning the funds, awaiting corporate guidance due to an outstanding balance owed by the resident. This action was not in compliance with the facility's policy on managing residents' personal funds.
A facility failed to provide a bed hold notice to a resident transferred to the hospital due to the Business Office Manager's lack of awareness of her responsibilities. The resident, who was not cognitive, did not receive the notice because the BOM was newly hired and unaware of the requirement. The facility's policy mandates written notification of bed hold policies prior to transfers, but this was not followed.
A facility failed to provide a comprehensive care plan for a resident with stroke and respiratory failure, including tracheostomy and oxygen needs. The care plan lacked specific, measurable interventions, as acknowledged by the MDS Nurse, who found it vague. The facility's policy requires the Interdisciplinary Team to update care plans upon hospital readmission and during quarterly MDS assessments, which was not adequately followed.
A resident with severe cognitive impairment and muscle weakness did not receive adequate nail care, as their care plan required. Observations showed the resident's nails were excessively long and dirty, with no record of nail care in the electronic health record. The resident reported infrequent nail trimming, and an LPN confirmed the nails' condition, noting that CNAs were responsible for this task.
A resident with heart failure and respiratory issues was not administered oxygen at the physician-ordered flow rate of 2 l/min. Instead, the oxygen concentrator was set at higher rates of 3.5 and 4 l/min on multiple occasions. The facility's policy requires oxygen to be administered under physician orders and documented, which was not followed, leading to the deficiency.
A resident with type 2 diabetes requested a blood sugar check, which was performed by an RN. After the test, the RN placed the glucometer back into the medication cart without cleaning it, violating the facility's policy requiring disinfection after each use. The RN acknowledged the oversight when questioned.
Failure to Promptly Notify Representative After Resident Fall
Penalty
Summary
The facility failed to ensure Resident #54’s representative was promptly notified after the resident had an unwitnessed fall on 12/03/2025. Resident #54 was admitted with diagnoses including intervertebral disc degeneration, bilateral primary osteoarthritis of the knee, age-related physical debility, and repeated falls, and the admission record identified the resident’s child as the POA for care, responsible party, and emergency contact. The resident’s quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment. The care plan and incident records documented the fall, and the progress note from 12/03/2025 at 3:00 AM stated the resident was found on the floor of the room with a skin tear to the left ear, was assisted back to bed by two staff members, and neurological checks were started. The Medical Director was notified at 3:15 AM, and the family notification section stated, “Will call in AM.” The record further showed orders for STAT x-rays of the back, pelvis, left hip, and lumbar spine related to the fall. A progress note on 12/04/2025 at 3:40 PM documented that a voicemail was left for the resident’s representative about paperwork sent to a radiology provider, and at 4:10 PM the representative returned the call. During interview, the resident’s representative stated they were told about the fall only after returning the facility’s call and reported the nurse said, “I meant to call you the other night.” The Administrator stated the nurse should notify the family of a change in condition or incident, document each attempted notification, and pass the task to the next nurse if contact had not been made. The grievance log also showed the representative filed a grievance on 12/4/2025 for not being notified of the fall.
Failure to Update Care Plan for New Exit-Seeking Behaviors Leading to Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective, updated comprehensive care plan with individualized interventions in response to new onset wandering, exit‑seeking, and elopement‑related behaviors for a resident on a secured unit. The resident had a history of traumatic brain injury, cerebral infarction (stroke), altered mental status, and was admitted to the secured unit due to traumatic brain injury and elopement risk. A quarterly MDS showed the resident was cognitively intact with a BIMS score of 12 and independent with ambulation, but a later BIMS showed a score of 2, indicating moderately impaired cognition. Despite these changes and the resident’s known elopement risk, the care plan initiated months earlier contained only general interventions such as therapeutic activities and medication monitoring, and no additional or revised interventions were added after 08/25/2025 to address later‑emerging behaviors or elopement attempts. On 01/13/2026, multiple progress notes documented significant behavioral changes and explicit exit‑seeking behavior. Early that morning, staff recorded that the resident was up all night walking the halls, refusing to go to bed, entering other residents’ rooms, and voicing that they did not live in the facility. The resident stated an intent to get out of the window. Later that day, another note documented that the resident had been seeking elopement since returning from a home visit, admitted a desire to leave, had been looking for ways to get out, and followed staff out locked doors, showing force when staff tried to return the resident to the unit. A further note that evening described the resident talking loudly, being aggressive toward staff, and again stating a desire to get out of the facility. Although an elopement assessment was completed at that time, there were no new care plan interventions put in place to guide staff in preventing exit‑seeking or managing the aggressive behaviors. In the weeks that followed, staff interviews and documentation showed that the resident continued to exhibit wandering and exit‑seeking behaviors without corresponding care plan revisions. Staff reported that after a family home visit, the resident began trying to leave the unit, walked door to door asking how to get out, watched staff to see if they were paying attention, and talked about leaving. On the night of the elopement, camera footage showed the resident repeatedly moving between the room, day room, and bathroom before entering the room and not re‑emerging. A CNA on duty stated that the resident had been going in and out of the room earlier in the shift, then went back to the room and was not checked on again; the CNA also reported dozing off during the shift and not hearing the window break. In the early morning hours, staff discovered the resident’s window busted and the resident missing, and a progress note documented that the resident had eloped by throwing an end table through the window. A police report and interviews confirmed that the resident was found off‑site after nearly being struck by a vehicle, having left the facility to find family. Throughout this period, the facility did not update the resident’s care plan with individualized, effective interventions to address the clearly documented new onset wandering, exit‑seeking, and elopement behaviors.
Removal Plan
- Revise Resident #1's care plan to include individualized elopement prevention interventions updated to include all interventions per the Plan of Removal.
- Complete new elopement risk assessments for residents residing on the secured unit.
- For any resident scoring moderate or high risk, review care plans to ensure individualized elopement interventions are present.
- Complete environment exit safety checks.
- Revise and update all secured unit residents' care plans based on the Plan of Removal.
- Provide in-service education to nursing and direct care staff on the elopement policy and missing resident procedures.
- Provide in-service education to nursing and direct care staff on the definition and examples of elopement and exit-seeking behaviors, early warning signs requiring interventions, and requirements to notify the nurse, administrator, or DON of new or increased behaviors.
- Provide in-service education to nurse management responsible for updating care plans on mandatory care plan revision following behavior changes with individualized interventions.
- Order shatter-resistant film for front-facing secured unit windows and install it.
- Implement monitoring for the DON or designee to review the 24-hour report to identify new or increasing exit-seeking behaviors.
- Implement monitoring for the DON or designee to complete audits to verify elopement risk assessments are completed, individualized interventions are present, and documentation reflects staff implementation, then transition to routine QAPI monitoring.
Elopement from locked unit due to inadequate supervision and response to exit-seeking behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with known wandering and elopement risk, resulting in an elopement through a broken bedroom window. The resident had a history of traumatic brain injury, cerebral infarction, altered mental status, and wandering, and had been admitted to a secured unit due to elopement risk. An MDS assessment earlier in the year showed the resident as cognitively intact and independently ambulatory, but a later BIMS assessment showed moderately impaired cognition. The resident’s care plan identified the need for placement on a secured unit related to traumatic brain injury and elopement risk, with interventions focused on therapeutic activities and monitoring of psychotropic medications, but did not include enhanced supervision measures in response to escalating exit-seeking behaviors. In the weeks prior to the elopement, multiple progress notes and staff interviews documented increased exit-seeking and behavioral changes after the resident returned from a home visit. On one day, progress notes recorded that the resident was up all night walking the halls, going in and out of other residents’ rooms, voicing that they did not live in the facility, and stating an intention to get out through a window. Staff documented that the resident had been seeking elopement since returning from a home visit, had been looking for ways to get out, followed staff out locked doors, and showed force when staff tried to return the resident to the unit. Another note from the same day described the resident talking loudly, being aggressive toward staff, and repeatedly expressing a desire to leave the facility. An elopement assessment documented that the resident ambulated independently, had a history of following staff and others, and had been wandering halls and standing by locked exit doors after returning from home. On the night of the elopement, camera footage showed the resident repeatedly moving between the resident’s room, the day room, and the bathroom until entering the room at approximately 3:12 a.m. and not re-emerging. Staff interviews revealed that the CNA assigned to the unit acknowledged that the resident had been trying to start a fight with another resident for two days, that the resident typically went in and out of the room throughout the night, and that staff did not normally go back to check on the resident once the resident returned to the room. The CNA reported that she did not check on the resident after the last interaction around 9:30–10:00 p.m., that she sometimes could not take breaks due to staffing, and that she dozed off for about 30 minutes during the shift. The DON later stated that the CNA reported falling asleep and not hearing the window break. Staff discovered the broken window only when an LPN returned from break around 4:25 a.m., at which point the resident was found to be missing. Law enforcement records and interviews confirmed that the facility reported the resident missing in the early morning hours and that the resident was located off-site by police after a citizen reported almost striking the resident with a vehicle. The police officer stated that the resident was found near a school approximately 1.9 miles from the facility, requiring travel across an intersection and along areas without sidewalks. The resident told police they were walking to find family. Interviews with multiple CNAs and nurses indicated that the resident had been going door to door asking how to get out, watching staff to see if they were paying attention, and walking back and forth to doors after returning from a family visit. The DON and Administrator both stated they were not aware of prior elopement attempts beyond wandering and walking back and forth, and the MDS Coordinator reported she had not been informed of the January incident in which the resident voiced a plan to escape through a window. Facility policies required staff to know the location of residents under their care and to implement care plan strategies for residents at risk of wandering or elopement, but staff interviews showed that routine checks were not performed on the resident during the night of the incident and that the resident’s escalating exit-seeking behaviors were not effectively communicated or translated into increased supervision. A police incident report and witness statements further detailed that the resident exited the building by throwing an end table through the bedroom window. The facility’s own missing resident and wandering/elopement policies stated that staff are responsible for knowing residents’ whereabouts and that care plans for at-risk residents must include safety strategies and interventions. Despite documented behaviors such as wandering, standing at locked doors, following staff out locked exits, verbalizing intent to leave, and specifically stating a plan to get out through a window, there was no evidence in the record that supervision was increased or that staff adjusted monitoring practices during periods of heightened exit-seeking. Staff interviews also revealed that for several weeks there had often been only one CNA on the locked unit at night, and that the CNA on duty the night of the elopement positioned herself in a doorway with hall lights off and later admitted to dozing off. These actions and inactions resulted in the resident being able to break the window, leave the secured unit and facility, and travel a significant distance off-site before being located and returned by police.
Failure to Prevent Resident-to-Resident Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to prevent resident-to-resident abuse for two of four residents reviewed for abuse. In one incident, a resident with severe cognitive impairment, metabolic encephalopathy, and Parkinson’s disease, who was known to crawl on the floor and wander, attempted to enter another resident’s room. The second resident, also severely cognitively impaired and with a history of behavioral disturbances, kicked the first resident in the face multiple times, resulting in significant injuries including contusions, lacerations, and bruising. At the time of the incident, only one staff member was present on the secure unit, and there were no interventions in place to prevent the first resident from entering other residents’ rooms, despite known wandering behaviors. Staff interviews confirmed that the resident had been crawling around the unit since admission and that staffing levels were insufficient to monitor all residents effectively. In a separate incident, a resident with a history of traumatic brain injury, stroke, and moderate cognitive impairment sustained a laceration and a linear skull fracture after an unwitnessed event in their room. The resident reported being struck on the head by another resident, who was later seen with a razor in hand. Staff discovered the injury after hearing a commotion, and both residents involved reported that the injury was caused by the other. The facility did not immediately complete an incident report, and there was confusion among staff regarding the cause of the injury, with explanations ranging from a razor cut to being struck with a metal object. Documentation and neurological checks were lacking, and the incident was not initially logged or reported as required. Both incidents involved residents with significant cognitive and behavioral challenges residing on a secure unit. The facility’s care plans and interventions did not adequately address the risks of resident-to-resident altercations, particularly for residents with known wandering or aggressive behaviors. Staff interviews revealed gaps in supervision, incident reporting, and follow-through on required documentation, contributing to the failure to protect residents from abuse and neglect as required by facility policy and federal regulations.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper hand hygiene for a resident with a pressure ulcer and skin graft infection. The resident, who was severely cognitively impaired and dependent on staff for daily activities, had a care plan indicating the need for EBP due to wounds. However, during an observation, a Licensed Practical Nurse (LPN) provided wound care without donning a gown, and her scrubs came into contact with the resident's bed sheets. The LPN also failed to perform hand hygiene between glove changes, citing the absence of a sink in the resident's room and lack of alcohol hand sanitizer. The facility's system for identifying residents on EBP was inconsistent. While some staff members stated that residents on EBP were identified by signage on their room doors, others mentioned signage by the resident's bed. Additionally, there was confusion about the location of Personal Protective Equipment (PPE) supplies, with some staff indicating they were kept in a supply room, while others mentioned they were in a central supply closet or under the sink in the resident's room. The Director of Nursing (DON) and Assistant Director of Nursing/Infection Preventionist (ADON/IP) were unable to locate PPE in several resident rooms identified as being on EBP. The facility's policy for Infection and Prevention Control aimed to prevent the transmission of infections, but the implementation was lacking. The policy indicated that gowns and gloves should be available near or outside the resident's room, but this was not consistently the case. A list of residents on EBP provided by the DON did not include any residents with wounds, including the resident in question, highlighting a gap in the facility's infection control practices.
Failure to Timely Repair Leaking Water Heater
Penalty
Summary
The facility failed to repair or replace a leaking water heater in a timely manner, affecting two residents capable of ambulation or self-propelling on the North Hall. On August 12, 2024, wet linens and water were observed on the floor outside the soiled linen and equipment room, extending beyond a yellow caution sign. Interviews with the Floor Tech and Housekeeping staff revealed that the hot water heater had been leaking for several weeks. A review of the maintenance log showed no documentation of the leak, and the Maintenance Director acknowledged that it should have been documented earlier. The Administrator could not confirm the exact date the leak began but provided plumbing estimates dated June 25, 2024, and July 11, 2024. The facility's maintenance policy requires the maintenance department to keep the building safe and operational at all times.
Failure to Revise Care Plans for Changing Resident Needs
Penalty
Summary
The facility failed to ensure care plans were revised to reflect the changing needs and preferences of two residents. Resident #11, who had a history of stroke and respiratory failure, was admitted with a feeding tube and required a specific diabetic tube feeding formula. However, the care plan was not updated to reflect the correct formula and rate, despite changes in physician orders. The MDS Nurse confirmed that the care plan was not revised to include the updated tube feeding information, which is crucial for ensuring the resident receives the necessary nutrients. Additionally, the facility's policy on care planning did not address the need for revisions, and there was no specific policy related to care plan revisions. Resident #35, diagnosed with seizures, had a care plan that failed to specify seizure precautions and did not list the medications or side effects to monitor. The resident was prescribed Dilantin and Levetiracetam for seizure management, but the care plan lacked detailed interventions to ensure proper monitoring and administration of these medications. This oversight in care planning could potentially impact the resident's safety and well-being, as the necessary precautions and medication details were not clearly documented.
Multiple Safety Hazards and Supervision Failures in Facility
Penalty
Summary
The facility failed to maintain a safe environment in the North Hall, where water and wet linens were left on the floor, posing a fall risk to residents. The hot water heater had been leaking for weeks, and despite staff awareness, the issue was not addressed, leading to water accumulation in the hallway. Additionally, the North Hall shower room was found unlocked with soapy, wet floors and open razors accessible, increasing the risk of injury to residents. The tub room, used for storing oxygen tanks, was also left unlocked, posing a potential hazard. Resident #39, who has a medical history of acute respiratory failure and chronic obstructive pulmonary disease, was observed smoking unsupervised, contrary to their care plan which required supervision. The resident was left alone in the smoking area after a staff member provided and lit a cigarette. This lack of supervision was confirmed by a registered nurse and the Director of Nursing, who acknowledged the potential for harm or fire. The facility also failed to address physical hazards in the 200 Hallway, where missing tiles created an uneven surface. This area had been in disrepair for several weeks, as noted by the Maintenance Supervisor. Furthermore, an aerosol insect spray was found in a resident's room, which is flammable and not intended for direct use on people, posing a risk to residents, especially those who wander into other rooms.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to proper food storage and handling guidelines, which could potentially lead to food spoilage and the growth of bacteria. During an inspection, it was observed that a bottle of lemon juice concentrate was not refrigerated after opening, contrary to the manufacturer's instructions. Additionally, a foam cup was found inside a bin of rice, posing a risk of cross-contamination. An open bag of breadcrumbs and a bag of bread slices were not properly sealed or dated, further indicating improper food storage practices. The steam table pans were also found to have brown residue, suggesting inadequate cleaning. Dietary staff did not consistently follow handwashing and glove-changing protocols during meal preparation. One staff member was observed handling food with the same pair of gloves after touching various items, without washing hands in between. This included handling tortilla shells, cooked meat, and shredded cheese. The facility's handwashing policy requires hands to be washed before starting work with food, before putting on gloves, and as often as needed during food preparation. The dietary manager confirmed the lapses in food storage and handling practices, acknowledging that the lemon juice should have been refrigerated and that the steam table pans were not adequately cleaned.
Failure to Return Deceased Resident's Funds Timely
Penalty
Summary
The facility failed to return a deceased resident's personal funds within the required 30-day period. Resident #207 passed away on March 15, 2024, but as of August 13, 2024, the facility's financial records still showed an active balance of $94.08 in the resident's account. The Business Office Manager indicated that the delay in returning the funds was due to awaiting guidance from the corporate office on whether to return the money to the resident's family, as there was an outstanding balance owed to the facility. The facility's policy on the management of residents' personal funds, revised in March 2021, mandates compliance with federal and state requirements, which was not adhered to in this instance.
Failure to Provide Bed Hold Notice Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice prior to the discharge of a resident who was transferred to the hospital. This deficiency was identified during a review of the facility's practices, where it was found that a resident did not receive a bed hold notice because the Business Office Manager (BOM) was unaware of her responsibility to issue such notices. The BOM, who was newly hired, stated that she did not know it was her job to handle bed holds and was under the impression that it was a Medicare/Medicaid requirement for safe transfers. The resident in question was not cognitive, and their family member could not be reached, which contributed to the oversight. Further investigation revealed that the facility had an existing policy requiring residents or their representatives to be informed of bed hold policies in writing prior to transfers and therapeutic leaves. Despite this policy, the BOM did not become responsible for bed holds until after the previous manager left, and there was a discrepancy in the documentation, as a bed hold from a previous transfer was signed by the current BOM. The issue with incomplete bed holds was identified on a specific date, but the deficiency occurred due to a lack of awareness and communication regarding the responsibilities of the BOM.
Failure to Provide Comprehensive Care Plan for Resident with Respiratory Needs
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident diagnosed with stroke, chronic obstructive respiratory failure, and acute respiratory failure. The resident was moderately cognitively impaired, as indicated by a Brief Interview for Mental Status score of 9. The resident required specific interventions for respiratory failure, tracheostomy, and oxygen use, which were not clearly documented in the care plan. The MDS Nurse acknowledged the care plan was vague and lacked measurable interventions necessary to maintain the resident's well-being and prevent rehospitalizations. The process for forming a comprehensive care plan involves creating a baseline care plan and updating it based on triggers identified through the MDS, guided by the Resident Assessment Instrument manual. However, the facility's policy on care planning, which requires the Interdisciplinary Team to review and update care plans upon a resident's readmission from a hospital and during quarterly MDS assessments, was not adequately followed. This oversight resulted in the failure to ensure the resident received appropriate care tailored to their specific medical needs.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure proper nail care for a resident with muscle weakness and altered mental status, as observed during a survey. The resident, who was severely cognitively impaired with a BIMS score of 06, had an ADL self-care performance deficit documented in their care plan. Despite the care plan's intervention to check, trim, and clean nails as necessary, there was no data found in the electronic health record for nail care. Observations on two separate occasions revealed the resident's fingernails were over a quarter inch long with a dark brown substance underneath. The resident confirmed that their nails were trimmed only once a year. An LPN confirmed the nails were too long and dirty, and noted that CNAs were responsible for nail care on bath/shower days.
Failure to Administer Oxygen at Ordered Flow Rate
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician's ordered flow rate for a resident with heart failure and respiratory issues. The resident had an order for oxygen to be administered at two liters per minute via a nasal cannula as needed for shortness of breath. However, observations revealed that the oxygen concentrator was set at higher flow rates of 3.5 and 4 liters per minute on multiple occasions. This discrepancy was confirmed by a registered nurse who acknowledged that the resident's order was for 2 liters per minute and that nurses were responsible for monitoring the oxygen flow rate. The facility's Oxygen Administration policy, which requires oxygen to be administered under physician orders and staff to document the resident's condition and response to oxygen use, was not adhered to. There was no documentation in the electronic medication administration record indicating the use of oxygen for the resident during the specified period. The failure to monitor and document the correct oxygen flow rate as per the physician's order led to the deficiency identified during the survey.
Failure to Clean Glucometer After Use
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed during a glucometer check for Resident #107, who has a diagnosis of type 2 diabetes mellitus. On August 13, 2024, Resident #107 requested a blood sugar check from RN #5. The nurse performed the procedure by pricking the resident's finger and using a glucometer to measure the blood sugar level, which read 116. After completing the test, RN #5 discarded her gloves and placed the glucometer back into the medication cart without cleaning it, contrary to the facility's policy that requires reusable equipment to be cleansed and disinfected after each use. RN #5 acknowledged the oversight when questioned by the surveyor, admitting that the glucometer should have been cleaned immediately after use.
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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.
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Nursing homes near Brinkley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Des Arc Nursing And Rehabilitation Center | 18.9 mi | ★★★★★ | 0 | 0 |
| Maple Healthcare | 22.3 mi | ★★★★★ | 0 | 0 |
| Woodruff County Health Center | 25.2 mi | ★★★★★ | 8 | 0 |
| Crestpark Marianna, L L C | 25.2 mi | ★★★★★ | 4 | 0 |
| Crestpark Forrest City, Llc | 25.4 mi | ★★★★★ | 11 | 0 |
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