Citations in Arkansas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Arkansas.
Statistics for Arkansas (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Arkansas
A resident with multiple neuropsychiatric diagnoses and identified as an elopement risk was able to leave the facility unsupervised by using a door code and a key stored on the property. Staff did not realize the resident was missing until after breakfast was delivered, and the resident was later found off property and returned by a staff member. Required routine checks were not effectively carried out, leading to the resident's unsupervised exit.
The facility did not properly credit monthly interest to the trust fund accounts of two residents, despite policy and bank statements indicating interest should be paid. Both residents had authorized the facility to manage their funds, but only a single interest payment was recorded, with no credits for subsequent months. The Administrator, acting as BOM, was unaware of the correct interest rate and did not follow federal regulations, while the DON and ADON had no involvement with the accounts.
The facility failed to use an acceptable accounting system for resident trust funds, resulting in commingling of resident money with operational and payroll accounts, lack of individual ledgers for several residents, and failure to provide required quarterly statements. Some residents and their representatives did not receive documentation of their funds, and significant discrepancies were found between trust fund account balances and resident ledgers.
A resident with a recent abdominal surgery was admitted with staples in place and severe pain, but the facility did not obtain or implement physician orders for wound care or assessment. Nursing staff failed to perform or document wound assessments, did not notify a provider despite significant drainage and pain, and removed surgical staples without confirming the wound's readiness. This led to wound dehiscence, rehospitalization, and emergency surgery.
A resident with severe cognitive impairment and a history of impulsiveness exited the facility through a malfunctioning secure door that had been reported as faulty by staff but not properly documented or repaired. The resident, who was not yet on an elopement care plan or electronic monitoring, was found walking in traffic by police and EMS after the facility was initially unaware of their absence. Staff interviews revealed ongoing issues with the door and inconsistent maintenance reporting, leading to the resident's unsupervised exit.
A resident with moderate cognitive impairment and a history of wandering, assessed as high risk for elopement, was inadequately supervised and left the secure unit. The resident was later found by bystanders off facility grounds, confused and with minor injuries, after staff were unable to locate them during routine rounds. Documentation and interviews indicated the resident likely exited through a door that did not close completely or by following someone out, and there was a delay in notifying the physician and administration.
A resident with severe cognitive impairment and a history of threatening behavior repeatedly verbally threatened and ultimately physically assaulted their cognitively impaired roommate, resulting in injury. Despite staff awareness of ongoing threats and verbal aggression, effective interventions such as room changes or psychiatric evaluation were not consistently implemented, and documentation of monitoring was lacking. The facility failed to protect residents from abuse as required by policy.
A resident with severe cognitive impairment and total dependence on staff for transfers sustained a spiral femur fracture after being improperly transferred with a mechanical lift by only one staff member, despite care plan requirements for two-person assistance. Staff interviews revealed that single-person operation of the lift occurred during short staffing, and there was confusion about proper lift procedures, including whether to lock the wheels, leading to inconsistent practices and ultimately resident harm.
Surveyors found that expired food items, such as buttermilk and bread, were not promptly removed from storage, and opened bags of hamburger buns were left unsealed, exposing them to contamination. Ice scoop holders were dirty, and dietary staff failed to follow hand hygiene protocols, handling clean equipment and food items after touching dirty surfaces without washing their hands. These deficiencies were confirmed through staff interviews and direct observation.
A cognitively impaired resident with a history of sexual behaviors engaged in a sexual act with a staff member, which was witnessed by another staff and reported to administration and law enforcement. Despite ongoing reports of the resident's inappropriate sexual behaviors, the facility did not implement adequate supervision or interventions, and the abuse policy lacked specific guidance on sexual abuse prevention. The resident's care plan and assessments failed to accurately document these behaviors or address the risk, contributing to the incident.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of progressive brain disease, paranoid schizophrenia, dementia psychosis, depression, convulsions, and nicotine dependence was not adequately supervised, resulting in an elopement from the facility. The resident, who was assessed as having fair to poor safety awareness and identified as an elopement risk, was able to leave the facility premises without staff knowledge. The resident reported knowing the code to the door leading outside and accessed a key stored in a box on the fence to unlock the gate, leaving the facility while it was still dark outside. Staff interviews revealed that routine checks were supposed to be conducted every two hours, but the resident was last seen in their room at approximately 5:00 AM and was not accounted for during subsequent checks. The absence was only discovered after breakfast was delivered to the resident's room and the resident was not found. The resident was later located by a staff member off facility property and returned to the facility. Review of facility policy indicated that routine checks were required to ensure resident safety, but these were not effectively implemented in this case.
Failure to Properly Credit Interest on Resident Trust Funds
Penalty
Summary
The facility failed to properly manage resident trust fund interest payments for two residents who had authorized the facility to handle their personal funds. Both residents had signed authorizations, either by themselves or through their Power of Attorney, allowing the facility to hold and disburse their funds. A review of the facility's policy indicated that resident trust accounts should be maintained in interest-bearing accounts, with interest credited accordingly. However, the resident ledgers for both individuals showed only a single, undated interest payment for June balances, with no interest credited for the following months. The facility's pooled trust account bank statement confirmed that interest was paid monthly, but this was not reflected in the residents' individual ledgers for July and August. Interviews with the DON and ADON revealed that neither had any involvement or access to the resident fund ledgers or bank accounts. The Administrator, who also served as the Business Office Manager, admitted to not knowing the actual interest rate on the resident trust fund account and stated she used a calculation method provided by her accountant, rather than following federal regulations or the facility's own policy. This lack of proper oversight and failure to credit interest as required resulted in the deficiency.
Failure to Properly Manage and Account for Resident Trust Funds
Penalty
Summary
The facility failed to properly manage and account for residents' personal funds deposited with the nursing home, as required by regulation and facility policy. The facility did not utilize a generally acceptable accounting system for the resident trust fund, resulting in the commingling of residents' trust fund money with the facility's operational and payroll accounts. The Administrator routinely transferred resident funds from the trust fund account into the facility's operational and payroll accounts, and wrote checks for resident allowances and other disbursements from these facility accounts rather than from a dedicated trust fund account. There was no written consent from residents or their representatives to allow this commingling of funds. The facility also failed to maintain accurate and complete records for all residents whose funds were managed. For several residents, there were no individual ledger pages to track deposits, withdrawals, and balances, and in some cases, there was no signed authorization for the facility to manage personal funds. Errors were found in the accounting of at least one resident's ledger, and the combined balances in the trust fund account did not match the total of the residents' personal ledgers, with significant amounts missing from the account at the beginning of each month reviewed. The Administrator acknowledged that only two residents had ledgers maintained, and that checks for allowances were written from the operational account without documentation of the disposition of funds for other residents. Additionally, the facility did not issue required quarterly statements to residents or their representatives regarding the status of their trust fund accounts. Interviews with residents and their representatives confirmed that they did not receive any statements or documentation about their funds. The Administrator admitted to not being familiar with the federal regulations governing resident trust funds and confirmed that no quarterly statements were provided. The Director of Nursing and Assistant Director of Nursing stated they had no role or access to the resident ledgers or bank accounts.
Failure to Obtain and Implement Physician Orders for Post-Operative Wound Care
Penalty
Summary
The facility failed to obtain and implement physician orders for the care of a post-operative surgical wound for one resident, resulting in significant complications. Upon admission, the resident had a recent abdominal surgery with staples in place and was experiencing severe, nearly constant pain. The hospital discharge instructions indicated that staples were to be removed on post-operative day ten, but did not provide specific instructions for wound assessment, care, documentation, or criteria for physician notification. Facility documentation and care plans lacked any plan of care or interventions for the surgical wound, and there were no orders or documentation related to wound care, assessment, or monitoring for complications. Nursing staff did not perform or document appropriate wound assessments or dressing changes during the initial days following admission. The resident's pain was not effectively managed, and staff failed to notify a physician or seek further guidance despite the presence of significant drainage and an unhealed incision. The wound was not assessed by an RN, and the LPN who provided care did not contact the on-call provider. When the staples were eventually removed, the wound dehisced, leading to rehospitalization and emergency surgery. Interviews with staff revealed a lack of clarity regarding responsibilities for wound care and assessment, and a reliance on incomplete or absent orders from the hospital. The resident's family reported concerns about uncontrolled pain and saturated dressings, and staff interviews confirmed that wound assessments were not performed as required. The treatment nurse removed the staples based solely on the discharge paperwork, without confirming the wound's readiness or consulting the surgeon or provider. The lack of a coordinated approach to wound care, absence of physician orders, and failure to document or communicate changes in the resident's condition directly contributed to the resident's wound dehiscence and subsequent complications.
Failure to Prevent Elopement Due to Unaddressed Door Malfunction and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent an elopement. A resident with severe cognitive impairment, dementia, and a history of impulsiveness and communication deficits was admitted to the facility. The resident was identified as being at risk for elopement during an initial evaluation, but no care plan addressing elopement was initiated at that time. The resident resided on a secure unit, but the electronic monitoring system was not activated prior to the incident. The deficiency was further compounded by a malfunctioning electronic locking door on the secure unit, which had been known to have intermittent issues for several weeks. Multiple staff members reported problems with the door not locking properly, requiring extra effort to ensure it was secure, and making unusual mechanical noises. Despite these reports, there were no documented maintenance work orders for the door, and the issue was not properly escalated or tracked in the facility's maintenance system. On the night of the incident, the resident was last seen in the hallway and later found to have exited the facility through the faulty door, walking down a city street in traffic with a walker. The facility was initially unaware that the resident was missing, and only after being contacted by local police and further investigation did staff realize the resident had eloped. The police and EMS were involved in locating and returning the resident, who was found unable to communicate their identity. Interviews with staff revealed inconsistent reporting and follow-up on the door's malfunction, as well as a lack of clear documentation and communication regarding maintenance issues. The facility's policy required immediate notification and monitoring of malfunctioning exit doors, but this was not followed, contributing to the resident's elopement.
Failure to Prevent Elopement of High-Risk Resident from Secure Unit
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and multiple psychiatric and neurological diagnoses, including non-Alzheimer's dementia, psychotic disorder, schizophrenia, and Parkinsonism, was not adequately supervised and eloped from a secure unit. The resident had a documented history of wandering and was assessed as high risk for elopement, with care plan interventions specifying placement on a secure neighborhood and a goal of no elopement episodes. However, the care plan form did not delineate specific interventions, and the resident was observed wandering the halls, expressing a desire to leave, and was later found missing from the unit. Staff were unable to locate the resident during routine rounds, and a search of the unit and facility grounds was initiated. The resident was eventually found by bystanders nearly a mile from the facility, appearing confused and lying in the grass, and was attended by EMS, police, and fire department personnel. The LPN retrieved the resident from EMS care and returned them to the facility, noting minor injuries such as skin tears to both hands and an elevated temperature due to the hot weather. The resident's physician was notified of the incident after the resident's return. Interviews and documentation revealed that the resident likely exited the secure unit through a door that did not close completely or by following another person out, as the resident did not have the capacity to use the keypad code. The facility's disaster plan for elopement was not fully implemented at the time of the incident, and there was a delay in notifying the physician and administration. The lack of specific care plan interventions and inadequate supervision contributed to the resident's ability to leave the secure unit and the facility grounds.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse between residents, specifically involving a resident with severe cognitive impairment who repeatedly threatened and ultimately physically assaulted their roommate, who also had severe cognitive impairment and decreased physical mobility. The first incident involved verbal threats and aggressive language directed at the roommate, with staff intervention and short-term monitoring, but no room change or psychiatric consultation was initiated at that time. Staff and CNA interviews revealed that threatening behavior and verbal aggression from the resident continued over a period of weeks, with multiple reports made to nursing staff. Despite ongoing threats and escalating behaviors, the residents continued to share a room. Staff were aware of the repeated threats and verbal altercations, but interventions such as room changes or psychiatric evaluations were not consistently implemented. The facility's Director of Nursing and Administrator cited a lack of available beds and did not recall or act upon all reported incidents. Documentation of one-on-one monitoring after the second incident was not provided, and there was no evidence of consistent or effective measures to separate the residents or address the aggressive behaviors. The situation culminated in a physical assault, where the aggressive resident struck their roommate on the forehead with a remote control, resulting in visible injury and bleeding. Staff responded to the incident, provided treatment, and initiated neuro checks, but the failure to act on prior threats and to implement protective interventions contributed to the occurrence of abuse. The facility's policy required protection from abuse and management of aggressive behaviors, but these measures were not adequately followed, leading to the cited deficiency.
Improper Mechanical Lift Use Resulting in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and fully dependent on staff for all activities of daily living, sustained a right distal third spiral femur fracture due to improper use of a mechanical lift during transfer. The resident had multiple diagnoses, including brain damage, weakened bones, and contractures, and required two-person assistance with a mechanical lift for all transfers, as documented in the care plan and Kardex. Despite these requirements, staff interviews and record reviews revealed that the mechanical lift was sometimes operated by a single staff member, particularly during periods of short staffing, contrary to facility policy and the resident's care plan. Multiple staff members, including CNAs and LPNs, admitted or reported witnessing the mechanical lift being used by only one person, with the second staff member sometimes merely standing at the doorway or not present at all. The incident leading to the resident's injury was not directly witnessed, but interviews indicated that the resident was found with a swollen knee, and subsequent x-rays confirmed a displaced femur fracture. The family was informed of the injury after they noticed the swelling, and there was confusion and lack of clear communication from staff regarding the cause of the injury. The facility's policy required two staff for mechanical lift transfers, and staff were aware of this requirement, but it was not consistently followed. Further review revealed inconsistencies in staff training and understanding of manufacturer guidelines for the mechanical lift, particularly regarding whether the wheels should be locked during transfers. Staff in-services had provided conflicting information, and some staff continued to lock the wheels despite manufacturer instructions to leave them unlocked. The facility's accident prevention policy emphasized a culture of safety and adherence to protocols, but the failure to ensure proper supervision and adherence to transfer procedures resulted in harm to the resident.
Deficient Food Storage, Expired Items, and Hand Hygiene in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and handling practices. Expired food items, including a half-gallon of buttermilk and three bags of bread, were found in storage past their expiration dates, despite the Dietary Manager's routine checks. Additionally, several opened bags of hamburger buns were left unsealed, exposing them to environmental contaminants and potential pests. Ice scoop holders attached to ice chests were found to be dirty, with residue at the bottom, and the scoops were resting directly on the unclean surfaces. Staff interviews confirmed that cleaning responsibilities for these items were not consistently followed. Dietary staff were also observed failing to adhere to proper hand hygiene protocols. One dietary aide turned off a faucet with bare hands and then handled clean glasses without washing hands. Another aide handled milk cartons, shakes, and condiments, then picked up cups and glasses by the rims without washing hands after touching potentially dirty objects. A third staff member touched a blender motor and then handled clean equipment without washing hands. These actions were in direct violation of the facility's hand washing policy, which requires hand hygiene after contact with dirty equipment or surfaces and before handling clean items.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Staff
Penalty
Summary
A cognitively impaired resident with a history of stroke, moderate dementia, and mood disorders was involved in a sexual act with a staff member, specifically a housekeeper, within the facility. The incident was witnessed by a CNA, who observed the resident performing oral sex on the housekeeper in the resident's bathroom. The event was reported to the facility administrator and local law enforcement, and the housekeeper was immediately terminated. The resident had a documented history of sexual behaviors with other residents and staff, as reported by multiple employees, but these behaviors were not consistently identified or addressed in the resident's Minimum Data Set (MDS) assessments or care plan documentation. Despite the resident's ongoing sexually inappropriate behaviors, the facility failed to implement adequate interventions or supervision to prevent such incidents. Staff interviews revealed that the resident was known for groping and attempting sexual contact with both staff and other residents, yet there were no specific measures in place to restrict unsupervised access to the resident by male staff or to ensure staff were not alone with the resident. The facility's abuse and neglect policy did not specifically address sexual abuse, nor did it provide clear guidance or training for staff on recognizing, preventing, or intervening in cases of sexual abuse involving residents. The facility's documentation and care planning did not accurately reflect the resident's sexual behaviors or risk for abuse, and there was a lack of physician orders or assessments regarding the resident's capacity to consent to sexual activity. Interviews with facility leadership and clinical staff indicated uncertainty about how to assess sexual consent capacity and how to manage residents with hypersexual behaviors. The failure to identify, document, and address the resident's risk for sexual abuse, combined with insufficient staff training and supervision, directly contributed to the occurrence of sexual activity between the resident and a staff member.
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