Following are some of the deficiencies found during inspections of this nursing home on 2/12/09, 12/3/08, (OWNERSHIP CHANGED 12/1/08), 7/9/08, 4/20/07 and 3/15/07. These Reports and others dated 4/18/08 – 5 pp, 8/16/06 – 10 pp and 4/18/06 – 41 pp, can be found at www.arknursinghomeinspectiondeficiencies.com.
Inspection on 2/12/09 (22 pages) 1. ACCIDENTS AND SUPERVISION: . . . the facility failed to ensure staff received training prior to the use of a mechanical lift for Resident #13 . . . and failed to ensure interventions were developed and implemented to prevent the potential for continued falls for Resident #5 . . . who sustained multiple falls. These failed practices resulted in . . . serious injury, harm, impairment . . . for Resident #13 who sustained a fracture when falling from an improperly secured lift sling and Resident #5 who sustained multiple falls. Resident #13. . . c. A Hospital Discharge Summary dated 2/1/09 documented a diagnosis of “Left femur fracture. . .procedures performed: surgery for left femur fracture. Pages 8-9 and 11.
2. SANITARY CONDITIONS: . . .the facility failed to ensure . . . employees washed their hands or changed gloves between handling food items, dirty towel, and equipment and the kitchen was free of pest . . . 3. On 2/11/09 at 4:56 p.m., there was a roach crawling on the shelf by the steam table where clean dishes were kept. There was another roach crawling on the board on the wall where information was posted. This board was located by the door leading to the dish room. Pages 20-22.
Inspection on 12/3/08 (8 pages) 1. INFECTION CONTROL: . . . the facility failed to ensure the staff followed the policy for maintaining aseptic technique during a dressing change, handling and disposal of contaminated linen and trash to prevent the potential for the spread of infection during treatment of a wound for Resident #6 . . . Page 3.
OWNERSHIP CHANGED 12/1/08 Inspection on 7/9/08 (23 pages) 1. ACCIDENTS AND SUPERVISION: . . . the facility failed to ensure the Q-straint wheelchair and occupant restraint system in the facility van were applied in accordance with the manufacturer’s instructions to prevent potential accident / injuries for Residents #5 and #6 . . . who required transfers via wheelchair in the facility van . . . This failed practice resulted in. . . serious harm, injury . . . to Resident #5, who slid out the wheelchair during transportation and sustained a cervical (C2 dens) fracture. Page 1.
Inspection on 4/20/07 (7 pages) 1. ACTIVITIES OF DAILY LIVING: . . . the facility failed to ensure incontinent care was provided for Resident #2 . . . On 4/19/07 at 9:30 a.m., the resident’s bed sheet was wet with urine. CNA #1 and #2 stood the resident up and removed the urine saturated incontinent brief, then placed a clean incontinent brief on the resident and laid the resident back down on the bed. The resident’s shirt was changed and a pair of pants was put on the resident. The CNA’s did not provide any incontinent care. Pages 3-4.
Inspection on 3/15/07 (14 pages) 1. NUTRITION: . . . the facility failed to ensure dietary recommendations and physician orders for dietary supplements were implemented for Resident #2 . . . who had a history of weight loss. Resident #2 . . . A Quarterly Minimum Data Set dated 12/5/06 documented the resident . . . had a weight loss. a. A physician order dated 4/14/06 documented Mighty Shakes with meals 3 times daily . . . c. The Resident’s Weight Listing documented the following weights: 1) 8/06 – 161 pounds (lbs); 2) 9/06 – 160 lbs; and 3) 10/06 – 122.8 lbs; and . . b. A physician order dated 10/26/06 documented Mighty Shakes Plus three times a day. 4) 11/06 – 124 lbs; 5) 12/06 – 125.6 lbs; 6) 1/07 – 123 lbs; 7) 2/07 – 115.9 lbs; and 8) 2/28/07 – 113 lbs. . . d. The Interdisciplinary Progress Notes dated 11/29/06 and signed by the Registered Dietician (RD) documented the resident had a 22.5% weight loss in 6 months and was started on Mighty Shakes 3 times a day in October 2006. e) The Interdisciplinary Progress Notes dated 1/24/07 and signed by the RD documented the resident weighed 123.6 pounds and the resident had a 2% weight loss in a month and a 23% weight loss in 6 months. The recommendation was to continue Mighty Shakes 3 times a day. . . g. On 2/27/07 at 12:10 p.m., the resident was not served a shake of any kind with lunch. h. On 2/27/07 at 5:10 p.m., the resident was not served a shake of any kind with supper. i. . . . n. On 3/15/07 the facility was unable to provide the “FOOD INTAKE RECORD,” for February 2007. Page 9.
