The Springs of Brinkley

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident # 54's representative was promptly notified of a fall, for one (Resident #54) out of one resident reviewed for notification of change. Specifically, Resident #54 had an unwitnessed fall on 12/03/2025. Based on record review and interview, the facility failed to ensure a resident's representative was promptly notified of a fall, for one (Resident #54) of one resident reviewed for notification of change in condition.

Inspectors wroteBased on record review, observation, interview, and video review, the facility failed to ensure effective care planned interventions were created and implemented following new on-set of wandering and/or elopement associated behaviors, in which Resident #1 attempted on multiple occasions to exit the facility and voiced intent to exit the facility in the future. At the time of the survey, there were 8 residents in the secured unit at risk of eloping. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.10(c)(3) (Comprehensive Care Plans) at a scope and severity of J. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure increased supervision was provided by staff during periods of increased exit seeking behaviors for one (Resident #1) of four sampled residents reviewed for elopement. The lack of effective supervision resulted in Resident #1 eloping from the facility, and the facility staff being unaware of the residents' whereabouts. At the time of the survey, there were eight residents residing on the locked unit.

Inspectors wroteBased on record review, interviews, and facility policy review, it was determined that the facility failed to prevent resident to resident abuse for two (Resident #1 and Resident #3) of four residents reviewed for abuse.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and hand hygiene was performed to prevent the possible spread of infection for 1 (Resident #5) of 1 resident sampled for infection prevention and control.

Inspectors wroteBased on observation, record review, interview, and facility policy reviews, it was determined the facility failed to repair or replace a leaking water heater in a timely manner for 2 sampled (Resident #31, Resident #39) capable of ambulation or self-propelling on North Hall to ensure a sanitary, orderly, and comfortable interior.

Inspectors wroteBased on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure care plans were revised to reflect the changing needs and preferences for 2 (Residents #11 and #35) of 20 (Residents #1, #4, #8, #11, #12 , #13, #14, #17, #19, #20, #21, #31, #32, #34, #35, #38, #39, #42, #49 and #53) sampled residents reviewed for care plan revisions.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the North Hall was free of water and wet linens affecting 2 (Resident #31 and #39) sampled residents when ambulating in the hallway to prevent falls, and accidents; failed to ensure the North Hall shower door tub room was locked to prevent residents from having access to open razors, and to prevent falls on wet, soapy floors; failed to ensure the tub room on the North Hall, being used to store portable oxygen tanks, was kept locked to prevent resident accidents or injuries failed to ensure 1 smoker requiring supervision (Resident #39) of 1 sampled (Resident #39) was not smoking without supervision to prevent accidents or injuries; failed to ensure the 200 Hallway was free of missing tile with an uneven surface to prevent accidents and injury; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure manufacture's guidelines found on the container were followed to prevent the potential for food spoilage and / or growth of bacteria, foods were stored properly after being opened and dietary staff washed their hands and changed gloves during the meal preparation to decrease the potential for food borne illnesses for residents who received meals from 1 of 1 kitchen. This had the potential to affect 49 residents (Census: 51), as indicated on a list provided by the District Dietary Manager on 08/15/2024.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure residents personal funds were returned within 30 days of death for 1 (Resident #207) of 3 sampled (Residents #207, #14, #6) sampled residents.

Inspectors wroteBased on observation, record review, interview, and facility policy review, it was determined the facility failed to provide a bed hold notice prior to discharge for 1 (Resident #11) of 2 sampled residents (Resident #11 and Resident #54) who were discharged or transferred to the hospital.

Inspectors wroteBased on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure a comprehensive care plan was provided for 1 (Resident #11) of 20 (Residents #1, #4, #8, #11, #12, #13, #14, #17, #19, #20, #21, #31, #32, #34, #35, #38, #39, #42, #49, #53) sampled residents requiring a comprehensive care plan to ensure residents receive appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fingernails were cleaned and trimmed for 1 (Resident #35) sampled resident who was reviewed for nail care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen was administered at the physician's ordered flow rate to decrease the potential for respiratory complications for 1 (Resident #38) of 2 (Residents #38 and #39) sampled residents who were reviewed for oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a glucometer machine was cleansed after being used for 1 (Resident #107) of 1 sampled resident observed during a glucometer check.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen area air conditioner intake filter and vents were clean to prevent potential food borne illness. This failed practice had the potential to affect 47 residents who received food from the kitchen (total census: 49), according to the Diet List provided by the Dietary Manager on 08/21/23 at 10:55 AM.

Inspectors wroteBased on observation and interview, the facility failed to ensure waste was properly contained in a dumpster with the door and lid closed to reduce the potential of insect and/or rodent infestation. The failed practice had the ability to affect all 49 residents who resided in the facility according to the Resident Census and Conditions of Residents provided by the Administrator on 08/25/23 at 1:05 PM.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a physical restraint was released in accordance with a Physician's Order for 1 (Resident #25) of 2 (Residents #25 and #33) sampled residents with a Physician's Order for a physical restraint according to the Resident Matrix provided by the Administrator on 08/21/23 at 1:05 PM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the doors to the Electrical Equipment Room and the Water Heater Mechanical Room located in the Dining Room were locked and inaccessible by residents. This failed practice had the potential to affect 20 residents who were mobile and able to access the dining area according to a list provided by the Administrator on 08/23/23 at 8:00 AM.

Inspectors wroteBased on observation and interview, the facility failed to ensure an effective pest control program was maintained. The failed practice had the potential to affect all 49 residents residing in the facility according to the Resident Census and Conditions of Residents provided by the Administrator on 08/21/23 at 1:05 PM.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's Emergency Contact was notified after a fall for 1 (Resident #40) of 1 sampled resident who had a documented fall without injury.