HIGHLANDS OF LITTLE ROCK AT CUMBERLAND THERAPY AND LIVING CENTER
LOCATED: 1516 SOUTH CUMBERLAND ST, LITTLE ROCK, AR 72022

HIGHLANDS OF LITTLE ROCK AT CUMBERLAND THERAPY AND LIVING CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT

LEVEL OF HARM –IMMEDIATE JEOPARDY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Complaint #’s (AR 820) and (AR 813) was substantiated (all or in part) with these findings:

Based on observation, record review and interview, the facility failed provide Resident #1 the necessary treatment and services to promote healing of a wound and prevent infection. The facility failed to identify the need for treatment of [REDACTED]. #1) of 4 (Resident #s 1 – 4) case mix residents who had a non-pressure related wound. The failed practice resulted in Immediate Jeopardy, which caused or could have cause serious injury, harm or death to Resident #1 whose unmonitored/untreated wound developed gangrene and required a left [MEDICAL CONDITION] and had a potential to affect 13 residents who had non pressure related wounds. The facility was informed of the Immediate Jeopardy on 11/12/15 at 10:10 a.m.

Resident #1 had [DIAGNOSES REDACTED].

The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & (and) Exploitation of Residents in Long Term Care DMS-762 dated 9/26/15 time of incident 4:45 p.m. documented, On 9/26/15 (Saturday) treatment nurse (Licensed Practical Nurse (LPN) #2) notified charge nurse (LPN #3) that resident’s foot was bleeding when he entered the room he noticed a deep laceration under the great left toe of her left foot. He asked the (Certified Nurse Assistant (CNA) #1) that was assigned to resident did she know anything about how this may have happened and she stated she did not know what happened. Charge nurse notified the doctor and received order to send to hospital. Administrator, DON (Director of Nursing), was notified and charge nurse was instructed to look at residents w/c (wheel chair) and bed to see if resident may have hit her foot on the w/c or bed and to complete I&A (Incident and Accident) to investigate to see how this injury may have occurred. Family notified. On 9/27/15 Administrator was notified by charge nurse that (Resident #1) had a fracture on her great left toe in two areas and a deep laceration between her great toe and her second toe that required eight stitches, 1cm (centimeter) deep x 4cm long. Received splint on left foot. During investigation discovered, CNA #1 was getting resident up for dinner and she did not follow the care plan for transferring.

The Nurse’s Note dated 9/30/15 at 8:00 a.m. documented, (Doctor) has been contacted r/t family request for resident to be seen by orthopedic surgeon. There was no documentation found in the Nurses Notes to indicate the wound had been monitored or to indicate the physician or APN was notified of a change in (Resident #1’s) left foot wound until 10/20/15 when the Primary Care Physician (PCP) assessment and documented on 10/20/15, approximately 3 weeks later.

The hospital operative report dated 11/3/15 documented, the patient is an [AGE] year old female, who has developed progressive worsening pain in her left leg associated with dry gangrene. This did seem to increase after an injury about a month ago. Given the findings, operative intervention was discussed. Preoperative Diagnosis: [REDACTED]. 2. Left leg [MEDICAL CONDITION]. Procedure: Left below-the-knee amputation.

Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

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