Inspection Reports for
Ash Flat Healthcare and Rehabilitation Center
66 Ozbirn Lane, Ash Flat, AR, 72513
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
10% occupied
Based on a March 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 12, 2025
Visit Reason
The inspection was conducted as an annual survey of the Ash Flat Healthcare and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 10
Deficiencies: 11
Date: Mar 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, dental services, food service, safety, and other aspects of nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to provide meal service to entire tables before serving the next, lack of posting required state agency contact information, inaccurate Minimum Data Set coding, incomplete care plans, inadequate personal hygiene assistance, failure to prevent contractures, unsafe storage of cigarettes, improper oxygen therapy administration, failure to provide regular dental care, improper preparation of pureed food, and poor food safety and hygiene practices in the kitchen.
Deficiencies (11)
Failed to provide meal service to an entire table before serving the next table, affecting 10 residents.
Failed to post contact information for pertinent State agencies and advocacy groups for 13 residents on the men's secure unit.
Failed to ensure Minimum Data Set (MDS) was coded accurately to reflect resident's dental status for 1 resident.
Failed to update comprehensive care plan to include oxygen therapy for 1 resident.
Failed to provide shaving assistance to 1 resident requiring extensive assistance.
Failed to provide services to minimize potential for further decline in range of motion for 1 resident with contracture.
Failed to ensure safe and hazard-free environment; cabinet with cigarettes was left unlocked.
Failed to follow physician's order for oxygen therapy; resident received oxygen at 3.5L instead of ordered 2L.
Failed to ensure regular dental services were provided to 1 resident with painful teeth.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to ensure food items were dated, expired food discarded, proper hand hygiene and glove use by dietary staff, and proper food storage to prevent contamination.
Report Facts
Residents affected: 10
Residents affected: 13
Residents affected: 65
Residents affected: 5
Residents affected: 68
Oxygen liters per minute: 2
Oxygen liters per minute observed: 3.5
Length of facial hair: 1.5
Containers of cottage cheese expired: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #3 | Observed meal tray delivery practices and cabinet lock practices | |
| Administrator | Confirmed lack of meal tray delivery policy and posting policy | |
| Director of Nursing (DON) | Confirmed meal tray delivery practices, oxygen therapy order discrepancy, shaving and care plan deficiencies | |
| Nurse Consultant #1 | Provided policy documents and confirmed lack of policies | |
| Certified Nursing Assistant (CNA) #1 | Provided information on resident shaving and feeding assistance | |
| Licensed Practical Nurse (LPN) #1 | Described resident shaving and oxygen therapy | |
| Social Director (SD) | Provided information on dental appointments and emergency dental requests | |
| Dietary Employee #1 and #2 | Observed food preparation and hygiene practices | |
| Dietary Supervisor | Provided information on food consistency and food safety policies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 5, 2023
Visit Reason
The inspection was conducted due to a complaint regarding inadequate supervision during medication administration, specifically involving residents consuming medications mixed in food and the risk of residents consuming other residents' medications.
Complaint Details
The complaint involved a medication administration error where Resident #2 ate pudding containing Resident #1's medications. The incident was substantiated through witness statements from CNA and LPN staff, interviews, and review of medication orders and care plans. The facility took corrective actions including monitoring vital signs, notifying family and staff, and providing in-service training to staff on medication supervision.
Findings
The facility failed to ensure proper supervision of residents during medication administration, resulting in Resident #2 consuming medication intended for Resident #1. The investigation included interviews, witness statements, and review of care plans and physician orders, revealing lapses in supervision and medication administration protocols.
Deficiencies (1)
Failure to ensure Resident #1 was observed consuming medications mixed in food and failure to prevent Resident #2 from consuming Resident #1's food containing medication.
Report Facts
Resident BIMS score: 9
Resident BIMS score: 11
Medication dosage: 250
Medication dosage: 10
Date of incident: Apr 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Provided witness statement and reported the medication error incident |
| Licensed Practical Nurse #1 | LPN | Administered medication, provided witness statement, assessed Resident #2, and completed incident paperwork |
| Director of Nursing | DON | Instructed staff on medication supervision, reviewed incident, and provided in-service training |
Inspection Report
Routine
Census: 53
Deficiencies: 6
Date: Dec 30, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, hygiene, safety, food handling, and COVID-19 reporting at Ash Flat Healthcare and Rehabilitation Center.
Findings
The facility was found deficient in providing adequate nail and foot care for diabetic residents, ensuring fingernail clippers were not accessible to residents to prevent accidents, enforcing hair covering policies in the kitchen, properly covering garbage containers, and timely notifying residents and families of confirmed COVID-19 cases.
Deficiencies (6)
Failed to ensure residents' fingernails were cleaned and trimmed to promote good personal hygiene and grooming for diabetic residents dependent on staff for nail care.
Failed to provide appropriate foot/toenail care to keep toenails trimmed and shaped to decrease potential for diabetic-related foot complications.
Failed to ensure fingernail clippers were not in reach to prevent potential accident/hazard for residents dependent on staff for nail care.
Failed to ensure hair coverings were worn consistently by staff entering the meal prep area to prevent potential contamination of food.
Failed to ensure garbage and refuse waste was properly covered with a lid to prevent potential insect or rodent infestation.
Failed to ensure residents, resident representatives, and families were notified by 5 PM the next calendar day following confirmed positive COVID-19 cases.
Report Facts
Residents sampled: 9
Residents affected: 26
Residents sampled: 16
Residents affected: 53
COVID-19 positive residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Interviewed about nail care responsibilities and resident nail clipper access | |
| Registered Nurse (RN) #1 | Interviewed about nail care responsibilities and resident nail clipper access | |
| Director of Nursing (DON) | Interviewed about nail care responsibilities, resident nail clipper policy, foot care concerns, and COVID-19 notification procedures | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about foot care condition and comfort with nail care | |
| CNA #3 | Interviewed about foot lotion application and reporting foot condition | |
| Treatment Nurse (LPN #2) | Interviewed about foot care and podiatry referral | |
| Dietary Manager | Interviewed about hair covering policy in kitchen | |
| Administrator | Interviewed about hair covering policy and COVID-19 notification procedures |
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