Inspection Reports for
Fayetteville Health and Rehabilitation Center
AR, 72703
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
21.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
310% worse than Arkansas average
Arkansas average: 5.2 deficiencies/year
Deficiencies per year
36
27
18
9
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the family of Resident #132 about a significant change in condition and subsequent death.
Complaint Details
The complaint investigation focused on the failure to notify Resident #132's family of a significant change in condition and death. The family reported no contact from the facility or Hospice during the resident's decline and death.
Findings
The facility failed to notify the family of Resident #132 about a significant decline and death, despite Hospice and facility staff being responsible for family notification. Additional deficiencies included failure to implement care plan interventions to prevent skin tears for Resident #22 and failure to follow Enhanced Barrier Precautions during wound care for Resident #14.
Deficiencies (3)
Failed to ensure family was notified of a change in condition for Resident #132.
Failed to ensure interventions of the comprehensive care plan were implemented to prevent possible skin tears to Resident #22.
Failed to ensure staff followed appropriate Enhanced Barrier Precautions (EBP) when providing wound care for Resident #14.
Report Facts
Respiration rate: 30
Pulse rate: 30
SpO2: 70
Skin tear observation dates: 3
Admission date: Sep 18, 2023
Admission date: Mar 11, 2024
MDS assessment reference date: Jul 2, 2025
MDS assessment reference date: Aug 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented change in condition for Resident #132 and medication administration |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding Hospice communication and care for Resident #132 |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding Hospice communication and care for Resident #132 |
| CNA #4 | Certified Nursing Assistant | Interviewed about use of Care Plan for Resident #22 |
| Treatment Nurse | Observed and interviewed regarding failure to follow Enhanced Barrier Precautions for Resident #14 | |
| Administrator | Interviewed regarding responsibility for family notification for Resident #132 | |
| Assistant Director of Nursing | ADON | Interviewed regarding responsibility for family notification for Resident #132 |
| Medical Director | Interviewed regarding infection control practices for Resident #14 | |
| Director of Nursing | Interviewed regarding care plan adherence and infection control for Residents #22 and #14 |
Inspection Report
Routine
Deficiencies: 2
Date: Nov 21, 2025
Visit Reason
The inspection was conducted to assess compliance with medication administration and adherence to physician orders for residents, specifically focusing on medication administration and care plan adherence for two sampled residents.
Findings
The facility failed to ensure one resident (Resident #94) received an ordered medication injection as prescribed, and failed to follow a physician's order for another resident (Resident #4) regarding head of bed elevation. Observations and interviews confirmed these deficiencies with minimal harm or potential for harm.
Deficiencies (2)
Failure to administer the ordered [Name Brand Contraceptive] injection to Resident #94 in June as prescribed.
Failure to elevate Resident #4's head of bed to 30-45 degrees as ordered, observed multiple times with the resident lying flat.
Report Facts
Residents Affected: 2
Medication dose: 150
Head of bed elevation degrees: 30
Head of bed elevation degrees: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #10 | Interviewed regarding missed medication injection for Resident #94 | |
| Director of Nursing (DON) | Interviewed regarding medication ordering and head of bed elevation orders | |
| Medical Director | Interviewed regarding medication schedule and head of bed elevation importance | |
| Administrator | Interviewed regarding staff adherence to physician orders and medication documentation | |
| Certified Nursing Assistant (CNA) #6 | Interviewed regarding care provided to Resident #4 and observations of head of bed elevation | |
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding Resident #4's head of bed elevation order and guardian's request | |
| MDS Nurse | Interviewed regarding Resident #4's physician orders and care plan |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a family member of a significant change in condition for Resident #132, who was under Hospice care.
Complaint Details
The complaint investigation focused on the failure to notify Resident #132's family of a significant decline and death. The family reported no notification from the facility or Hospice. The investigation found both Hospice and facility staff were responsible but failed to notify the family. The family refused further questions.
Findings
The facility failed to ensure family notification of Resident #132's change in condition and subsequent death. Interviews revealed confusion and lack of clear responsibility between Hospice and facility staff regarding family notification. Additional deficiencies were found related to care plan implementation for Resident #22 and infection control practices for Resident #14.
Deficiencies (3)
Failed to ensure family was notified of a change in condition for Resident #132 under Hospice care.
Failed to implement care plan interventions to prevent possible skin tears for Resident #22.
Failed to follow Enhanced Barrier Precautions (EBP) during wound care for Resident #14.
Report Facts
Deficiencies cited: 3
Resident #22 admission date: Sep 18, 2023
Resident #14 admission date: Mar 11, 2024
Resident #14 wound bandage date: Sep 22, 2022
Resident #14 mental status score: 1
Resident #22 mental status score: 3
Resident #14 respiration rate: 30
Resident #14 pulse rate: 30
Resident #14 pulse oxygen saturation: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented Resident #132's change in condition and medication administration; interviewed about Hospice notification |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding Hospice notification procedures |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding familiarity with Resident #132 and Hospice notification |
| CNA #4 | Certified Nursing Assistant | Interviewed about use of Care Plan for Resident #22 |
| Treatment Nurse | Observed and interviewed regarding failure to follow Enhanced Barrier Precautions for Resident #14 wound care | |
| Administrator | Interviewed about family notification responsibility and Hospice in-service training | |
| Assistant Director of Nursing | ADON | Interviewed about family notification responsibility and Hospice communication |
| Medical Director | Interviewed regarding infection control requirements for Resident #14 wound care | |
| Director of Nursing | Interviewed regarding infection control and care plan expectations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 21, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to administer an ordered medication to Resident #94 and failure to follow a physician's order for Resident #4 regarding head of bed positioning.
Complaint Details
The complaint investigation found substantiated deficiencies related to medication administration and failure to follow physician orders for head of bed positioning, affecting a few residents.
Findings
The facility failed to ensure Resident #94 received a scheduled contraceptive injection in June 2025 as ordered, and failed to follow the physician's order for Resident #4 to have the head of bed elevated 30-45 degrees while in bed, as multiple observations showed the resident lying flat.
Deficiencies (2)
Failure to administer ordered contraceptive injection to Resident #94 in June 2025.
Failure to follow physician's order for Resident #4 to have head of bed elevated 30-45 degrees while in bed.
Report Facts
Residents affected: 2
Mental status score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Interviewed regarding failure to administer Resident #94's medication. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication ordering and failure to follow physician orders. |
| Medical Director | Medical Director | Interviewed regarding Resident #94's medication and Resident #4's head of bed order. |
| Administrator | Administrator | Interviewed regarding staff expectations to follow physician orders and medication documentation. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding Resident #4's head of bed order. |
| MDS Nurse | MDS Nurse | Interviewed regarding Resident #4's physician orders and care plan. |
| CNA #6 | Certified Nursing Assistant | Interviewed regarding care provided to Resident #4 and observations of head of bed positioning. |
Inspection Report
Routine
Deficiencies: 12
Date: Jun 27, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal regulations regarding resident rights, safety, care planning, medication management, infection control, food service, and facility environment at Fayetteville Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' dignity, inadequate environmental maintenance, inaccurate resident assessments and care plans, improper medication management, unsafe use of transfer lifts, failure to follow physician orders for oxygen therapy, poor food preparation and storage practices, inadequate infection control including hand hygiene and pest control, and unsafe and unsanitary facility conditions.
Deficiencies (12)
Failure to ensure residents' dignity during transfers and meal assistance, including exposure of residents and improper staff positioning.
Walls and fixtures in residents' rooms were damaged, unclean, and in disrepair, creating an unsafe and unhomelike environment.
Inaccurate Minimum Data Set (MDS) assessments and incomplete care plans for residents, including failure to document contractures and removal of call lights.
Failure to provide pressure relieving devices as ordered, resulting in residents sitting on unprotected surfaces.
Transfer lifts were missing critical attachments, posing a risk of injury during resident transfers.
Failure to follow physician orders for oxygen therapy, with oxygen flow set below prescribed levels.
Expired medications were found on medication carts; controlled substances were not properly secured after seal breakage; medications and creams were stored improperly within resident reach.
Meals were not prepared or served according to the planned menu; pureed foods were inconsistently prepared with improper texture; hot foods were served at unsafe temperatures.
Food storage areas contained unlabeled, undated, and expired food items; improper hand hygiene and glove use by dietary staff during food preparation and service; unsanitary conditions observed in ice machine and scoop holder.
Failure to implement proper hand hygiene by staff during meal service, increasing risk of infection transmission.
Resident exposed to pest infestation with multiple flies observed in resident room and dining areas despite ongoing pest control efforts.
Facility environment was unsafe and unsanitary with damaged furniture, exposed sharp edges, peeling paint, missing drywall, and electrical hazards in resident rooms and common areas.
Report Facts
Residents affected: 6
Medication expiration dates: 2023
Temperature readings: 50
Fly counts: 8
MDS Assessment Reference Dates: May 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #17 | Certified Nursing Assistant | Named in findings related to failure to maintain resident dignity and hand hygiene during meal service |
| CNA #12 | Certified Nursing Assistant | Interviewed regarding resident dignity and hand hygiene |
| Director of Nursing | Director of Nursing | Interviewed regarding staff responsibilities for resident dignity, medication management, oxygen therapy, and infection control |
| Maintenance | Interviewed regarding facility maintenance issues and pest control | |
| LPN #19 | Licensed Practical Nurse | Interviewed regarding oxygen therapy and medication cart management |
| Dietary Manager | Interviewed regarding food preparation, storage, and sanitation practices | |
| CNA #18 | Certified Nursing Assistant | Observed and interviewed regarding pest issues and resident care |
| CNA #8 | Certified Nursing Assistant | Observed during meal service with hand hygiene concerns |
| DC #11 | Dietary Cook | Observed and interviewed regarding food preparation and hand hygiene |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to assess the facility's maintenance and repair of the physical environment, specifically the condition of walls, floors, bathroom fixtures, and door hardware in resident rooms to ensure a safe, clean, and homelike environment.
Findings
The facility failed to maintain walls, floors, bathroom fixtures, and door hardware in residents' rooms in good repair, exposing residents to potential hazards such as damaged drywall, peeling toilet seats, loose door handles, and missing floor tiles. Maintenance acknowledged these issues and reported ongoing repair efforts, including replacement of a toilet seat during the survey.
Deficiencies (5)
Walls in residents' rooms were damaged exposing gypsum compound and peeling paint.
Toilet seat in resident bathroom was peeling and stained.
Loose door handle with escutcheon plate falling forward interfering with door operation.
Missing tile on floor exposing concrete and creating a fall risk.
Bathroom sink missing drain cover with cracks and brownish black gritty substance.
Report Facts
Date of survey completion: Jun 27, 2024
Tile missing size: 1.5
Tile missing size: 2
Tile depth: 0.125
Toilet seat replacement time: 1630
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #18 | Certified Nursing Assistant | Interviewed regarding floor fall risk and bathroom sink condition |
| Maintenance | Interviewed about maintenance logs, repair schedules, and specific room repairs | |
| Administrator | Administrator | Interviewed about maintenance program, repair plans, and resident relocation for repairs |
Inspection Report
Routine
Deficiencies: 12
Date: Jun 27, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident rights, care planning, environment, safety, infection control, food service, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' dignity, inaccurate assessments and care plans, environmental maintenance issues, improper medication management, unsafe use of transfer lifts, failure to follow physician orders for oxygen therapy, food service deficiencies including improper food preparation and storage, inadequate infection control practices, and pest control issues.
Deficiencies (12)
Failure to ensure residents' rights were acknowledged and dignity maintained during care and meal service.
Failure to maintain walls, floors, and bathroom fixtures in good repair, creating unsafe and unclean environment.
Failure to ensure accurate Minimum Data Set (MDS) assessments and care plans for residents.
Failure to provide pressure relieving devices as ordered to prevent skin breakdown.
Failure to ensure transfer lifts were properly maintained and safe to use.
Failure to follow physician orders for oxygen therapy resulting in incorrect oxygen flow rate.
Failure to remove expired medications and properly manage controlled substances; medications stored within resident reach without proper labeling.
Failure to prepare and serve meals according to planned menus and nutritional needs, including improper food temperatures and inconsistent pureed food textures.
Failure to maintain proper food storage practices including labeling, dating, and removal of expired foods; failure to perform proper hand hygiene during food handling and distribution.
Failure to implement effective infection prevention and control practices including hand hygiene and pest control, resulting in resident exposure to pests and potential infection risks.
Failure to maintain a safe, functional, sanitary, and comfortable environment for residents, including damaged furniture, walls, and fixtures.
Failure to maintain an effective pest control program to prevent flies and other pests in kitchen and dining areas.
Report Facts
Residents affected: 6
Medication expiration dates: 2023
Temperature readings: 50
Fly counts: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #17 | Certified Nursing Assistant | Named in multiple findings related to failure to perform hand hygiene and dignity during meal service |
| Director of Nursing | Interviewed regarding responsibility for pressure relieving devices, importance of accurate MDS, medication management, and infection control | |
| Maintenance | Interviewed regarding facility maintenance issues and pest control | |
| Dietary Manager | Interviewed regarding food storage, preparation, and sanitation deficiencies | |
| LPN #19 | Licensed Practical Nurse | Interviewed regarding medication cart checks and oxygen therapy order compliance |
| CNA #12 | Certified Nursing Assistant | Interviewed regarding hand hygiene and pest control |
Inspection Report
Deficiencies: 5
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, specifically focusing on the physical condition of residents' rooms and related maintenance issues.
Findings
The facility failed to ensure walls in residents' rooms were maintained in good repair, with multiple observations of damaged walls, chipped paint, loose door handles, missing tiles, and stained bathroom fixtures. Maintenance acknowledged the issues and described the repair process, while the Administrator confirmed awareness and plans to address the damages.
Deficiencies (5)
Walls in residents' rooms were damaged exposing gypsum compound and peeling paint.
Toilet seat in resident's bathroom was peeling and stained.
Loose doorknob and escutcheon plate interfering with door operation.
Missing tile on floor exposing concrete and cracked surrounding tiles.
Bathroom sink missing drain cover with cracks and brownish black gritty substance.
Report Facts
Maintenance rounds frequency: 2
Tile missing size: 3
Date of inspection: Jun 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #18 | Certified Nursing Assistant | Provided statements regarding floor fall risk and bathroom sink condition. |
| Maintenance | Provided information on maintenance logs, repair schedules, and specific room repairs. | |
| Administrator | Administrator | Interviewed regarding maintenance program, repair plans, and resident relocation if needed. |
Inspection Report
Routine
Census: 92
Deficiencies: 10
Date: May 26, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, facility safety, staff certification, medication management, food service, and facility maintenance.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to incorporate PASARR recommendations into care plans, inadequate nail care for residents, uncertified nurse aides working beyond allowed timeframes, improper medication storage and handling including expired medications and medications left in resident rooms, failure to serve meals according to planned menus and proper temperature standards, poor food preparation consistency, unsanitary kitchen conditions, improper hand hygiene among dietary staff, reuse of leftover pureed foods, and damaged resident rooms with peeling paint and holes in walls.
Deficiencies (10)
Failed to ensure Minimum Data Set (MDS) assessment accurately reflected Level II PASARR evaluation for Resident #12.
Failed to incorporate PASARR Level II recommendations into Resident #12's Care Plan.
Failed to provide nail care to promote hygiene and reduce risk of injury for Residents #22 and #40.
Failed to ensure Nurse Aide #2 was certified within 4 months of training.
Failed to ensure refrigerated narcotic medications were stored in a permanently affixed compartment; expired medications stored with others; medications left in resident rooms for Residents #12, #15, and #82.
Failed to serve meals according to planned menu portions for mechanical soft and pureed diets.
Failed to ensure food was served at safe temperatures and maintained palatability for residents on B and C Halls.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to maintain kitchen cleanliness and sanitation including floor tiles, baseboards, vents, ice machine, and proper food storage; failed to ensure dietary staff practiced proper hand hygiene; failed to prevent reuse of leftover pureed foods.
Failed to maintain resident rooms free of damage including peeling paint and holes in walls in multiple rooms.
Report Facts
Residents affected: 1
Residents affected: 2
Nurse Aide hours worked: 126.62
Residents affected: 3
Residents affected: 27
Residents affected: 7
Residents affected: 92
Missing floor tiles: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #2 | Nurse Aide | Worked over 4 months without certification |
| LPN #1 | Licensed Practical Nurse | Described medication administration and food service practices |
| LPN #4 | Licensed Practical Nurse | Identified medications left in resident rooms and discussed medication protocols |
| DE #1 | Dietary Employee | Observed contaminating gloves and improper hand hygiene |
| DE #2 | Dietary Employee | Prepared pureed foods with improper consistency and reused leftovers |
| DON | Director of Nursing | Provided census data and discussed importance of care planning and room maintenance |
| Maintenance Director | Discussed delays in room repairs |
Inspection Report
Routine
Census: 92
Deficiencies: 10
Date: May 26, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication management, dietary services, staff certification, and facility maintenance.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to incorporate PASARR recommendations into care plans, inadequate nail care for residents, uncertified nurse aides working beyond allowed timeframes, improper medication storage and administration practices, failure to maintain food quality and safety, unsanitary kitchen conditions, and damaged resident rooms.
Deficiencies (10)
Failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a Level II PASARR evaluation for Resident #12.
Failed to incorporate PASARR Level II recommendations into Resident #12's Care Plan.
Failed to provide nail care to promote hygiene and reduce risk of injury for 2 residents requiring assistance.
Failed to ensure full-time Nurse Aides were certified within 4 months of training.
Failed to ensure refrigerated narcotic medications were stored in a permanently affixed compartment, expired medications were removed, and medications were not left in resident rooms.
Failed to ensure meals were prepared and served according to the planned menu and nutritional needs, including incorrect portion sizes and improper food consistency.
Failed to ensure food was served at safe temperatures and maintained palatability.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to maintain kitchen cleanliness and sanitation, including unclean ice machine, improper food storage, and staff not following hand hygiene protocols.
Failed to ensure resident rooms were free of damage, with peeling paint and holes in walls in multiple rooms.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 92
Nurse Aide hours worked: 126.62
Residents affected: 27
Residents affected: 7
Residents affected: 92
Resident rooms affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Described nail care issues for Resident #22 |
| RN #1 | Registered Nurse | Described nail care issues for Resident #22 |
| LPN #2 | Licensed Practical Nurse | Described nail care responsibilities and frequency |
| NA #2 | Nurse Aide | Worked over 4 months without certification |
| DON | Director of Nursing | Provided information on nurse aide certification and medication policies |
| LPN #4 | Licensed Practical Nurse | Described medication administration and risks of leaving meds in rooms |
| DE #1 | Dietary Employee | Observed contaminating clean dishes and improper glove use |
| DE #2 | Dietary Employee | Prepared pureed foods with improper consistency and contaminated gloves |
| Maintenance Director | Discussed delays in room repairs and importance of room maintenance |
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