Inspection Reports for
Fayetteville Health and Rehabilitation Center
AR, 72703
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
106% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
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
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
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 |
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