Inspection Reports for
Gassville Therapy and Living
203 Cotter Road, Gassville, AR, 72635
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than Arkansas average
Arkansas average: 5.2 deficiencies/year
Deficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
20% occupied
Based on a July 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: Dec 18, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Gassville Therapy and Living.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 2
Date: Nov 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, oral care, and environmental safety in the nursing home.
Findings
The facility failed to ensure dignity and proper oral care for a resident by not providing accessible denture care supplies and assistance. Additionally, the facility did not maintain a clean and safe environment in multiple resident rooms, with issues such as unemptied trash, stained toilets, and damaged wall trim.
Deficiencies (2)
Failure to ensure dignity and proper oral care for resident #3, including lack of accessible denture cup and oral hygiene assistance.
Failure to maintain a safe, clean, and comfortable environment, including unemptied trash, stained toilets, and damaged wall trim in multiple resident rooms.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding awareness of denture care issues and environmental deficiencies. | |
| Director of Nursing (DON) | Interviewed regarding plans to provide bedside table with drawer for oral hygiene supplies. | |
| Maintenance | Interviewed about responsibility for repairs of wall trim and sheetrock. |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 3
Date: Jul 11, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding Resident #15's grievances about call light response times and staff responsiveness.
Complaint Details
The complaint involved Resident #15 reporting delayed call light responses, staff neglect, and improper handling of grievances. The investigation was found to be incomplete and not thorough, with only one staff member interviewed and no interviews of other involved staff or cognitively intact residents. The grievance was filed on 07/02/2024 and resolved on 07/03/2024 with a call light audit and staff counseling, but Resident #15 reported no direct follow-up contact.
Findings
The facility failed to ensure that Resident #15's grievances about delayed call light responses were thoroughly investigated, with inadequate staff interviews and incomplete grievance follow-up. Additionally, the facility was found to have unlocked treatment carts and unlocked shower rooms containing hazardous chemicals, posing potential safety risks to residents.
Deficiencies (3)
Failure to thoroughly investigate Resident #15's grievances regarding call light response times, including inadequate interviews of cognitively intact residents and involved staff.
Unlocked shower room next to secure unit with access to potentially hazardous chemicals and supplies.
Unlocked treatment cart containing medications and medical supplies accessible to residents.
Report Facts
Resident call light response times: 18
Resident call light response times: 9
Resident call light response times: 1
Resident call light response times: 15
Resident call light response times: 11
Residents interviewable with BIMS 12 or higher: 6
Residents non-interviewable: 15
Insulin needles: 15
Arginaid powder packets: 8
COVID-19 Ag Card tests: 60
Hemorrhoid suppositories: 12
Vitamin B-12 dosage: 500
Vitamin D-3 dosage: 2000
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 6
Date: Jul 11, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding call light response times and resident grievances at the facility.
Complaint Details
The complaint investigation focused on Resident #15's grievance about call light response times not being answered timely. The investigation revealed inadequate grievance investigation processes, lack of interviews with cognitively intact residents and involved staff, and unresolved concerns despite grievance filings.
Findings
The facility failed to thoroughly investigate resident grievances related to call light response times, failed to implement securement devices for catheters for sampled residents, did not provide appropriate interventions for contractures, failed to ensure residents received necessary assistance with activities of daily living, and had issues with food preparation consistency and food safety practices.
Deficiencies (6)
Failed to ensure residents with grievances regarding call light answering times had their complaints thoroughly investigated.
Failed to revise care plans to include securement device interventions for catheters for 2 sampled residents and failed to ensure interventions for contracture for 1 sampled resident.
Failed to provide necessary assistance with activities of daily living, resulting in a resident not being shaved as scheduled.
Left treatment cart unlocked and shower room unlocked with chemical hazards accessible to residents.
Failed to ensure pureed food was processed to the correct consistency for a resident requiring pureed diet.
Failed to ensure food items were dated and labeled in the walk-in refrigerator, expired items discarded, and prevented cross contamination during food service.
Report Facts
Call light response times: 18
Call light response times: 9
Call light response times: 1
Call light response times: 15
Call light response times: 11
Residents with BIMS score 12 or higher: 6
Residents non-interviewable: 15
Bath sheets records: 3
Pureed food scoops: 3
Expired food items: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #3 | Confirmed no securement device in place for Resident #9 catheter after bed bath | |
| Registered Nurse (RN) #4 | Confirmed no securement device for Resident #9 and #25 catheters and explained skin breakdown risk | |
| Certified Nursing Assistant (CNA) #6 | Reported no interventions for Resident #42 contracture and requested sling | |
| Director of Nursing (DON) | Acknowledged lack of contracture interventions and importance of securement devices and shaving | |
| Dietary Manager | Described pureed food consistency issues and confirmed cross contamination during food service | |
| Licensed Practical Nurse (LPN) #1 | Confirmed shower room should be locked and treatment cart should be locked | |
| Certified Nursing Assistant (CNA) #2 | Confirmed shower room should be locked and cleaned immediately after use | |
| Social Activity Director | Admitted grievance investigation was not thorough and did not interview cognitively intact residents | |
| Administrator | Acknowledged limited staff interviews and follow-up on Resident #15 complaint |
Inspection Report
Routine
Census: 43
Deficiencies: 2
Date: Jan 25, 2024
Visit Reason
The inspection was conducted to evaluate compliance with food safety and hygiene standards in the facility's kitchen, focusing on food handling, storage, and employee hygiene practices.
Findings
The facility failed to ensure proper handwashing between clean and dirty tasks and failed to date food items when received or opened, increasing the risk of cross contamination and foodborne illness. Observations and interviews confirmed these deficiencies affecting 42 residents.
Deficiencies (2)
Food items in dry storage and refrigerator were not dated when received or opened.
Cook failed to wash hands between tasks and placed thumbs on plates during meal service.
Report Facts
Residents affected: 42
Census: 43
Food items without received date: 4
Food items without open date: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook | Observed failing to wash hands and placing thumbs on plates during meal service | |
| Dietary Manager | Confirmed observations and facility policies regarding food dating and handwashing |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 7, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to revise care plans and complete resident assessments following falls for certain residents.
Complaint Details
The visit was complaint-related, focusing on the failure to revise care plans and complete fall assessments after each fall for residents #3 and #4, and failure to assess resident #1's independent tracheostomy care. The Nursing Consultant and Director of Nursing confirmed these issues during interviews.
Findings
The facility failed to revise care plans to reflect new fall interventions for residents #3 and #4 and did not complete fall assessments after each fall for residents #3 and #4. Additionally, resident #1 was not assessed for providing her own tracheostomy care despite doing so. Interviews with the Nursing Consultant and Director of Nursing confirmed these deficiencies.
Deficiencies (3)
Failure to revise the plan of care to reflect current needs of new fall interventions for residents #3 and #4.
Failure to complete fall assessments after each fall for residents #3 and #4.
Failure to ensure resident assessments were completed for resident #1 regarding independent tracheostomy care.
Report Facts
Falls recorded for Resident #3: 7
Falls recorded for Resident #4: 2
Residents with incomplete fall assessments: 2
Residents with incomplete assessments: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Consultant | Confirmed during interviews that care plans and fall assessments were incomplete for residents #3 and #4 | |
| Director of Nursing | Confirmed during interviews that care plans and fall assessments were incomplete for residents #3 and #4 and that resident #1 was not assessed for independent tracheostomy care |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 13, 2023
Visit Reason
The inspection was conducted to assess compliance with resident rights, care and treatment, and food safety standards at Gassville Therapy and Living.
Findings
The facility was found deficient in maintaining resident dignity during meal assistance, failing to obtain physician orders and properly date wound dressings, and not following proper food safety practices including labeling, dating, and staff hygiene in the kitchen. These deficiencies had the potential to affect multiple residents with minimal harm.
Deficiencies (3)
Failed to ensure residents requiring assistance to eat were assisted with dignity and respect, including staff not sitting at eye level during feeding.
Failed to provide appropriate wound care including obtaining physician orders and dating wound dressings for a resident's skin tear.
Failed to ensure food items in refrigerators were properly sealed, labeled, and dated, and failed to ensure staff wore hair nets/beard restraints while serving food.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 41
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in dignity during feeding deficiency and wound care responsibility |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding meal assistance staffing and dining room practices |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding meal assistance staffing and dining room practices |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed regarding wound care and meal assistance practices |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding wound care and treatment orders |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding wound care and treatment orders |
| Dietary Manager | Dietary Manager | Interviewed regarding food labeling, dating, and staff hygiene |
| Dietary Employee #2 | Dietary Employee | Observed preparing food without beard restraint |
| Registered Dietician | Registered Dietician | Interviewed regarding food safety and labeling practices |
| Administrator | Administrator | Interviewed regarding staff expectations and facility policies |
Inspection Report
Routine
Census: 46
Deficiencies: 9
Date: Apr 21, 2023
Visit Reason
Routine inspection to assess compliance with regulatory requirements related to resident care, safety, therapy services, staffing, food service, infection control, and other facility operations.
Findings
The facility failed to ensure residents' rights to make treatment decisions, proper pre-admission screening for mental health, development of complete care plans, safe respiratory care, adequate staffing, proper food preparation and storage, and infection control practices including hand hygiene and laundry handling. Several residents experienced risks related to these deficiencies.
Deficiencies (9)
Failed to ensure residents had the right to make treatment decisions and therapy evaluations were provided for cognitively intact residents.
Failed to ensure pre-admission screening and resident review (PASRR) was completed for residents with serious mental health disorders.
Failed to develop and implement complete care plans for respiratory therapy, heel protector usage, and wandering interventions.
Failed to ensure therapy evaluations were conducted to prevent decline in range of motion for residents requiring continued therapy services.
Failed to ensure oxygen supplies were properly stored to prevent contamination and tubing length was inadequate for resident use.
Failed to provide adequate direct care staff coverage to properly supervise and provide care for residents to prevent accidents, injury, and decline.
Failed to ensure pureed food items were blended to a smooth, pudding-like consistency to minimize choking risk.
Failed to ensure food items stored in refrigerators, freezers, and dry storage were covered, sealed, dated, and expired or spoiled items discarded; kitchen was not deep cleaned regularly.
Failed to ensure staff washed or sanitized hands during meal service and failed to ensure clean personal laundry was covered during transport to prevent contamination.
Report Facts
Residents affected: 7
Residents affected: 13
Residents affected: 46
Residents affected: 16
Staff training dates: 6
Staff signatures: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Occupational Therapy Assistant | OTA | Interviewed regarding evaluation of resident-bought therapy devices. |
| Director of Nursing | DON | Interviewed regarding resident care, staffing adequacy, therapy evaluations, and infection control. |
| Certified Nursing Assistant #1 | CNA | Observed and interviewed regarding meal service hand hygiene and resident wandering. |
| Dietary Manager | DM | Interviewed regarding food storage, preparation, and kitchen sanitation. |
| Laundry Supervisor | Interviewed regarding laundry handling and infection control. | |
| Infection Control & Preventionist | ICP | Interviewed regarding hand hygiene and laundry infection control practices. |
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