Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 4
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to assess compliance with food procurement, storage, preparation, distribution, and serving standards in the facility's kitchen.
Findings
The facility failed to ensure proper storage of meats to prevent cross contamination, proper covering of stored foods, and timely removal of expired food items. Multiple instances of unsealed, undated, or improperly stored food items were observed in the freezer, refrigerator, dry storage, and cooking areas.
Deficiencies (4)
Improper storage of meats leading to potential cross contamination, including raw meats stored with vegetables and expired items not discarded.
Unsealed and undated food items in refrigerator and dry storage areas.
Dented can of ketchup stored, posing contamination risk.
Two seasoning containers stored with open and unsealed lids, risking contamination.
Report Facts
Weight of drink mix bags: 8.6
Weight of ketchup can: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Observed and commented on food storage deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: May 3, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, medication administration, infection control, nutrition, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, inadequate personal hygiene and nail care, failure to provide appropriate care for residents with limited range of motion, medication administration errors, improper food preparation and serving practices, poor infection control practices including hand hygiene, and unsafe, unsanitary environmental conditions such as peeling paint and damaged walls in resident areas.
Deficiencies (8)
Failure to ensure dignity and privacy for residents during care.
Failure to provide proper personal hygiene related to nail care for residents.
Failure to provide appropriate care to maintain or improve range of motion for a resident with contracture.
Medication error rate exceeded 5%, with multiple medications not administered as ordered.
Failure to prepare and serve meals according to planned menus and nutritional needs, including improper portion sizes and inconsistent pureed food texture.
Failure to ensure food safety practices including proper storage, hand hygiene, and maintenance of hot food temperatures.
Failure to implement infection prevention and control program, including inadequate hand hygiene between glove changes, meal tray passing, and medication administration.
Failure to maintain a safe, clean, and comfortable environment due to peeling paint, gouged drywall, and unrepaired damage in resident areas.
Report Facts
Medication error rate: 19.23
Number of residents affected by dignity/privacy deficiency: 2
Number of residents affected by nail care deficiency: 3
Number of residents affected by range of motion deficiency: 1
Number of residents affected by food preparation deficiencies: 9
Temperature of walk-in refrigerator: 55
Temperature of milk in refrigerator: 53
Temperature of pureed cut green beans on steam table: 123
Temperature of mashed potatoes on steam table: 132.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in dignity/privacy and infection control deficiencies related to resident care and hand hygiene |
| LPN #1 | Licensed Practical Nurse | Named in medication administration and infection control deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and food consistency observations |
| LPN #3 | Licensed Practical Nurse | Named in medication administration deficiency interview |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy, dignity, nail care, contractures, medication administration, and infection control |
| Dietary Employee #3 | Dietary Employee | Named in food preparation and serving deficiencies |
| Dietary Employee #4 | Dietary Employee | Named in food preparation and serving deficiencies |
| Dietary Employee #1 | Dietary Employee | Named in food safety and hygiene deficiencies |
| Dietary Employee #2 | Dietary Employee | Named in food safety and hygiene deficiencies |
| Dietary Employee #6 | Dietary Employee | Named in food consistency deficiency |
| Maintenance Director | Maintenance Director | Named in environmental safety deficiency |
| Restorative Nurse RN #2 | Registered Nurse | Named in contracture care deficiency |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in food consistency observation |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in nail care deficiency |
| Restorative Aide | Named in contracture care deficiency | |
| Director of Physical Therapy | Director of Physical Therapy | Named in contracture care deficiency |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident notification of bed hold policies and the development and revision of care plans reflecting current resident needs, including fall interventions and injury documentation.
Findings
The facility failed to notify resident representatives or Power of Attorney in writing about the bed hold policy for a resident transferred to the hospital. Additionally, the facility failed to ensure care plans were updated to reflect current needs and fall-related injuries for two residents, with multiple documented falls and injuries not properly incorporated into care plans.
Deficiencies (2)
Failed to notify resident representatives or Power of Attorney in writing of the bed hold policy upon resident transfer to hospital or discharge.
Failed to ensure care plans were revised to reflect current needs and updated to include fall interventions and injuries for two residents.
Report Facts
Residents affected: 1
Residents affected: 2
Falls documented: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed bed hold notice should have been sent and that all falls and fall-related injuries should be documented on care plans |
| Business Office Manager | Business Office Manager | Confirmed that a Bed Hold Notice was not sent to the Power of Attorney |
Inspection Report
Routine
Census: 119
Deficiencies: 4
Date: Mar 24, 2023
Visit Reason
The inspection was conducted to assess compliance with nutritional, food safety, and food preparation standards in the facility's kitchen and dining services.
Findings
The facility failed to ensure meals were prepared and served according to the planned menu, with issues in portion sizes, food consistency, and temperature. Additionally, food storage and handling practices were inadequate, including uncovered food items, unclean ice machine components, and improper hand hygiene by dietary employees, potentially affecting resident safety and nutrition.
Deficiencies (4)
Meals were not prepared and served according to the planned written menu, affecting portion sizes and nutritional needs for residents on pureed diets.
Hot foods were not served hot and cold foods/beverages were not served cold, compromising palatability and nutritional intake.
Pureed food items were not blended to a smooth, lump-free consistency, increasing risk of choking for residents on pureed diets.
Foods stored in freezer and dry storage were uncovered, unsealed, and undated; ice machine and scoop holder were unclean; dietary employees failed to wash hands or change gloves properly; ceiling air vents were dirty.
Report Facts
Residents affected: 8
Residents affected: 114
Meal trays: 20
Meal trays: 31
Meal trays: 33
Meal trays: 22
Meal trays: 20
Meal trays: 31
Meal trays: 18
Meal trays: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Employee #1 | Named in findings related to improper portioning, pureeing, and hand hygiene violations. | |
| Dietary Employee #3 | Named in findings related to food cart delivery and temperature checks. | |
| Dietary Employee #4 | Named in findings related to improper food preparation and hand hygiene violations. | |
| Dietary Employee #5 | Named in interview regarding beverages served to residents on pureed diets. | |
| Dietary Supervisor | Provided lists of residents and conducted temperature checks. | |
| License Practical Nurse #1 | LPN | Interviewed regarding ice machine usage. |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding ice machine usage. |
Inspection Report
Annual Inspection
Census: 119
Deficiencies: 8
Date: Mar 24, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including call light accessibility for residents, maintenance of resident rooms, oxygen therapy administration, food preparation and safety, infection control in laundry and resident personal care item storage, and immunization documentation and administration.
Deficiencies (8)
Failed to ensure call light was within reach for 2 of 12 sampled residents who could use their call lights.
Failed to maintain doors and towel racks in good condition in resident rooms.
Failed to ensure oxygen was administered at the ordered flow rate and nasal cannula stored properly for 3 of 11 sampled residents.
Failed to ensure meals were prepared and served according to the planned menu and pureed food items were blended to a smooth consistency.
Failed to ensure foods in freezer and dry storage were covered, sealed, and dated; failed to maintain ice machine and scoop in sanitary condition; failed to ensure proper hand hygiene by dietary staff; and failed to maintain clean ceiling air vents.
Failed to ensure laundered linens and personal clothing were kept free from contamination and failed to maintain separation between clean and dirty laundry areas.
Failed to ensure accurate and complete documentation and administration of Pneumococcal, Influenza, and COVID-19 immunizations for eligible residents.
Failed to ensure resident personal hygiene items and wash basins were stored in a sanitary manner in resident bathrooms.
Report Facts
Residents affected by call light deficiency: 2
Residents affected by oxygen therapy deficiency: 3
Residents affected by food preparation deficiencies: 8
Total census: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | CNA | Mentioned in relation to call light accessibility for Resident #20 |
| Licensed Practical Nurse #2 | LPN | Accompanied surveyor during oxygen therapy observations |
| Licensed Practical Nurse #3 | LPN | Discussed call light accessibility for Resident #164 |
| Dietary Employee #1 | DE | Involved in food preparation and hand hygiene observations |
| Dietary Employee #4 | DE | Involved in food preparation and hand hygiene observations |
| Dietary Employee #5 | DE | Interviewed about beverages served to residents on pureed diets |
| Housekeeping and Laundry Supervisor | Supervisor | Observed during laundry infection control deficiencies |
| Laundry Employee #1 | LE | Observed eating in clean laundry area |
| Laundry Employee #2 | LE | Observed sitting on clean laundry cart |
| Infection Control and Preventionist | ICP | Interviewed regarding immunization tracking and infection control |
| Director of Nursing | DON | Interviewed regarding immunization documentation and laundry policies |
| Certified Nursing Assistant #3 | CNA | Interviewed about wash basin cleaning and storage |
| Assistant Administrator | Interviewed regarding facility policies and observations |
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