Deficiencies (last 3 years)
Deficiencies (over 3 years)
17.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
240% worse than Arkansas average
Arkansas average: 5.2 deficiencies/year
Deficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 5
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food storage and safety standards in the kitchen and food preparation areas.
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 observations included unsealed and open food items, improper storage of raw meats with vegetables, unsealed seasoning containers, and dented cans posing contamination risks.
Deficiencies (5)
Improper storage of meats leading to potential cross contamination, including unsealed and open frozen beef patties and fish fillets.
Expired and undated food items stored together, such as raw meats and chopped greens in the same container.
Unsealed and undated food items in refrigerator and dry storage areas, including block cheese and drink mix bags.
Dented can of ketchup stored in dry storage area, posing contamination risk.
Open and unsealed seasoning containers in the kitchen area, risking contamination by bugs.
Report Facts
Food item quantities: 3
Can size: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Observed and commented on food storage deficiencies |
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 for Hickory Heights Health and Rehab, LLC.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, personal hygiene and nail care, range of motion care, medication administration errors, meal preparation and food safety, infection control practices, and environmental safety. Deficiencies were generally of minimal harm but affected multiple residents.
Deficiencies (8)
Failed to ensure dignity and privacy for residents during care, exposing residents unnecessarily.
Failed to provide proper nail care for residents, resulting in long, jagged nails with brown substances under nails.
Failed to provide appropriate care to maintain or improve range of motion for a resident with a contracted hand and no device in place.
Medication error rate exceeded 5%, with multiple medications not administered as ordered.
Meals for residents on pureed diets were not prepared or served according to the planned menu and consistency standards.
Food safety violations including uncovered opened food items, improper food storage temperatures, and poor hand hygiene by dietary staff.
Failed to ensure staff performed hand hygiene between glove changes, before leaving rooms, and between passing meal trays and administering medications.
Facility environment was unsafe and unsanitary with peeling paint, gouged drywall, and holes in walls in resident areas.
Report Facts
Medication error rate: 19.23
BIMS score: 15
BIMS score: 3
Temperature: 55
Temperature: 53
Temperature: 123
Temperature: 132.3
Wall damage length: 15
Wall damage size: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in dignity/privacy and infection control deficiencies |
| 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 |
| LPN #4 | Licensed Practical Nurse | Named in nail care and contracture care deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy, dignity, nail care, contracture care, infection control |
| Dietary Employee #3 | Dietary Employee | Named in food preparation and food safety deficiencies |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding food preparation and storage deficiencies |
| Maintenance Director | Maintenance Director | Interviewed regarding environmental deficiencies |
| Restorative Nurse RN #2 | Restorative Nurse | Interviewed regarding contracture care |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding food consistency |
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
Complaint Investigation
Deficiencies: 2
Date: Jan 4, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify resident representatives of bed hold policy upon hospital transfer and failure to update care plans to reflect current resident needs and fall interventions.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify resident representatives of bed hold policy and failure to update care plans for fall interventions and injuries.
Findings
The facility failed to notify the resident's representative in writing about the bed hold policy for one resident transferred to the hospital. Additionally, the facility failed to revise care plans to include fall interventions and injuries for two residents, despite multiple documented falls and injuries.
Deficiencies (2)
Failure to notify resident representatives or Power of Attorney in writing of the bed hold policy upon resident transfer to hospital or discharge.
Failure to ensure the plan of care was revised to reflect current needs and updated to include fall interventions and injuries for sampled residents.
Report Facts
Residents affected: 1
Residents affected: 2
Falls documented: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed that a Bed Hold Notice should have been sent to the POA and that all falls and fall-related injuries should be documented on the resident's care plan. | |
| Business Office Manager | Confirmed that a Bed Hold Notice was not sent to the POA. |
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 evaluate compliance with nutritional and food safety standards, including meal preparation, food temperature, food consistency, and sanitation practices in the facility's kitchen.
Findings
The facility failed to ensure meals were prepared and served according to the planned menu to meet residents' nutritional needs, failed to maintain proper food temperatures, failed to ensure pureed foods were smooth and lump-free, and failed to maintain sanitary conditions in food storage and handling areas. These deficiencies had the potential to affect multiple residents receiving pureed or mechanical soft diets.
Deficiencies (4)
Meals were not prepared and served according to the planned menu, resulting in incorrect portion sizes and missing items for residents on pureed diets.
Hot foods were not served hot and cold foods/beverages were not served cold, with multiple food items served at unsafe temperatures.
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 dirty; dietary employees failed to wash hands or change gloves properly; ceiling air vents were dirty and stained.
Report Facts
Residents affected: 8
Residents affected: 114
Residents affected: 22
Residents affected: 20
Residents affected: 31
Residents affected: 33
Residents affected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Employee #1 | Named in findings related to incorrect pureed meal preparation and poor hand hygiene | |
| Dietary Employee #2 | Named in findings related to pureed bread preparation | |
| Dietary Employee #3 | Named in findings related to food cart delivery and temperature checks | |
| Dietary Employee #4 | Named in findings related to mechanical soft diet preparation and hand hygiene | |
| Dietary Employee #5 | Named in findings related to beverage service for residents on pureed diets | |
| Dietary Supervisor | Provided lists of residents and described food consistency issues | |
| Assistant Administrator | Provided grievance logs and facility policies | |
| License Practical Nurse (LPN) #1 | Interviewed about ice machine usage | |
| Certified Nursing Assistant (CNA) #1 | Interviewed about ice machine usage |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 8
Date: Mar 24, 2023
Visit Reason
The inspection was conducted based on complaint investigations regarding multiple deficiencies including call light accessibility, maintenance issues, oxygen therapy administration, food preparation and safety, infection control, immunization documentation, and resident hygiene item storage.
Complaint Details
The visit was complaint-driven, investigating multiple allegations including call light accessibility, maintenance issues, oxygen therapy administration, food safety, infection control, immunization documentation, and hygiene item storage. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in ensuring call lights were within reach for residents, maintaining doors and towel racks, administering oxygen therapy at ordered flow rates, preparing and serving meals according to nutritional needs and safety standards, maintaining food storage and kitchen sanitation, preventing cross contamination in laundry areas, accurately documenting and administering immunizations including influenza, pneumococcal, and COVID-19 vaccines, and properly storing resident personal hygiene items and wash basins.
Deficiencies (8)
Failed to ensure call lights were within reach for residents #20 and #164.
Failed to maintain bathroom doors and towel racks in good condition in resident rooms.
Failed to ensure oxygen was administered at ordered flow rates and nasal cannulas stored properly for residents requiring oxygen therapy.
Failed to prepare and serve meals according to planned menus and nutritional needs, including pureed diets.
Failed to ensure food storage, ice machine sanitation, and employee hand hygiene in the kitchen.
Failed to prevent cross contamination in laundry areas by allowing food/beverages and improper staff behavior in clean laundry areas and lacking separation between clean and dirty laundry.
Failed to ensure accurate and complete documentation and administration of influenza, pneumococcal, and COVID-19 immunizations for eligible residents.
Failed to store resident personal hygiene items and wash basins in a sanitary manner, including labeling and bagging.
Report Facts
Residents affected by call light deficiency: 2
Residents affected by oxygen therapy deficiency: 3
Residents affected by food preparation deficiency: 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 | Mentioned in relation to oxygen therapy administration for Residents #21 and #164 |
| Licensed Practical Nurse #3 | LPN | Mentioned in relation to call light accessibility for Resident #164 |
| Dietary Employee #1 | DE | Mentioned in relation to food preparation and hand hygiene deficiencies |
| Dietary Employee #4 | DE | Mentioned in relation to food preparation deficiencies |
| Dietary Employee #5 | DE | Mentioned in relation to food service and beverage provision |
| Housekeeping and Laundry Supervisor | Mentioned in relation to laundry infection control deficiencies | |
| Laundry Employee #1 | Mentioned in relation to eating in clean laundry area | |
| Laundry Employee #2 | Mentioned in relation to sitting on clean laundry cart | |
| Infection Control and Preventionist | ICP | Mentioned in relation to infection control and immunization tracking |
| Director of Nursing | DON | Mentioned in relation to oxygen therapy, immunization documentation, and hygiene item storage |
| Assistant Administrator | Mentioned in relation to facility policies and observations |
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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