Inspection Reports for
Johnson County Health and Rehab, LLC
1451 East Poplar Street, Clarksville, AR, 72830
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
56% better than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure staff followed a care planned intervention while transferring Resident #113, which resulted in the resident being lowered to the floor without injury.
Complaint Details
The complaint investigation found that the facility failed to follow the care plan for Resident #113 during transfers. The incident was substantiated with findings that staff did not use the mechanical lift or gait belt and did not review the care plan prior to transfer. Resident #113 was lowered to the floor but sustained no injuries.
Findings
The facility failed to ensure that two Medication Aides followed the care plan requiring use of a mechanical lift for all transfers of Resident #113. The aides did not review the care plan, did not use the mechanical lift or a gait belt, and lowered the resident to the floor during transfer attempts. No injuries were sustained, but the incident revealed inadequate staff training and failure to follow care plans.
Deficiencies (1)
Failure to ensure staff followed care plan requiring mechanical lift for transfers of Resident #113, resulting in resident being lowered to floor without injury.
Report Facts
Residents reviewed: 6
Incident date: Jul 29, 2025
Assessment Reference Date: Jul 6, 2025
Admission date: Jun 30, 2025
Care Plan initiation date: Jul 8, 2025
Physician order date: Jul 3, 2025
In-service interview date: Aug 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA-C #1 | Medication Aide | Named in transfer incident for not following care plan and not using mechanical lift |
| MA-C #2 | Medication Aide | Named in transfer incident for not following care plan and not using mechanical lift |
| Director of Nursing | Director of Nursing | Conducted follow-up and provided verbal warnings; interviewed regarding incident and staff training |
| Physical Therapist #3 | Physical Therapist | Interviewed regarding Resident #113's strength and therapy status |
| MDS Coordinator | MDS Coordinator | Responsible for updating care plans and in-service training; interviewed about care plan changes |
| Medical Records | Administrator (filling in) | Interviewed about importance of reviewing care plans prior to care |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident #1 eloped from the facility on 02/28/2025, raising concerns about the facility's ability to prevent accidents and ensure resident safety.
Complaint Details
The complaint investigation was triggered by Resident #1 eloping from the facility on 02/28/2025. The Immediate Jeopardy began at 07:38 AM when the resident exited and the alarm was turned off by an Office Aide who did not notify other staff. The Administrator was notified on 03/12/2025. The facility implemented corrective actions prior to survey completion, resulting in a Past Noncompliance citation.
Findings
The facility failed to ensure residents were free from elopement risks, specifically Resident #1 who left the facility unsupervised. The Office Aide turned off the alarm without notifying staff, delaying the response. Resident #1 was found 1.25 miles away and returned safely. The facility was cited for immediate jeopardy due to non-compliance with safety requirements, but corrective actions were implemented before survey completion.
Deficiencies (1)
Failure to ensure residents were free from elopement risks, specifically Resident #1 eloped and the alarm was turned off without notifying staff.
Report Facts
Elopement risk assessment score: 13
Elopement risk assessment score: 9
Distance Resident #1 traveled: 1.25
Distance Resident #1 traveled: 3588
Distance Resident #1 traveled: 1500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Office Aide | Turned off the alarm and failed to notify staff of Resident #1 elopement | |
| CNA Supervisor | Located Resident #1 at park 1.25 miles away and returned resident to facility | |
| Administrator | Notified of elopement and reviewed video footage confirming events | |
| LPN #3 | Licensed Practical Nurse | Reported Resident #1 elopement to dispatcher and confirmed alarm procedures |
| LPN #7 | Licensed Practical Nurse | Confirmed front door alarm sounded and Resident #1 left unsupervised |
| CNA #8 | Certified Nursing Assistant | Reported Resident #1 missing and searched for resident |
| Housekeeper #9 | Aware Resident #1 left building unsupervised and participated in search | |
| Housekeeper #10 | Observed Resident #1 leaving room and confirmed staff training on elopement | |
| Maintenance Director | Provided information on door inspections and door alarm operation |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident dignity during feeding, medication labeling and storage, and food safety practices in the facility.
Findings
The facility was found deficient in ensuring residents on the secure unit were fed with dignity, medication carts had properly labeled medications with open dates, and food items were properly covered and equipment sanitized during meal preparation. These deficiencies had the potential to affect multiple residents and posed risks of harm or potential harm.
Deficiencies (3)
Failed to ensure residents on the secure unit were fed in a manner that provided dignity, with CNAs standing over residents during feeding.
Failed to ensure medication carts had medications properly labeled with open dates, including eye drops and inhalers not discarded according to manufacturer guidelines.
Failed to ensure food items were sealed or covered during meal preparation and equipment was cleaned, rinsed, and sanitized to prevent potential food borne illness.
Report Facts
Residents affected: 28
Medication carts assessed: 6
Residents affected: 104
Biscuits observed: 108
Scoops of cooked green beans: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Observed standing while feeding residents on secure unit and interviewed about feeding practices | |
| Certified Nursing Assistant (CNA) #2 | Observed standing while feeding residents on secure unit and interviewed about feeding practices | |
| Certified Nursing Assistant (CNA) #3 | Observed standing while feeding residents on secure unit and interviewed about feeding practices | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about proper feeding posture | |
| Registered Nurse (RN) #4 | Confirmed no open dates on medications on medication carts | |
| Director of Nursing (DON) | Interviewed about medication labeling and discard practices | |
| Dietary Aid #1 | Observed food preparation and cleaning practices | |
| Dietary Aid #2 | Observed food handling and interviewed about food covering | |
| Dietary Aid #3 | Interviewed about uncovered soup bowls | |
| Dietary Manager (DM) | Interviewed about cleaning and food safety procedures |
Inspection Report
Routine
Census: 106
Deficiencies: 2
Date: Mar 24, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and hygiene standards, specifically focusing on dietary staff practices related to handwashing, glove use, and food handling to prevent cross contamination and food borne illness.
Findings
The facility failed to ensure dietary staff washed their hands and changed gloves before handling food items, leading to potential cross contamination. Multiple instances of improper hand hygiene and glove use were observed, affecting 104 residents who received meals from the kitchen.
Deficiencies (2)
Dietary staff failed to wash hands and change gloves before handling food items, risking cross contamination.
Food items such as Sorghum Molasses bottles were not dated when received, risking improper food rotation.
Report Facts
Residents affected: 104
Total census: 106
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