Deficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 25, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident #1 eloped from the facility on 7/14/2025 by exiting through a bedroom window without staff knowledge.
Complaint Details
The complaint investigation was substantiated. Resident #1 eloped on 7/14/2025 at 11:45 AM by manipulating a window and exiting the facility unnoticed by staff. The resident was found outside by a passerby and returned to the facility with a small skin tear. The facility was notified by the police and city officials. Immediate Jeopardy was declared and later removed after the facility implemented corrective actions.
Findings
The facility failed to provide adequate supervision and an effective monitoring plan to prevent elopement for Resident #1, resulting in immediate jeopardy to resident health or safety. The resident was found outside the facility with a small skin tear. The facility implemented a Removal Plan including securing windows, staff training, resident assessments, and increased monitoring, which was verified and accepted by the survey team.
Deficiencies (1)
Failure to ensure adequate supervision to prevent elopement for Resident #1, resulting in immediate jeopardy.
Report Facts
Elopement Score: 5
Staff trained: 89
Staff interviews: 25
Window opening restriction: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #3 | Nursing Assistant | Sat one-on-one with Resident #1 after elopement until ambulance arrival. |
| Administrator | Notified of immediate jeopardy, confirmed corrective actions, and provided facility action plan. | |
| Director of Nursing (DON) | Director of Nursing | Notified of elopement, involved in investigation and resident care post-elopement. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Involved in resident return, window inspection, and implementation of interventions. |
| Maintenance Director | Secured windows post-elopement and responsible for ongoing window maintenance checks. | |
| Social Director | Reported on admission elopement risk assessment and interventions for Resident #1. | |
| Medical Director | Informed about the elopement and facility concerns. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the elopement of Resident #66 from the facility, which resulted in the resident being missing for approximately three hours and twenty minutes.
Complaint Details
The complaint investigation found that Resident #66 eloped from the facility on 08/23/2024 at approximately 8:20 PM, was missing for about three hours and twenty minutes, and was found unharmed at an event center. The facility was notified of the immediate jeopardy on 10/23/2024 and implemented corrective actions prior to survey completion.
Findings
The facility failed to provide adequate supervision for Resident #66, who eloped from the facility and was found approximately 900 feet away at an event center. The lack of supervision was determined to pose an immediate jeopardy to resident health or safety. The facility implemented corrective actions including placing the resident on a secured unit, conducting elopement assessments for all residents, updating care plans, and providing staff in-service training on wandering and elopement.
Deficiencies (1)
Failure to ensure staff provided supervision for Resident #66, resulting in elopement and the resident being missing for over three hours.
Report Facts
Distance resident eloped: 900
BIMS score: 9
Date of admission: Jul 22, 2024
Date of MDS assessment: Jul 29, 2024
Number of staff signed in-service: 49
Date of in-service: Aug 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Confirmed advising Laundry Aide #2 that Resident #66 could go outside unsupervised | |
| Laundry Aide #2 | Allowed Resident #66 to exit the facility after consulting CNA #1 | |
| First Responder #3 | Performed head-to-toe assessment of Resident #66 with no injuries noted | |
| Director of Nursing | DON | Performed skin assessment on Resident #66 and confirmed placement on secured unit as part of plan of correction |
| Administrator | Notified of immediate jeopardy and confirmed corrective actions including changing smoking area and staff supervision |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident #66 eloped from the facility and was missing for approximately three hours and twenty minutes.
Complaint Details
The complaint investigation found that Resident #66 eloped from the facility on 08/23/2024 at approximately 8:20 PM and was missing for over three hours. The facility staff were unaware of the resident's whereabouts during this time. The resident was found safe with no injuries. The facility was cited for immediate jeopardy related to inadequate supervision.
Findings
The facility failed to provide adequate supervision for Resident #66, who eloped from the facility without assistive devices and was found approximately 900 feet away at an event center. The lack of supervision was determined to be an immediate jeopardy to resident health or safety, but no injuries were noted upon the resident's return. The facility implemented corrective actions including placing the resident on a secured unit, updating care plans, and staff in-service training on wandering and elopement.
Deficiencies (1)
Failure to ensure staff provided supervision for Resident #66, resulting in elopement from the facility.
Report Facts
Duration resident was missing: 200
Distance resident eloped: 900
BIMS score: 9
Date resident admitted: Jul 22, 2024
Date of MDS assessment: Jul 29, 2024
Number of staff signed in-service: 49
Date of in-service: Aug 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Confirmed advising Laundry Aide #2 that Resident #66 could go outside unsupervised and was present for the in-service on wandering and elopement. | |
| Laundry Aide #2 | Was asked by Resident #66 if they could go outside and asked CNA #1 for permission; confirmed no staff were outside at the time Resident #66 left. | |
| First Responder #3 | Performed head-to-toe assessment of Resident #66 with no injuries noted. | |
| Director of Nursing | DON | Performed skin assessment on Resident #66, confirmed placement on secured unit, and initiated staff in-service training. |
| Administrator | Notified of the immediate jeopardy, confirmed changes to smoking area and supervision policies. | |
| Resident #66's family member | Power of Attorney | Confirmed resident's cognitive impairment and history of unsafe decision making; was notified of the elopement. |
Inspection Report
Routine
Deficiencies: 7
Date: Nov 17, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, maintenance, personal care, and medication management at Lakeside Health and Rehab.
Findings
The facility was found to have multiple deficiencies including unsafe and uncomfortable bed conditions, maintenance issues such as stained ceiling tiles, damaged walls and doors, loose floor tiles, inadequate nail care for residents requiring assistance, and improper labeling and storage of medications and enteral feeding supplies. These issues posed minimal harm or potential for actual harm to some residents.
Deficiencies (7)
Failure to maintain bed frame and mattress causing discomfort and potential fall risk for Resident #5.
Stained and bulging ceiling tiles above Resident #7's bed not repaired.
Damaged walls and paint peeling in Resident #13's room with exposed sheetrock.
Damaged bathroom door and wall patch in Resident #42's bathroom with rough and splintered edges.
Loose and warped floor tiles in the secured unit posing potential tripping hazards.
Failure to provide regular nail care for Residents #19, #38, and #75 resulting in long, jagged, and dirty nails.
Failure to properly label enteral feeding formula bags for Resident #45 and expired medications found in medication storage.
Report Facts
Residents affected: 17
Floor tiles: 3
Floor tiles: 5
Nail care in-service: 21
Tube feeding volume: 1000
Expired medication: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Discussed bed frame issues and maintenance logs related to facility repairs | |
| Assistant Director of Nursing | ADON | Provided information about Resident #19's nail care dependency and family involvement |
| Director of Nursing | DON | Provided in-service documentation on nail care and discussed medication expiration and disposal protocols |
| Licensed Practical Nurse #1 | LPN | Discussed tube feeding bag labeling and medication room inspection |
| Nurse Consultant | NC | Provided facility policy on enteral feeding safety precautions |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 14, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with safe and appropriate respiratory care practices, specifically regarding inhalation medication administration and oxygen therapy.
Findings
The facility failed to ensure that inhalation medication administration was properly monitored by a licensed nurse and that oxygen administration was provided using clean nasal cannula and tubing for one resident, posing potential respiratory complications. Observations revealed a resident receiving a nebulizer treatment unattended with improperly positioned equipment and oxygen tubing lying on the floor.
Deficiencies (2)
Failure to ensure inhalation medication administration was monitored by a licensed nurse to ensure medication was fully administered.
Failure to ensure oxygen administration was administered with a clean nasal cannula and tubing.
Report Facts
Residents affected: 3
Oxygen flow rate: 2
Nebulizer frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Assistant #1 | Certified Medication Assistant | Observed resident receiving nebulizer treatment unattended and handling oxygen tubing from the floor |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Admitted to leaving resident unattended during nebulizer treatment and acknowledged improper oxygen tubing handling |
| Director of Nursing | Director of Nursing | Provided statements on proper monitoring of nebulizer treatments and oxygen tubing use |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided facility policies on administering medications through nebulizer and oxygen administration |
| Activities Director | Activities Director | Observed resident with improperly positioned nebulizer mask and alerted staff |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 4
Date: Aug 19, 2022
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to implement sexual behavioral interventions in a resident's care plan, improper respiratory care including oxygen administration and equipment cleaning, inadequate preparation of pureed food consistency, and poor food handling and storage practices in the kitchen.
Deficiencies (4)
Failure to ensure sexually inappropriate behavioral interventions were implemented on the Resident's Care Plan for Resident #48.
Failure to ensure oxygen was administered at the physician-ordered flow rate, oxygen tubing was changed and dated, and tubing and respiratory masks were stored properly for Residents #61, #27, and #41.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failure to ensure dietary staff washed their hands before handling clean equipment or food items and failure to ensure dried goods were sealed in storage.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 6
Residents affected: 69
Total Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | LPN | Mentioned in relation to Resident #48 sexual behavior observation |
| Director of Nursing | DON | Provided statements regarding Resident #48 sexual behaviors and respiratory care practices |
| Licensed Practical Nurse #1 | LPN | Accompanied surveyor and provided information about BIPAP mask storage and cleaning |
| Licensed Practical Nurse #2 | LPN | Accompanied surveyor and provided information about Resident #41 BIPAP mask usage and cleaning |
| Dietary Employee #1 | Observed preparing pureed food and noted for improper food consistency | |
| Dietary Employee #2 | Observed for improper hand hygiene and food handling practices | |
| Restorative Certified Nursing Assistant #1 | CNA | Assisted residents with breakfast and described pureed food consistency |
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