Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
6% worse 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 triggered by an elopement incident involving Resident #1 who exited the facility without staff knowledge on 7/14/2025.
Complaint Details
The complaint investigation was substantiated. Resident #1 eloped from the facility on 7/14/2025 by exiting through a bedroom window that had been manipulated. The resident was found outside the facility by a passerby and returned to the facility with a small skin tear. The facility was notified of immediate jeopardy, implemented a Removal Plan, and the immediate jeopardy was removed on 7/25/2025 after verification of corrective actions.
Findings
The facility failed to provide adequate supervision to prevent elopement for Resident #1, resulting in immediate jeopardy to resident health or safety. The resident exited through a manipulated window and was found outside the facility with a minor skin tear. The facility implemented a Removal Plan, secured windows, trained staff on elopement prevention, and updated care plans and assessments.
Deficiencies (1)
Failure to ensure adequate supervision to prevent elopement for Resident #1, resulting in immediate jeopardy.
Report Facts
Elopement Score: 5
Skin tear size: 0.25
Number of staff trained: 89
Number of staff interviewed: 25
Distance from facility to city hall: 0.7
Window opening size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Notified of immediate jeopardy and involved in Removal Plan implementation and interviews. |
| Director of Nursing | Director of Nursing (DON) | Notified of immediate jeopardy, involved in investigation, care, and Removal Plan. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Involved in investigation, interviews, and care planning. |
| Maintenance Director | Maintenance Director | Secured windows and implemented physical interventions to prevent elopement. |
| NA #3 | Nursing Assistant | Provided one-on-one supervision to Resident #1 after elopement incident. |
| Psychiatric Advanced Placement Registered Nurse | Psychiatric APRN | Notified regarding Resident #1's suicidal statements and involved in care. |
| Social Director | Social Services Director | Assessed Resident #1 for elopement risk and involved in care planning. |
| Medical Director | Medical Director | Informed of 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 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: 8
Date: Nov 17, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to facility maintenance, resident care, medication storage, and labeling of enteral feeding in a nursing home setting.
Findings
The facility failed to maintain a safe, clean, and homelike environment, including issues with bed maintenance, stained ceiling tiles, damaged walls and doors, loose floor tiles, and inadequate nail care for residents. Additionally, the facility failed to properly label enteral feeding bags and had expired medications in storage.
Deficiencies (8)
Failed to maintain bed frame and mattress level causing discomfort and potential harm to Resident #5.
Ceiling tiles above Resident #7's bed had water spots and bulging, creating an unclean environment.
Walls in Resident #13's room had visible patches, gouges, and cracks affecting the room's condition.
Bathroom door and wall in Resident #42's room were damaged with holes and missing kick plates.
Loose and warped floor tiles in the secure unit posed potential tripping hazards.
Nail care was not regularly provided to Residents #19, #38, and #75, resulting in long, jagged, and dirty nails.
Residents' gastrostomy tube feeding formula bags were not properly labeled with required information.
Expired medications were found in the Medication Storage room, including Preparation H suppositories expired since 11/11/21.
Report Facts
Residents affected: 4
Residents affected: 3
Expired medication count: 4
Tube feeding volume: 1000
Tube feeding total daily volume: 690
Nail care in-service staff signatures: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Discussed bed maintenance and floor tile issues | |
| Administrator | Provided documentation on Resident Rights and Building Maintenance policies | |
| Assistant Director of Nursing (ADON) | Discussed nail care dependency and resident nail care needs | |
| Director of Nursing (DON) | Provided information on nail care responsibilities, medication expiration checks, and tube feeding training | |
| Licensed Practical Nurse (LPN) #1 | Discussed tube feeding bag labeling and medication room inspection | |
| Nurse Consultant (NC) | Provided information on enteral feeding labeling and policies | |
| Certified Nursing Assistants (CNA) #1, #2, #3 | Described residents' nail conditions and care routines | |
| Licensed Practical Nurse (LPN) #2 | Described nail care needs for Resident #75 |
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
Complaint Investigation
Deficiencies: 2
Date: Jul 14, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure proper administration and monitoring of inhalation medication and oxygen therapy for residents, specifically Resident #2.
Complaint Details
The complaint investigation found that Resident #2 was left unattended during nebulizer treatment, oxygen tubing and nasal cannula were found on the floor before being placed on the resident, and the nebulizer mask was improperly positioned, creating a choking hazard. The Director of Nursing confirmed these practices were inappropriate and unsafe.
Findings
The facility failed to ensure that inhalation medication administration was monitored by a licensed nurse and that oxygen was administered with clean nasal cannula and tubing, posing potential respiratory complications for Resident #2. Observations showed the nebulizer treatment was left unattended, oxygen tubing was on the floor before being placed on the resident, and the nebulizer mask was improperly positioned, creating a choking hazard.
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 treatments per day: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to leaving resident unattended during nebulizer treatment and improper oxygen tubing handling |
| CMA #1 | Certified Medication Assistant | Named in findings related to improper handling of oxygen tubing and nebulizer mask placement |
| Director of Nursing | Director of Nursing | Provided statements confirming unsafe practices and risks associated with the deficiencies |
| Activities Director | Activities Director | Observed and reported improper nebulizer mask placement and oxygen tubing on the floor |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided facility policies on nebulizer medication administration and oxygen administration |
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 |
Inspection Report
Census: 70
Deficiencies: 4
Date: Aug 19, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, respiratory therapy, dietary services, and infection control at Lakeside Health and Rehab.
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 such as oxygen administration and equipment cleaning/storage, inadequate preparation of pureed food consistency, and poor dietary staff hygiene and food storage practices.
Deficiencies (4)
Failure to ensure sexually inappropriate behavioral interventions were implemented on Resident #48's Care Plan.
Failure to ensure oxygen was administered at the physician-ordered flow rate, oxygen tubing was changed and dated, and respiratory equipment was properly stored and cleaned 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 hands before handling clean equipment or food items and failure to ensure dried goods were sealed in storage to prevent potential foodborne illness.
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 | Licensed Practical Nurse | Mentioned in relation to Resident #48's sexual behavior observation |
| Director of Nursing | Director of Nursing | Provided information on Resident #48's sexual behaviors and respiratory care practices |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Accompanied surveyor and discussed respiratory equipment storage and cleaning |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Accompanied surveyor and discussed respiratory equipment storage and cleaning |
| Dietary Employee #1 | Dietary Employee | Observed preparing pureed food and described food consistency |
| Dietary Employee #2 | Dietary Employee | Observed handling food and equipment with poor hygiene practices |
| Restorative Certified Nursing Assistant #1 | Certified Nursing Assistant | Assisted residents with meals and described pureed food consistency |
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