Deficiencies (last 3 years)
Deficiencies (over 3 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
Annual Inspection
Deficiencies: 1
Date: Dec 31, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically focusing on whether fall interventions were properly included in person-centered care plans following resident falls.
Findings
The facility failed to ensure that fall interventions were placed in person-centered care plans for five of seven residents reviewed who experienced falls in October 2024. Interviews with staff confirmed that fall interventions were not documented in care plans, increasing the risk for future falls.
Deficiencies (1)
Failure to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions, specifically fall interventions for residents who experienced falls.
Report Facts
Residents reviewed for fall interventions: 7
Residents with missing fall interventions: 5
Fall incidents: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) Supervisor / MDS Coordinator | Explained the care planning process and confirmed responsibility for care planning falls | |
| Director of Nursing (DON) | Confirmed responsibility for care planning falls and the importance of fall interventions in care plans | |
| Restorative Certified Nurse Assistant (CNA) #1 | Collaborated with DON and floor nurses on fall interventions and confirmed use of care plans for resident care | |
| Administrator | Oversaw care planning process and confirmed expectations for fall interventions in care plans |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Sep 26, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to report resident-to-resident abuse incidents, an unwitnessed fall with serious injury, and failure to complete thorough investigations of these incidents.
Complaint Details
The complaint investigation revealed failure to report multiple resident-to-resident abuse incidents and an unwitnessed fall with major injury, failure to complete thorough investigations, and multiple deficiencies in care planning, assessment, infection control, and administration oversight.
Findings
The facility failed to report multiple incidents of resident-to-resident abuse and an unwitnessed fall with major injury to the State Survey Agency. Additionally, the facility failed to complete timely Minimum Data Set (MDS) assessments, develop and implement baseline and comprehensive care plans, follow infection control procedures, and maintain an effective Quality Assurance and Performance Improvement Plan (QAPI). The Administrator and Director of Nursing lacked adequate oversight and staffing for MDS and care plan duties.
Deficiencies (11)
Failure to report 3 incidents of resident-to-resident abuse and an unwitnessed fall with serious injury to the State Survey Agency.
Failure to electronically transmit accurate and complete Minimum Data Set (MDS) assessments within required time frames for 6 residents.
Failure to complete baseline care plan within 48 hours of admission for Resident #120.
Failure to develop and implement comprehensive person-centered care plans for 5 residents, including failure to address cognitive function, fall risk, medication administration, and behavioral needs.
Failure to complete clinical assessments and implement care plan interventions for 6 residents, resulting in overdue assessments and incomplete care plans.
Failure to follow the menu for pureed diets, specifically omission of pureed white beans during lunch service.
Failure of administration to ensure immediate reporting of resident-to-resident altercations and unwitnessed fall with major injury to the State Survey Agency.
Failure to have an effective governing body to ensure proper management and operation of the facility, including oversight of MDS, care plans, and QAPI.
Failure to employ qualified staff to accurately encode, transmit, and implement assessments and care plans, including lack of MDS Coordinator and inadequate training for DON and ADON.
Failure to ensure an effective Quality Assurance and Performance Improvement Plan (QAPI) feedback system to address resident care concerns such as falls, behaviors, and abuse/neglect.
Failure to follow infection prevention and control procedures, including lack of hand hygiene between residents during feeding and improper perineal and catheter care without personal protective equipment.
Report Facts
Incidents of resident-to-resident abuse not reported: 3
Residents with overdue MDS assessments: 6
Residents reviewed for care plan deficiencies: 19
Residents with overdue clinical assessments: 6
Pureed diet menu items omitted: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Witnessed resident-to-resident abuse incident and interviewed about incident |
| Administrator | Interviewed regarding failure to report incidents and oversight responsibilities | |
| Director of Nursing | DON | Interviewed regarding care plan deficiencies, MDS responsibilities, and infection control |
| Certified Nursing Assistant #8 | CNA | Interviewed about resident-to-resident altercation and care plan concerns |
| Licensed Practical Nurse #7 | LPN | Interviewed about resident behavioral issues |
| Certified Nursing Assistant #3 | CNA | Observed and interviewed regarding failure to use personal protective equipment during perineal care |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding failure to use personal protective equipment during perineal care |
| Certified Nursing Assistant #6 | CNA | Observed and interviewed regarding perineal and catheter care |
| Assistant Dietary Manager | Interviewed regarding pureed diet menu omission |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 28, 2023
Visit Reason
The inspection was conducted as an annual survey of Monette Manor, LLC to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Report
December 31, 2025
Report
September 26, 2024
Report
September 28, 2023
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