Inspection Reports for
Pocahontas Healthcare and Rehabilitation Center
105 Country Club Road, Pocahontas, AR, 72455
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure nursing staff responded appropriately to an unwitnessed fall of Resident #1, including failure to notify appropriate parties and initiate neurological checks.
Complaint Details
The complaint investigation found that the facility failed to notify the physician and initiate neuro checks after Resident #1's unwitnessed fall. The resident suffered serious injury and died from complications related to the fall. LPN #1 was terminated for violating policies. The facility implemented a corrective action plan.
Findings
The facility failed to properly respond to an unwitnessed fall of Resident #1, resulting in actual harm. The resident suffered subdural hematomas and was ultimately admitted for comfort care and later died. The facility terminated LPN #1 for violating policies related to fall protocols and initiated a corrective action plan.
Deficiencies (1)
Failure to ensure nursing staff responded appropriately to an unwitnessed fall, including failure to notify appropriate parties and initiate neurological checks for Resident #1.
Report Facts
Fall Risk Assessment Score: 13
Date of Resident #1's fall: Feb 20, 2025
Date of Resident #1's death: Feb 21, 2025
Blood Pressure Readings: 235110
Blood Pressure Readings: 240110
Subdural Hematoma Size: 1.8
Subdural Hematoma Size: 0.5
Brain Shift: 1.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in deficiency for failing to notify physician and initiate neuro checks after Resident #1's fall; terminated for policy violations. |
| LPN #4 | Licensed Practical Nurse | Assessed Resident #1 after fall, notified MD, and arranged transfer to emergency room. |
| LPN #5 | Licensed Practical Nurse | Witnessed fall incident and assisted Resident #1. |
| RN #6 | Registered Nurse | Notified of Resident #1's condition and gave instructions for treatment. |
| CNA #2 | Certified Nursing Assistant | Placed Resident #1 on toilet, heard fall, and reported to nursing staff. |
| MAC #3 | Medication Assistant Certified | Reported Resident #1's abnormal vital signs and alerted nurse and DON. |
| Director of Nursing | Director of Nursing | Oversaw fall protocols, suspended and terminated LPN #1 for violations. |
| Administrator | Facility Administrator | Described fall investigation process and confirmed termination of LPN #1. |
| MD | Medical Doctor | Assessed Resident #1 after fall and ordered transfer to hospital. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 31, 2024
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with nursing home regulations, including resident dignity, accident hazard prevention, and infection control.
Findings
The facility was found deficient in promoting resident dignity by shaving a resident in the dining room, failing to secure a portable oxygen cylinder to prevent accidents, and not properly implementing infection control practices by failing to wear required personal protective equipment in a contact isolation room.
Deficiencies (3)
Failed to promote the dignity of a resident by shaving in the dining room.
Failed to ensure a portable oxygen cylinder was secured to prevent an accident or injury.
Failed to ensure infection prevention and control practices by not wearing required PPE in a contact isolation room.
Report Facts
Residents reviewed for dignity: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Observed shaving Resident #6 in the dining room and confirmed shaving was done there for convenience | |
| Director of Nursing | Director of Nursing | Confirmed shaving should be done in resident rooms and not in dining room; confirmed oxygen tank should be secured to prevent accidents |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed oxygen tank should be secured and confirmed PPE requirements for Resident #7 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Confirmed portable oxygen tank should not be left unsecured |
| Consultant | Confirmed mask, gown, and gloves were required to provide personal care in contact isolation room |
Inspection Report
Routine
Deficiencies: 9
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care planning, medication storage, food service, infection control, and environmental conditions at Pocahontas Healthcare and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to address communication barriers for a resident with limited English proficiency, inadequate environmental maintenance, inaccurate resident assessments, incomplete care plans, failure to use required adaptive equipment for smoking safety, improper medication storage, improper food preparation and serving practices, risk of cross contamination during food service, and lapses in infection control practices during incontinent care.
Deficiencies (9)
Failed to provide an environment that promoted resident's quality of life by denying self-determination and adequate communication for Resident #29 with language barriers.
Failed to ensure a safe, clean, homelike environment on the 100-hall secured unit with water damage, peeling paint, and mold.
Failed to ensure accurate Minimum Data Set (MDS) assessment for Resident #29, incorrectly listing English as preferred language instead of Marshallese.
Failed to develop and implement a comprehensive person-centered care plan reflecting Resident #29's needs and preferences, including communication assistance and dietary preferences.
Failed to ensure Resident #20 used a required smoking apron to prevent burns.
Failed to ensure refrigerated narcotics were stored in a permanently affixed locked compartment.
Failed to ensure mechanical soft and puree diets were prepared and served in proper form consistent with residents' dietary needs.
Failed to prevent cross contamination during food service by staff touching food-contact surfaces improperly.
Failed to implement proper infection control measures during incontinent care, including failure to change gloves before applying barrier cream for Resident #5.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 51
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Mentioned in relation to communication barrier and infection control deficiencies | |
| Certified Nursing Assistant (CNA) #2 | Mentioned in relation to smoking apron deficiency | |
| Licensed Practical Nurse #7 | Interviewed about medication storage importance | |
| Dietary Manager | Interviewed regarding food preparation, diet consistency, and cross contamination | |
| Dietary Aide #6 | Observed and interviewed regarding food service and cross contamination | |
| MDS Coordinator | Interviewed regarding care plan and MDS assessment deficiencies | |
| Administrator | Interviewed regarding care plan and communication issues | |
| Director of Nursing (DON) | Interviewed regarding multiple deficiencies including care plan, smoking apron, and infection control | |
| Infection Preventionist (IP) | Interviewed regarding infection control practices | |
| Nurse Consultant | Advised on care plan improvements |
Inspection Report
Routine
Deficiencies: 8
Date: Sep 15, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to refund resident funds within 30 days after discharge or death, damaged walls and cracked floor tiles, inaccurate resident assessments, incomplete care plans, failure to administer nebulizer treatments as ordered, inadequate nutrition and hydration practices, lack of physician orders for respiratory equipment, and improper food storage and dishwasher maintenance.
Deficiencies (8)
Failed to ensure resident funds were refunded within 30 days after discharge or death for Resident #140.
Failed to ensure walls in 2 resident rooms were not damaged and cracked floor tiles were replaced on the 300 Hall.
Failed to accurately record the assessment for Resident #12.
Failed to ensure the Comprehensive Care Plan addressed the use of a Trilogy unit for Resident #5.
Failed to ensure nebulizer treatments were administered as ordered for Resident #15.
Failed to provide enough food/fluids to maintain Resident #15's health and failed to provide thickened liquids at bedside for Resident #6.
Failed to ensure a Physician's Order was obtained prior to administering a Trilogy unit for Resident #5 and oxygen for Resident #21.
Failed to ensure food items stored in the freezer were dated, dented cans removed, and dishwasher detergent levels monitored to prevent food borne illness.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 38
Closing balance: 675.82
Dishwasher temperature: 140
Dishwasher detergent concentration: 25
Dishwasher detergent concentration: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Verified resident expiration date and refund timeline for Resident #140 |
| Register Nurse #1 | Registered Nurse | Identified wall scrapes and confirmed oxygen order |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding MDS process, nebulizer treatment, hydration, and oxygen administration |
| Director of Nursing | Director of Nursing | Interviewed regarding nebulizer treatment administration |
| Maintenance Supervisor | Maintenance Supervisor | Acknowledged damaged walls and cracked floor tiles |
| Dietary Manager | Dietary Manager | Responsible for food storage and dishwasher maintenance |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Provided information about resident hydration |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Provided information about thickened liquids availability |
| Speech Therapist | Speech Therapist | Observed feeding and hydration practices for Resident #6 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Responsible for entering physician orders |
| Registered Nurse #1 | Registered Nurse | Responsible for entering physician orders and verifying oxygen orders |
| Dietary Employee #1 | Dietary Employee | Tested dishwasher detergent concentration |
| Nurse Consultant | Nurse Consultant | Commented on lack of hydration and oxygen policies |
| Administrator | Administrator | Provided explanations regarding refund timelines, nebulizer use, oxygen administration, and nutrition |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 1, 2023
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations, focusing on notification of residents' representatives about new skin issues and treatment orders, and the accuracy of body audits and wound assessments documentation.
Findings
The facility failed to ensure that family or resident representatives were notified of new skin issues and treatment orders for 2 of 3 sampled residents with skin issues. Additionally, body audits and wound assessments were not documented accurately to meet professional nursing standards for 2 of 3 sampled residents.
Deficiencies (2)
Failure to notify family or resident representatives of new skin issues and physician orders for treatment for Residents #1 and #3.
Inaccurate documentation of body audits and wound assessments for Residents #1 and #2.
Report Facts
Wound measurements: 1.9
Wound measurements: 1.1
Wound measurements: 6
Wound measurements: 2.5
Wound measurements: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Treatment Nurse | Interviewed regarding notification practices and wound care procedures |
| CNA #1 | Certified Nursing Assistant | Performed peri care on Resident #1 and described care procedures |
| Director of Nursing | Director of Nursing (DON) | Interviewed about family notification policies and documentation standards |
Inspection Report
Routine
Deficiencies: 8
Date: Jun 30, 2022
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident rights, care planning, discharge procedures, personal hygiene, safety, nutrition, food handling, and quality assurance activities at Pocahontas Healthcare and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to provide residents access to survey results, incomplete care plans especially regarding hospice care, inadequate discharge summaries, poor personal hygiene and bathing assistance, unsafe water temperatures, improper meal preparation and substitutions, unsanitary food storage and handling practices, and ineffective Quality Assessment and Assurance (QAA) monitoring and corrective actions.
Deficiencies (8)
Failed to ensure residents and visitors had the right to examine the results of the most recent survey and plan of correction.
Failed to develop and implement a complete care plan addressing hospice services for residents receiving hospice care.
Failed to ensure a complete written discharge summary including medication reconciliation and follow-up care for discharged resident.
Failed to ensure fingernails were trimmed and cleaned and residents received regular bathing assistance.
Failed to maintain water temperatures below 110 degrees Fahrenheit in resident bathroom sinks to prevent burns.
Failed to ensure meals were prepared and served according to the planned menu, with appropriate substitutions.
Failed to ensure food storage areas and utensils were properly labeled, dated, covered, and sanitized; failed to prevent flies from contaminating food; failed to exclude ill staff from food preparation; and failed to maintain proper sanitizing solution levels.
Failed to monitor and correct ongoing deficient practices related to shower and fingernail care and care plan revisions through the Quality Assessment and Assurance Committee.
Report Facts
Residents affected: 45
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 12
Residents affected: 30
Dishwasher sanitizing ppm: 35
Sanitizing bucket ppm: 100
Water temperature: 130
Water temperature: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Mentioned in relation to fingernail care deficiency for Resident #13. | |
| Licensed Practical Nurse #1 | Interviewed about discharge information responsibilities. | |
| Licensed Practical Nurse #2 | Interviewed about discharge information and diabetic nail care. | |
| Licensed Practical Nurse #3 | Interviewed about diabetic nail care procedures. | |
| Certified Nursing Assistant #2 | Interviewed about nail care and shower schedules. | |
| Certified Nursing Assistant #3 | Interviewed about nail care and shower schedules. | |
| Dietary Manager | Provided information on meal substitutions, food storage, and sanitation issues. | |
| Dietary Employee #1 | Observed serving incorrect meal substitutions and food handling. | |
| Dietary Employee #3 | Observed vomiting in kitchen and preparing drinks while ill. | |
| Regional Registered Nurse Consultant (RRNC) | Interviewed regarding survey binder and QAA committee activities. | |
| Administrator | Interviewed regarding QAA committee monitoring and corrective actions. | |
| Maintenance Man #1 | Checked water temperatures in resident bathrooms. | |
| Maintenance Man #2 | Checked and adjusted water temperatures in resident bathrooms. | |
| Director of Nursing | Interviewed about discharge summary responsibilities. | |
| MDS Coordinator | Interviewed about care plans and discharge summaries. | |
| Medical Records | Interviewed about scanning discharge documents. |
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