Deficiencies (last 3 years)
Deficiencies (over 3 years)
14.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
183% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 5
Date: Aug 28, 2025
Visit Reason
The inspection was conducted to assess compliance with nutritional and food safety standards, including meal preparation, serving according to the planned menu, food sanitation, and dietary staff hygiene practices.
Findings
The facility failed to ensure meals were served according to the planned menu portions and nutritional needs, maintain sanitary conditions of the ice machine and ice scoop, remove expired food items, ensure dietary staff washed hands between tasks, and maintain hot food at required temperatures. Multiple observations showed minimal harm or potential for harm to residents.
Deficiencies (5)
Meals were not served according to the planned written menu portion sizes, with dietary staff using incorrect scoop sizes.
Ice machine and ice scoop were not maintained in a sanitary manner, with wet black and brownish residue observed.
Expired food items (nineteen 24-ounce boxes of nectar thickened water) were found in storage.
Dietary staff failed to wash hands or change gloves between handling contaminated and clean items.
Hot food items (hamburger patties) were not maintained at required temperature and were served without reheating.
Report Facts
Expired food items: 19
Food temperature: 103
Meal portion size: 4
Inspection Report
Routine
Deficiencies: 5
Date: Aug 28, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with nutritional and food safety standards, including meal preparation, serving according to the planned menu, food sanitation, and storage practices.
Findings
The facility failed to ensure meals were served according to the planned menu portions, maintain sanitary conditions of the ice machine and ice scoop, discard expired food items, ensure dietary staff washed hands properly between tasks, and maintain hot food items at required temperatures. These deficiencies posed minimal harm or potential for actual harm to some residents.
Deficiencies (5)
Meals were not served according to the planned written menu portion size; a #8 scoop (4 oz) was used instead of an 8 oz ladle.
Ice machine and ice scoop were dirty with wet black and brownish residue, not cleaned adequately.
Expired food items (nineteen 24-ounce boxes of nectar thickened water) were found in storage.
Dietary staff failed to wash hands or change gloves between handling contaminated items and food.
Hot food items (hamburger patties) were not maintained at required temperature and were served at 103°F without reheating.
Report Facts
Expired food items: 19
Food temperature: 103
Meal portion size: 4
Inspection Report
Deficiencies: 1
Date: Feb 5, 2025
Visit Reason
The inspection was conducted to evaluate compliance with care plan implementation and resident safety, specifically regarding fall prevention measures for a resident at risk of falls.
Findings
The facility failed to ensure staff followed the care plan for a resident at risk for falls, as evidenced by the absence of a fall mat beside the resident's bed at the time of a fall, resulting in minimal harm or potential for actual harm to the resident.
Deficiencies (1)
Failed to ensure staff followed the care plan of a resident at risk for falls, specifically the intervention of placing a fall mat beside the resident's bed.
Report Facts
Fall Assessment Score: 9
Fall Assessment Score: 7
Residents Sampled: 3
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding fall mat placement and care plan adherence |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 5, 2025
Visit Reason
The inspection was conducted to evaluate compliance with care plan implementation, specifically regarding fall prevention interventions for residents at risk of falls.
Findings
The facility failed to ensure staff followed the care plan for a resident at risk for falls, as evidenced by the absence of a fall mat beside the resident's bed at the time of a fall incident. The deficiency was determined to cause minimal harm or potential for actual harm affecting a few residents.
Deficiencies (1)
Failed to ensure staff followed the Care Plan of a resident at risk for falls, specifically the intervention of placing a fall mat beside the bed.
Report Facts
Fall Assessment Score: 9
Fall Assessment Score: 7
Residents Sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding fall mat placement and care plan adherence for Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 1, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where a resident (Resident #2) slid out of a mechanical lift sling during transfer, raising concerns about proper transfer procedures and staff supervision.
Complaint Details
The complaint investigation focused on an incident on 06/10/2024 where Resident #2 slid out of a mechanical lift sling during transfer. The incident was not reported properly, no witness statements or in-service training were conducted, and key staff including the Director of Nursing were unaware of the event until the survey.
Findings
The facility failed to properly transfer Resident #2 using a mechanical lift and failed to investigate and educate staff to prevent possible injury. Multiple staff interviews revealed the incident was not reported timely, no formal in-service training was conducted afterward, and the Director of Nursing was unaware of the event until the survey.
Deficiencies (1)
Failure to properly transfer a resident using a mechanical lift and failure to investigate and educate staff to prevent possible injury.
Report Facts
Assessment Reference Date: Aug 19, 2024
Incident Date: Jun 10, 2024
Survey Date: Oct 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Reported incident to Treatment nurse and educated CNAs on proper transfer |
| Director of Nursing | Director of Nursing | Unaware of incident until survey, responsible for staff training |
| Assistant Director of Nursing | Assistant Director of Nursing | Unaware of incident until survey, questioned staff after learning of event |
| CNA #1 | Certified Nursing Assistant | Present during incident, confirmed no in-service or witness statements taken |
| CNA #5 | Certified Nursing Assistant | Helped transfer Resident #2, did not report incident |
| CNA #6 | Certified Nursing Assistant | Involved in transfer, did not report incident |
| CNA #7 | Certified Nursing Assistant | Assisted in transfer after incident, reported resident never touched floor |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 1, 2024
Visit Reason
The inspection was conducted due to a complaint regarding improper transfer of a resident using a mechanical lift, which resulted in the resident sliding out of the lift sling during transfer.
Complaint Details
The complaint involved Resident #2 sliding out of a mechanical lift sling during transfer on 06/10/2024. The incident was not documented as a fall, was not reported to nursing leadership promptly, and no formal in-service training was conducted afterward. Staff interviews revealed inconsistent reporting and awareness of the incident.
Findings
The facility failed to properly transfer Resident #2 using a mechanical lift and failed to investigate and educate staff to prevent possible injury. The incident was not reported timely, and no in-service training was conducted following the event. Several staff members were unaware or did not report the incident, and the Director of Nursing was not informed until much later.
Deficiencies (1)
Failure to properly transfer a resident using a mechanical lift and failure to investigate and educate staff to prevent injury.
Report Facts
Assessment Reference Date: Aug 19, 2024
Incident Date: Jun 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Reported the incident to the Treatment nurse and educated CNAs on proper transfer after learning about the incident. |
| Director of Nursing | Director of Nursing | Was unaware of the incident until the day of the survey and reported no in-service training was conducted. |
| Assistant Director of Nursing | Assistant Director of Nursing | Was unaware of the incident at the time but later questioned staff about it. |
Inspection Report
Routine
Deficiencies: 10
Date: May 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication storage, food service, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to conduct timely and accurate side rail assessments, incomplete care plans reflecting resident falls and side rail use, inadequate foot care, lack of interventions for contractures, unsafe use and padding of side rails for a resident with seizure disorder, unlocked wheelchair brakes posing safety risks, improper storage of controlled medications, failure to provide pureed diets with appropriate consistency, failure to accommodate resident dietary allergies, and food safety violations including expired food items and improper hygiene practices in the kitchen.
Deficiencies (10)
Failure to ensure comprehensive, accurate quarterly side rail assessments for Resident #06.
Failure to revise individualized care plans to reflect current needs including falls and side rail use for Residents #06 and #31.
Failure to provide appropriate foot care resulting in poor hygiene and toenail conditions for Resident #68.
Failure to provide interventions to prevent worsening contractures for Resident #8.
Failure to ensure residents were free from accident hazards related to half side rail use and seizure precautions for Resident #06 and unlocked wheelchair brakes for Resident #294.
Failure to perform bed rail assessments before use and failure to obtain consent and review risks for Resident #06's bed rails.
Failure to store controlled medications in a permanently affixed locked container in the medication room.
Failure to provide pureed diet food with smooth, lump-free consistency for 5 sampled residents.
Failure to accommodate dietary allergies and preferences for Resident #79, who received milk despite lactose intolerance.
Failure to discard food items past use-by dates, prevent cross contamination, and ensure hair coverings in the kitchen.
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: 5
Residents affected: 1
Expired food items: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Confirmed side rail use and risks for Resident #06 |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Observed Resident #06 and side rail use |
| Director of Nursing | Director of Nursing | Confirmed side rail use, falls, and assessment deficiencies for Resident #06 |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed seizure precautions and medication storage issues |
| Dietary Manager | Dietary Manager | Described pureed diet consistency and food safety policies |
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Reported Resident #79 received milk despite lactose intolerance |
| Maintenance Director | Maintenance Director | Confirmed side rails were not installed by him and assessment requirements |
| Licensed Practical Nurse #15 | Licensed Practical Nurse | Described toenail care needs for Resident #68 |
| Certified Nursing Assistant #15 | Certified Nursing Assistant | Described toenail condition for Resident #68 |
Inspection Report
Routine
Deficiencies: 10
Date: May 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication storage, food service, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to conduct timely and accurate side rail assessments, incomplete care plans reflecting resident falls and side rail use, inadequate foot care for a diabetic resident, lack of interventions for contractures, unsafe use and assessment of side rails, unsecured controlled medication storage, improper preparation of pureed diets, failure to accommodate resident dietary allergies, and food safety violations in the kitchen.
Deficiencies (10)
Failure to ensure comprehensive, accurate quarterly assessment of resident's side rail use.
Failure to revise individualized care plans to reflect current resident needs including falls and side rail use.
Failure to provide appropriate foot care resulting in unclean, untrimmed toenails for a diabetic resident.
Failure to provide interventions to prevent worsening of contractures in a resident.
Failure to ensure residents were free from accident hazards related to side rail use and wheelchair safety.
Failure to perform bed rail assessments before use and failure to complete timely side rail assessments.
Failure to store controlled medications in a permanently affixed locked container.
Failure to ensure pureed diet food was smooth and lump free as ordered.
Failure to accommodate resident's dietary allergies and preferences, resulting in a lactose intolerant resident receiving milk.
Failure to discard food items by use-by date, prevent cross contamination, and require hair coverings in the kitchen.
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: 5
Residents affected: 1
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #12 | Licensed Practical Nurse | Confirmed side rail use and risks, resident care details |
| CNA #10 | Certified Nursing Assistant | Provided information on resident side rail use and care |
| Director of Nursing | Director of Nursing | Confirmed side rail assessments, resident falls, and care plan issues |
| Minimum Data Set Coordinator | MDS Coordinator | Confirmed side rail assessment timing and accuracy |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed seizure disorder diagnosis and bed padding insufficiency |
| Dietary Manager | Dietary Manager | Described pureed diet preparation and food safety policies |
| CNA #11 | Certified Nursing Assistant | Reported resident received milk despite lactose intolerance |
| Administrator | Facility Administrator | Confirmed medication storage requirements and food safety policies |
| Maintenance Director | Maintenance Director | Confirmed side rails installation and assessment requirements |
| LPN #15 | Licensed Practical Nurse | Discussed resident toenail care and wheelchair safety |
Inspection Report
Routine
Census: 81
Deficiencies: 5
Date: Apr 7, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide ordered equipment (trapeze bar) to a resident, inadequate personal hygiene care for a resident, medication administration errors exceeding the acceptable rate, failure to prepare and serve meals according to the planned menu, and unsanitary kitchen conditions posing potential foodborne illness risks.
Deficiencies (5)
Failure to ensure a resident received a physician-ordered trapeze bar to assist with positioning.
Failure to keep a resident's feet clean despite requiring extensive assistance with personal hygiene.
Medication error rate exceeded 5%, with errors in medication type and IV administration rate for residents.
Meals were not prepared and served according to the planned written menu, affecting residents on pureed and mechanical soft diets.
Kitchen sanitation issues including dirty floors, cracked eggs, improperly stored food items, contaminated glove use, and an unclean ice machine.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Medication error rate: 5.88
Residents affected: 6
Residents affected: 17
Total census: 81
Medication opportunities observed: 34
Medication errors observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication error and trapeze bar deficiency findings |
| Licensed Practical Nurse #2 | LPN | Named in medication error findings |
| Director of Nursing | DON | Interviewed regarding trapeze bar order and medication administration |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding trapeze bar and ice machine usage |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding bathing frequency and foot hygiene |
| Dietary Employee #1 | DE | Observed and interviewed regarding meal preparation and hygiene practices |
| Dietary Employee #2 | DE | Observed preparing pureed carrot cake |
| Dietary Supervisor | Supervisor | Interviewed regarding meal preparation and ice machine cleaning |
| Maintenance Director | Director | Interviewed regarding ice machine cleaning frequency |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 7, 2023
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in several areas including failure to provide a physician-ordered trapeze bar for a resident, inadequate foot care for a cognitively impaired resident, medication administration errors including incorrect medication and improper IV infusion rates, failure to prepare and serve meals according to the planned menu, and unsanitary kitchen conditions including improper food storage and poor employee hygiene practices.
Deficiencies (5)
Failed to ensure a resident received a trapeze bar as ordered by the physician.
Failed to ensure residents' feet were kept clean for a resident requiring extensive assistance.
Failed to maintain medication error rates below 5%, including administration of incorrect medication and improper IV infusion rates.
Failed to ensure meals were prepared and served according to the planned written menu for residents on pureed and mechanical soft diets.
Failed to maintain kitchen and food preparation areas in a clean and sanitary condition, including dirty kitchen floor, improperly stored food items, and poor employee hygiene practices.
Report Facts
Medication error rate: 5.88
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 6
Residents affected: 17
Total census: 81
Eggs: 12
Corndogs: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Involved in medication error administering incorrect acetaminophen |
| LPN #2 | Licensed Practical Nurse | Administered IV medication at incorrect infusion rate |
| Director of Nursing | Director of Nursing | Interviewed regarding trapeze bar order and medication administration |
| DE #1 | Dietary Employee | Prepared meals not according to menu and poor hygiene practices |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding meal preparation and ice machine cleaning |
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