Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
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
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 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 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
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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