Inspection Reports for
St. Johns Place of Arkansas, LLC
1400 Hwy 79/167 Bypass, Fordyce, AR, 71742-1728
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 3
Date: Dec 4, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including notification of resident transfers to the Ombudsman, adequacy of the facility-wide assessment, and implementation of infection prevention and control programs.
Findings
The facility failed to provide evidence that the state Ombudsman was notified of resident transfers to the hospital, did not include required components such as governing body involvement and staff retention in the facility assessment, and failed to ensure proper hand hygiene was consistently implemented during incontinence care.
Deficiencies (3)
Failed to provide evidence that notice of transfers or discharges were sent to the state Ombudsman for residents transferred to hospital.
Facility assessment lacked required components including governing body involvement and staff retention information.
Failed to ensure proper hand hygiene was consistently implemented during incontinence care for one resident.
Report Facts
Residents reviewed for hospitalization: 2
Date of facility assessment: May 1, 2025
Observation date: Sep 29, 2025
MDS Assessment Reference Date: Sep 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged Social Worker sent transfer notices but could not provide proof; stated facility had no policy on Ombudsman notification | |
| Certified Nursing Assistant (CNA) #4 | Observed failing to perform proper hand hygiene during incontinence care; described hand hygiene expectations | |
| Certified Nursing Assistant (CNA) #7 | Described hand hygiene expectations during incontinence care | |
| Director of Nursing (DON) | Stated hand hygiene importance and expectations; noted facility lacked hand hygiene policy |
Inspection Report
Routine
Deficiencies: 8
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident financial rights, medication management, activities, safety, nutrition, and medication storage at St Johns Place of Arkansas, LLC.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had access to their trust account funds after hours, misdiagnosis and unnecessary psychotropic medication for a resident, inadequate activities for residents on the secured unit, unlocked housekeeping and medication carts, inadequate hydration for a resident, improper food handling and storage practices, and failure to serve meals according to the planned menu.
Deficiencies (8)
Failed to ensure residents with trust accounts had access to personal funds after business hours and weekends and failed to reimburse trust account funds within 30 days of discharge.
Resident #44 was misdiagnosed with schizoaffective disorder and received unnecessary psychotropic medication.
Failed to provide activities to residents on the secured unit despite having an activities calendar.
Housekeeping cart used to store harmful chemicals was unlocked when unattended.
Failed to ensure fluids were maintained within reach to promote hydration for Resident #1.
Medication carts were left unlocked when unattended and controlled medications were not stored in permanently affixed locked compartments.
Meals were not prepared and served according to the planned menu; portion sizes did not match menu specifications.
Foods stored in the freezer were uncovered and unsealed; dietary staff failed to wash hands properly before handling clean equipment or food; hot foods were not maintained at proper temperatures.
Report Facts
Residents affected by trust account access issue: 64
Resident trust account balance: 515.77
Residents affected by misdiagnosis and unnecessary medication: 1
Residents affected by inadequate activities: Some
Residents affected by unlocked housekeeping cart: Few
Residents affected by inadequate hydration: 1
Residents affected by medication cart security issues: Some
Residents affected by meal portion size issues: 29
Residents affected by food safety issues: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding misdiagnosis of Resident #44 and medication practices. |
| Business Office Manager | Business Office Manager (BOM) | Interviewed regarding resident trust account access and reimbursements. |
| Registered Nurse #10 | Registered Nurse | Observed leaving medication cart unlocked. |
| Licensed Practical Nurse #11 | Licensed Practical Nurse | Confirmed locked medication box was not affixed in refrigerator. |
| Dietary Manager | Dietary Manager | Provided information on meal portions and food safety policies. |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Observed during activities deficiency on secured unit. |
| Housekeeping Staff #9 | Housekeeping Staff | Confirmed housekeeping cart was left unlocked. |
| Dietary Aide #1 | Dietary Aide | Observed improper hand hygiene during dishwashing. |
| Dietary Aide #3 | Dietary Aide | Observed improper hand hygiene during food preparation. |
| Dietary [NAME] #2 | Dietary Cook | Observed improper hand hygiene and food handling. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 3, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to safeguard or return home medications brought in by Resident #1 upon discharge.
Complaint Details
The complaint was substantiated based on interviews and record reviews indicating the facility did not return Resident #1's home medications, which were subsequently destroyed.
Findings
The facility failed to ensure that Resident #1's home medications were safeguarded or returned upon discharge. The medications were not found in the facility and were presumed destroyed during routine medication destruction. The facility acknowledged the failure and has started an in-service to prevent future occurrences.
Deficiencies (1)
Failure to safeguard or return home medications brought in by Resident #1 upon discharge.
Report Facts
Residents sampled: 3
Date of discharge: Jul 6, 2023
Date medications destroyed: Jul 21, 2023
Date family contacted: Jul 10, 2023
Date family contacted again: Jul 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided information about the medication safeguarding failure and medication destruction | |
| Nurse Manager | Interviewed regarding medication list and storage |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 5
Date: Jun 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, nutrition, respiratory therapy, food safety, and building maintenance at St Johns Place of Arkansas, LLC.
Findings
The facility was found deficient in maintaining adequate nutritional support for residents, following physician orders for respiratory equipment changes, ensuring food preparation and serving met professional standards, maintaining kitchen and food storage sanitation, and keeping essential building equipment in good repair. These deficiencies posed minimal harm or potential for harm to residents.
Deficiencies (5)
Failed to maintain acceptable nutritional status for Resident #43 at risk for weight loss, including failure to provide ordered super-calorie diet enhancements.
Failed to follow physician orders by not changing respiratory equipment weekly for Residents #8 and #33 receiving oxygen therapy.
Failed to ensure fortified food was prepared and served according to the planned recipe, affecting nutritional needs of residents.
Failed to maintain sanitary conditions in the kitchen including unclean vents, rotten door frames, uncovered food in refrigerator, unclean ice machine, and improper hand hygiene by dietary staff.
Failed to keep essential building equipment in good repair, including water leaks in kitchen dry storage room and missing sheet rock, with no maintenance policy in place.
Report Facts
Weight loss percentage: 9.11
Census: 64
Residents affected by fortified food deficiency: 29
Residents affected by kitchen sanitation deficiencies: 62
Residents affected by building repair deficiencies: 61
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