Deficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
72% occupied
Based on a March 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 20, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide necessary care and services to a resident with a non-pressure related skin issue.
Complaint Details
The complaint investigation found that Resident #1 had bruising and scabbing on the left arm that was not documented in progress notes or treatment records. Staff failed to report or treat the skin issues properly. The resident had severely impaired cognition and was dependent on staff for care. The facility did not provide the required skin care policy when requested.
Findings
The facility failed to ensure appropriate treatment and care for Resident #1 who had bruising and scabbing on the left arm that was not documented or treated according to orders. Staff interviews revealed inconsistent reporting and documentation of skin issues, and the Director of Nursing did not provide the required skin care policy.
Deficiencies (1)
Failure to provide appropriate treatment and care for a resident with a non-pressure related skin issue.
Report Facts
Residents reviewed for non-pressure related skin issues: 2
Resident #1 admission date: Jun 7, 2024
Resident #1 Brief Interview for Mental Status score: 3
Dates of observations: Jun 17, 2025
Dates of observations: Jun 18, 2025
Dates of observations: Jun 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #2 | Stated procedures for reporting skin issues and notification of family, DON, and Administrator | |
| Certified Nursing Assistant (CNA) #17 | Described reporting procedures for skin issues | |
| Certified Nursing Assistant (CNA) #12 | Described reporting procedures for skin issues | |
| Licensed Practical Nurse (LPN) #13 | Observed bruising and scabbing on Resident #1's left arm and described reporting procedures | |
| Director of Nursing (DON) | Stated responsibility for notifying charge nurse and treatment nurse about skin issues |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 20, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including care planning, resident care, medication management, food safety, and vaccination protocols.
Findings
The facility was found deficient in multiple areas including failure to include residents and representatives in care planning, inadequate personal care such as nail care and bathing, insufficient treatment of skin issues, use of unnecessary medications, poor kitchen sanitation and food handling practices, and failure to ensure required pneumococcal vaccinations were administered or properly documented.
Deficiencies (6)
Failed to include resident and representative in care planning meetings and failed to revise care plan to reflect Do Not Resuscitate (DNR) status for Resident #63.
Failed to provide nail care for Resident #5 and failed to provide bath or shower for Resident #386.
Failed to provide appropriate treatment and care for non-pressure related skin issues for Resident #1.
Failed to ensure Resident #62 did not receive an unnecessary antidepressant medication related to weight loss.
Failed to maintain kitchen sanitation including unclean air vents, greasy equipment, uncovered food, dirty ice machine, and improper hand hygiene by dietary staff.
Failed to ensure required pneumococcal vaccinations were administered or properly documented for Residents #6, #52, and #63.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Weight measurements: 155
Weight measurements: 148
Weight measurements: 153
Dates of showers missed: 2
Dates of nail care: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding care plan meetings and nail care deficiencies |
| Certified Nursing Assistant #12 | Certified Nursing Assistant | Interviewed about nail care and skin issue reporting |
| Licensed Practical Nurse #13 | Licensed Practical Nurse | Interviewed about nail care and skin issue reporting |
| Maintenance Director | Maintenance Director | Interviewed about kitchen air vent and ice machine cleaning |
| Dietary Manager | Dietary Manager | Interviewed about kitchen sanitation and food handling |
| Medical Doctor | Medical Doctor | Interviewed about medication for Resident #62 |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about vaccination refusals and documentation |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 9, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on staff adherence to Enhanced Barrier Precautions (EBP) and proper disinfection of glucometers for residents on EBP.
Findings
The facility failed to ensure staff performed proper hand hygiene, adhered to Enhanced Barrier Precautions, and correctly disinfected glucometers for two of seven residents sampled. Observations and interviews revealed lapses in glove use, hand hygiene, and cleaning protocols inconsistent with facility policies and manufacturer guidelines.
Deficiencies (2)
Failure to ensure staff performed proper handwashing and adhered to Enhanced Barrier Precautions when providing care to residents on EBP.
Failure to correctly disinfect the facility glucometer according to manufacturer validated cleaning instructions.
Report Facts
Residents sampled for infection control: 7
Date of inspection visit: Apr 8, 2025
Date survey completed: Apr 9, 2025
Number of glucometers on medication carts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Observed failing to perform hand hygiene and proper glove use during care of Resident #2. | |
| Licensed Practical Nurse (LPN) #2 | Observed not performing hand hygiene before donning gloves and incorrectly disinfecting glucometer. | |
| Licensed Practical Nurse (LPN) #3 | Interviewed about knowledge of EBP and glucometer cleaning practices. | |
| Director of Nurses (DON) | Interviewed regarding staff training, PPE availability, and glucometer cleaning policies. |
Inspection Report
Routine
Census: 74
Deficiencies: 8
Date: Mar 28, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to medication administration, personal care, infection control, food safety, and other resident care standards.
Findings
The facility was found deficient in multiple areas including failure to ensure safe self-administration of medication without proper assessment and orders, inadequate personal hygiene care, improper catheter care, medication storage issues, food temperature and preparation problems, poor infection control practices including failure to use PPE for contact precautions, and unsanitary kitchen conditions.
Deficiencies (8)
Failed to ensure medications were not self-administered without a physician order and interdisciplinary team assessment for Resident #275.
Failed to ensure fingernails were cleaned to promote good personal hygiene for Resident #28.
Failed to ensure urinary catheter tubing was not touching the floor for Resident #172.
Failed to ensure medications were stored in the med cart with identifiers on medication cups.
Failed to ensure meals were served at safe and appetizing temperatures and maintained appearance.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to ensure dietary staff washed hands before handling clean equipment or food items; unsanitary kitchen conditions and improper food storage practices.
Failed to ensure Personal Protective Equipment (PPE) was used before entering a room with contact precautions for Resident #172.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication cups observed: 2
Pills in cups: 13
Residents affected: 16
Residents affected: 8
Residents affected: 16
Residents affected: 11
Residents affected: 8
Total census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in medication self-administration deficiency and medication storage deficiency |
| Director of Nursing | Director of Nursing | Provided policies and confirmed deficiencies related to medication self-administration and infection control |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed and commented on nail care deficiency |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Interviewed regarding nail care and catheter care deficiencies |
| Dietary Supervisor | Dietary Supervisor | Interviewed and observed regarding food temperature, food preparation, and kitchen sanitation deficiencies |
| Dietary Employee #1 | Dietary Employee | Observed contaminating clean equipment by not washing hands |
| Dietary Employee #2 | Dietary Employee | Observed contaminating clean equipment by not washing hands |
| Dietary Employee #3 | Dietary Employee | Observed preparing pureed food with improper consistency |
| Dietary Employee #4 | Dietary Employee | Observed preparing pureed food with improper consistency |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed not using PPE before entering contact isolation room |
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 4
Date: Mar 24, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident environment, assessment accuracy, care planning, and nursing services.
Findings
The facility was found deficient in maintaining a clean, homelike environment, ensuring accurate Minimum Data Set (MDS) assessments, developing comprehensive care plans addressing resident risks such as pressure ulcers and elopement, and conducting timely assessments and monitoring according to accepted nursing standards. Deficiencies were noted for multiple residents including issues with cleanliness, inaccurate MDS data, incomplete care plans, and missed or delayed risk assessments.
Deficiencies (4)
Failed to maintain a clean, homelike environment for Resident #28 with a large dried brown substance under the bed.
Failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' status for Residents #1 and #48.
Failed to develop and revise comprehensive care plans within 7 days of assessment to include risks, goals, and interventions for Residents #1 and #48.
Failed to ensure nursing assessments and monitoring were conducted and documented in accordance with accepted standards for Residents #1 and #48.
Report Facts
Residents sampled: 25
Residents sampled: 25
Residents sampled: 17
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Named in relation to failure to clean Resident #28's room | |
| Business Office Manager | BOM | Provided facility policies on housekeeping and MDS accuracy |
| Director of Nursing | DON | Interviewed regarding care plans, assessments, and facility policies |
| Assistant Director of Nursing | ADON, LPN | Performed Risk of Elopement/Wandering Review and responsible for quarterly assessments |
| Registered Nurse #1 | RN | Provided Risk of Elopement/Wandering Review documentation |
Report
June 20, 2025
Report
June 20, 2025
Report
April 9, 2025
Report
March 28, 2024
Report
March 24, 2023
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