Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ashley Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
Unsafe Food Handling and Poor Hand Hygiene During Meal Prep: A dietary staff member handled food, utensils, and blender parts with ungloved hands, placed items on an unsanitized prep table, reused a spoon after it touched a dirty lid, and performed multiple food prep and meal service tasks without hand hygiene. During lunch service, the staff member also handled tortillas and plated food with bare hands, and no hand hygiene was observed.
Menu Not Followed for Milk Service: The facility did not consistently follow the approved menu for all residents receiving meals. Milk was listed on the menu for multiple meals, but it was not served at lunch during observation, and the Dietary Manager stated the facility only offered milk twice a day and did not calculate how much to order. Records showed milk was ordered, and the Administrator stated staff were expected to follow the approved menu and maintain adequate supplies to serve what was listed.
Surveyors found that a nurse responsible for wound care and infection prevention failed to follow basic infection control practices while treating two residents with pressure ulcers and one with a suprapubic catheter. The nurse repeatedly handled keys, a phone, and a computer, then accessed and prepared wound supplies without performing hand hygiene, touched gauze with ungloved hands before using it on a wound, and set up supplies on non‑impervious paper towels next to personal items instead of on a properly disinfected, protected surface. During one observation, the nurse cleaned a hip pressure ulcer and then a suprapubic catheter site using separate gauze cups but without changing gloves or performing hand hygiene between dirty and clean tasks, and then applied dressings after glove removal without washing hands. Facility policies required clean technique, use of an impervious barrier, handwashing between dirty and clean steps, and labeling dressings, but these were not followed, and the nurse and leadership acknowledged that the nurse had not received formal wound care training from the facility.
Unnecessary Psychotropic Medication Use and Inadequate Behavior Monitoring: The facility failed to ensure antipsychotic and other psychotropic medications were supported by documented behaviors or an indicated diagnosis. One resident with dementia had antipsychotic therapy and behavior monitoring despite no behaviors documented for the prior year, and another resident with intact cognition had antianxiety medications ordered despite repeated behavior logs showing no behaviors. The DON acknowledged that the medications could have been reduced more or eliminated when no behaviors were documented.
A registered nurse left a medication cart unattended with a computer screen displaying residents' electronic medication administration records, allowing staff and residents passing by to view protected health information. Interviews confirmed staff are trained to lock screens, and facility policies require confidentiality of medical records.
Staff failed to perform hand hygiene after resident care and before and after medication administration for three residents. An RN was observed exiting a resident room without sanitizing hands, then handling and administering medications to other residents, including pouring a pill into an ungloved hand. Interviews confirmed that these actions were not in line with facility infection control policies.
A resident with moderate cognitive impairment experienced emotional abuse when a CNA made inappropriate comments and showed an inappropriate picture during a shower. The facility delayed investigating the incident, leading to the resident's distress, including nightmares and self-harm. The facility's inadequate staff training and improper rehiring practices contributed to the deficiency.
A resident, who was a full code, was found pulseless and breathless, but staff failed to administer CPR as required by the care plan and POLST. Despite the presence of staff at the bedside, CPR was not initiated, and there was no documentation of vital signs being taken. The DON confirmed the resident's full code status, but confusion arose due to a claimed physician order to withhold CPR, which the physician did not recall giving. The facility lacked a policy on when to withhold CPR, contributing to the inaction.
The facility experienced staffing deficiencies, resulting in residents not receiving scheduled showers. Interviews and records indicated that several shifts in September 2024 were understaffed, with some having only two staff members or none at all. Staff expressed concerns about insufficient time to complete duties, and grievance logs showed multiple complaints about missed showers. The facility's assessment lacked a contingency plan for staffing shortages.
The facility did not post the required daily nurse staffing information, including the facility name, date, staff hours, and resident census, potentially affecting all 60 residents. The DON believed these postings were no longer required.
The facility failed to maintain proper food storage and sanitation standards. Observations revealed uncovered and expired food items in storage areas, a dirty ice machine, and dietary staff not adhering to hand hygiene protocols. The facility's handwashing policy was not followed, compromising food safety.
The facility did not have a policy for the governing body, and the governing body was not involved in the development and implementation of the facility assessment. The Administrator confirmed that no governing body member assisted with the assessment and that the facility lacked a documented policy for the governing body.
The facility's assessment was incomplete, missing critical components such as resident population details, facility resources, risk assessments, staffing needs, and staff training. The Administrator, responsible for the assessment, admitted it was his first time completing it and that neither the governing body member nor the medical director contributed. This deficiency potentially affected all 60 residents.
The facility did not ensure that the arbitration agreement included the right for residents to rescind within 30 days, instead allowing only 21 days. The administrator confirmed the discrepancy and the lack of a policy on arbitration agreements, potentially affecting all residents who signed.
The facility's arbitration documentation failed to include details on selecting a neutral arbitrator and a convenient location, affecting all 47 residents. Interviews with the Administrator and Admission Director revealed the absence of such language in the admission agreement, and the Administrator confirmed there was no policy for arbitration agreements.
The facility failed to consistently implement infection surveillance and lacked a water management plan for Legionella. Incomplete Infection Control Log analysis forms and the absence of a Legionella management plan were noted. The Infection Control Nurse confirmed no infection surveillance was being conducted, contrary to the facility's policy requiring facility-wide surveillance to prevent infections.
The facility failed to maintain a consistent antibiotic stewardship program, as infection control assessments were not completed for several months. A resident with a cutaneous abscess was prescribed an intravenous antibiotic, but there was no evidence to confirm the necessity or adjustments of the treatment. The Infection Control Nurse admitted to not conducting necessary investigations, and the DON was not involved in the process. The facility's policy aimed to optimize antimicrobial use and control resistance, but these goals were not achieved due to inadequate assessments and documentation.
The facility did not conduct required annual in-service training on communication for direct care staff. A review of records showed no communication training was completed between late 2023 and late 2024. The Administrator could only provide documentation of an in-service on resident rights. The DON, unaware of the incomplete trainings, had been working on them since her arrival and provided a recent in-service covering other topics.
The facility did not conduct required annual in-service trainings on compliance and ethics for staff from late 2023 to late 2024. The Administrator could not provide documentation of these trainings, except for one on resident rights. The DON stated that the Administrator was responsible for these in-services and was unaware of their omission, although she had been working on completing them since her arrival.
The facility did not conduct required annual in-service trainings for staff in behavioral health services. The Facility Assessment lacked information on staff preparation for residents needing behavioral health care. In-service records from the past year showed no completed trainings in this area. The Administrator could only provide evidence of an in-service on resident rights, and the DON was unaware of the incomplete trainings, although she had been working on them since her arrival.
The facility did not conduct required annual in-service trainings for staff, particularly in dementia care and abuse prevention. A review of records showed no in-services for dementia care were completed over a year. The Administrator could only provide documentation for an in-service on resident rights, and the DON was unaware of the reason for the missing trainings.
The facility failed to maintain lint-free dryer traps, posing a fire hazard. A surveyor found excessive lint build-up in all three dryers, with the last documented cleaning entry made the previous morning. The Housekeeping Supervisor confirmed lint should be removed after every three loads, but the evening shift employee admitted to not doing so. The facility's Fire Policy did not address this issue.
A facility failed to implement its abuse prevention policies after a resident reported inappropriate behavior by a CNA. The resident, with moderate cognitive impairment, was shown an inappropriate picture by the CNA, leading to distress and self-harm. Despite the administrator's awareness, the CNA continued to work near the resident due to staffing issues, and no new background checks were conducted upon her return.
A resident's discharge summary was incomplete, missing details on medications and discharge status, and lacked a physician's signature. The facility's policy required these elements, but they were not included, leading to a deficiency.
A resident did not receive scheduled showers due to understaffing, with only one CNA available on the hall. The resident, who required substantial assistance due to medical conditions, reported the issue. Grievance logs showed multiple complaints about missed showers, and the DON acknowledged the problem, despite in-service training for staff.
A resident with Alzheimer's and frequent incontinence did not receive timely and proper incontinence care. CNAs failed to clean all areas exposed to urine, risking skin breakdown and infection. The facility's policy emphasizes thorough cleaning to prevent such issues.
A facility failed to assess the risk of entrapment before using bed rails for a resident with Alzheimer's and dementia. Despite the care plan requiring an unobstructed path to the bathroom, a CNA was observed lowering a side rail that blocked the resident's path. The DON confirmed that the side rail restrained the resident and that no entrapment assessment was conducted.
A resident did not receive prescribed Lactulose due to unavailability during medication administration. On two occasions, staff could not find the medication in the cart, and progress notes indicated it was out of supply. The DON stated nurses were responsible for ordering refills, but the medication was not delivered in time, leading to missed doses.
The facility exceeded the acceptable medication error rate, reaching 7.41%. One resident missed doses of Lactulose due to supply issues, while another received an incorrect dosage of a probiotic. Staff failed to adhere to medication administration guidelines.
The facility did not follow the planned menu during a meal service, serving incorrect portions and types of food to residents on specific diets. Residents on Minced Moist Soft diets received less chicken spaghetti and the wrong type of vegetables, while those on pureed diets received less chicken spaghetti than prescribed.
Unsafe Food Handling and Poor Hand Hygiene During Meal Preparation
Penalty
Summary
The facility failed to ensure that food preparation equipment and the kitchen environment were maintained in a clean and sanitary condition during lunch meal preparation and service. During observation, [NAME] #6 pureed rice and handled chicken base by placing the lid upside down on the preparation table, using a plastic spoon to remove the chicken base, and then placing the spoon on the lid that had touched the unsanitized table. [NAME] #6 then carried a dirty blender to the dishwasher, ran it through the dishwasher, returned it to the preparation table, and began pureeing tortillas without washing hands or wearing gloves. The same chicken broth container and plastic spoon were then used again without handwashing, and during mechanically chopped fajita preparation, [NAME] #6 removed the blender lid and blade with ungloved hands, placed the lid bottom side down on the prep table, sprayed a pan with non-stick spray, poured food into the pan, and replaced the blade into the blender without performing hand hygiene.
Menu Not Followed for Milk Service
Penalty
Summary
The facility did not consistently follow the supplied menu for 57 of 57 residents who received meals from the facility. The Spring/Summer 2026 menu showed that on week one, day three, milk was to be served at breakfast, lunch, and dinner, but during a lunch observation on 05/13/2026 at 12:10 PM, milk was not served to residents. Later that day at 11:30 PM, the refrigerator was observed to contain individual servings of milk, seven gallons of 2% milk, four gallons of whole milk, and four cases containing 25 individual chocolate milk cartons. A review of a detailed food order with a delivery date of 05/08/2026 showed milk ordered for 57 residents through 05/11/2026, including two cases of 8-ounce 1% chocolate milk, two cases of 8-ounce homogenized fresh milk, and two cases of 8-ounce 2% fresh milk. During interview, the Dietary Manager stated that even though milk was on the menu, the facility only offered it twice a day and that she was not sure how much to order, so she just ordered milk without calculating the amount. The Administrator stated that dietary staff were expected to follow the approved menu and order food supplies in advance in adequate supply to serve what was listed on the menu. A facility in-service titled Menu Substitution Record stated that a substitution record should be used when the facility was out of an item or used something else in place of the item that was out.
Inadequate Hand Hygiene and Aseptic Technique During Wound and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in a manner that prevented infection for two residents receiving wound treatments. For the first resident, who had cellulitis, type 2 diabetes mellitus, protein-calorie malnutrition, venous insufficiency of both lower extremities, chronic venous hypertension with inflammation, candidiasis of the skin and nails, and a stage 2 pressure ulcer to the sacrum, the Treatment Nurse (TN), who was also the Infection Preventionist (IP), did not consistently perform hand hygiene or maintain a clean field. During wound care, the TN handled personal items such as keys, a cell phone, and the computer, then accessed wound care supplies from the treatment cart without performing hand hygiene afterward. The TN touched gauze pads with ungloved hands, sprayed them with wound cleanser, and later used those same gauze pads to cleanse the resident’s wound. The TN also set up supplies on a bathroom counter using a non‑impervious paper towel as a barrier, contrary to facility policy requiring an impervious barrier, and did not date or initial the new dressing. For the second resident, who had diagnoses including congestive heart failure, protein-calorie malnutrition, hypertension, GERD, neuromuscular bladder dysfunction, a stage 3 pressure ulcer of the right hip, urethrocutaneous fistula, UTI, and an indwelling catheter, the TN again failed to follow infection prevention practices during wound care. The TN unlocked the treatment cart with keys from her pocket, returned the keys to her pocket, and touched the computer before retrieving wound care supplies, then proceeded without performing hand hygiene until later in the process. She prepared gauze pads in cups with wound cleanser while gloved, then removed her gloves and continued the setup. In the resident’s room, she cleaned only half of the bedside table with a wet, soapy paper towel and dried it with another towel, then placed a non‑impervious paper towel as a barrier for wound supplies, while the other half of the table remained cluttered with personal items including a basin with cups and straws hanging over the wound supplies. During the wound care for the second resident, the TN washed her hands in the bathroom for approximately six seconds before donning gloves. She removed the old dressing from the right hip pressure ulcer, changed gloves, and then used gauze from one cup to clean the hip pressure ulcer. Without performing hand hygiene or changing gloves between dirty and clean tasks, she then used gauze from a second cup to clean the resident’s suprapubic catheter site, which she stated had drainage and had been cauterized the previous week. After removing her gloves, she did not perform hand hygiene before placing a split drain gauze around the suprapubic catheter and applying calcium alginate and a bordered foam dressing to the right hip wound. The TN later acknowledged that she did not wash her hands when going from dirty to clean tasks, that she should have changed gloves before moving to the secondary dressing, and that she had not received wound care training from the facility despite functioning as the wound care nurse and IP. Facility policies required clean technique, prevention of supply and surface contamination, use of an impervious barrier, handwashing after removing dirty gloves and before donning clean gloves, and labeling new dressings with initials, date, and time, as well as adherence to handwashing guidelines consistent with CDC recommendations for at least 15 seconds of rubbing. Interviews with the TN, Nurse Practitioner (NP), and Director of Nursing (DON) further clarified the expectations and deviations from practice. The TN stated she believed she performed hand hygiene when entering rooms and after touching anything dirty, but acknowledged she did not wash her hands between dirty and clean tasks and recognized that setting up wound supplies next to personal items would be an infection control issue. The NP stated that the suprapubic catheter and pressure ulcer should be cleaned one at a time and not treated simultaneously, and that she would not want wound contaminants introduced to the suprapubic catheter. The DON reported that the TN had been performing wound care since around November, had no wound care certification, and had received no specific wound care training from the facility, although the DON believed the TN had prior wound care experience elsewhere. The DON stated that staff should clean hands and change gloves when going from dirty to clean tasks, that separate areas such as a suprapubic catheter and a pressure ulcer should not be treated at the same time due to infection concerns, that dressings should be dated as a standard practice, that bedside tables should be clean, uncluttered, and disinfected rather than just washed with soap and water, and that a brief six‑second handwash was not appropriate.
Unnecessary Psychotropic Medication Use and Inadequate Behavior Monitoring
Penalty
Summary
The facility failed to ensure consistent behavior monitoring with antipsychotic medications, failed to ensure antipsychotic medications were prescribed for an indicated diagnosis, and failed to gradually reduce or eliminate antipsychotic medications for residents with no documented behaviors. These findings were identified for 3 of 5 residents reviewed for unnecessary medications, with detailed findings for Resident #4 and Resident #41. Resident #4 had a quarterly MDS showing severe cognitive impairment with a BIMS score of 00, diagnoses including non-Alzheimer's dementia, and no behaviors within the lookback period. The care plan listed dementia with agitation, impaired cognition, impaired thought processes, impaired decision making, and use of antipsychotic medications related to maladaptive behaviors with agitation. The physician order record showed behavior monitoring every shift and an atypical antipsychotic ordered for dementia with agitation, along with an anticonvulsant for mental and behavioral disorders. A request for reduction of antipsychotic medication noted the resident had been on antipsychotic therapy for dementia with agitation since 4/18/2025 and stated that, in the absence of current documentation indicating the need for the medication, reduction of the morning dose should be considered. The form was unsigned, and behavior monitoring sheets showed no behaviors documented for the last year to support continued use or lack of GDR. Resident #41 had a quarterly MDS showing intact cognition with a BIMS score of 15 and no behavior symptoms or rejection of care during the lookback period. The care conference report listed diagnoses of depression and anxiety, with an antidepressant for a history of depression and an antianxiety medication. The physician order record showed antianxiety medications ordered for anxiety disorder and depressive episodes, including one initiated in late October 2025 and others initiated in late November 2025. Behavior monitoring documentation reviewed for this resident showed 524 of 543 shifts with no behaviors from January through June 2025 and 459 of 459 shifts with no behaviors from July through November 2025, yet the DON reported that a dose reduction had been thought to have been completed and acknowledged that without behaviors documented, the medications could have been reduced more or even eliminated. The DON also stated that antipsychotic medication was not an appropriate treatment for anxiety and that if an antipsychotic was prescribed without an approved diagnosis, the provider would be discussed with and Geri-Psych involved if needed.
Failure to Protect Resident PHI Due to Unattended Computer Screens
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' protected health information (PHI) on the 200 hall. During observations, a registered nurse left a medication cart unattended with a computer screen open to the electronic medication administration record of a resident. On a separate occasion, the same nurse prepared medication for another resident, locked the medication cart, but left the computer screen open to that resident's medication administration record while entering a resident's room. During these times, both residents and staff were observed walking past the unattended cart and visible computer screen. Interviews with the registered nurse, Director of Nursing, and Administrator confirmed that staff are trained to lock computer screens when unattended to protect resident information, and that leaving screens open constitutes a breach of confidentiality. Facility documents reviewed also emphasized the importance of maintaining the confidentiality and privacy of resident records and information.
Failure to Perform Hand Hygiene During Resident Care and Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during resident care and medication administration, as observed with three residents. Specifically, a registered nurse was seen exiting a resident's room without performing hand hygiene and then proceeded to handle medications and administer them to other residents without sanitizing hands between residents. The nurse also poured a vitamin D pill into their ungloved hand before placing it into a medication cup, contrary to infection control protocols. These actions were directly observed during medication passes and resident care activities. Interviews with the nurse, Director of Nursing, Administrator, and Infection Preventionist confirmed that facility policy requires hand hygiene before and after resident contact, as well as before and after medication administration. The nurse acknowledged awareness of these requirements but did not follow them during the observed incidents. Facility policies reviewed also emphasized the importance of hand hygiene and outlined specific procedures for staff to follow, which were not adhered to in these instances.
Failure to Protect Resident from Emotional Abuse
Penalty
Summary
The facility failed to protect a resident from emotional abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who made inappropriate comments and showed an inappropriate picture to the resident while they were in the shower. The incident occurred when CNA #4 entered the shower room and made comments about the resident's body, which was followed by showing a picture on her phone. This incident was not investigated by the facility until a week later, despite the resident showing signs of distress, such as having nightmares and self-harming behavior. The resident involved had a moderate cognitive impairment and required assistance with activities of daily living. The resident's care plan indicated that they could perform most functions with supervision and limited assistance. Following the incident, the resident exhibited signs of trauma, including being upset, having nightmares, and self-harming by biting their wrist until it bled. The facility's delay in addressing the incident and the lack of immediate investigation contributed to the resident's continued distress. The facility's policies on abuse and neglect were not effectively implemented, as evidenced by the failure to train staff adequately and the inappropriate rehiring of CNA #4 without conducting new background checks. The administrator's decision to allow CNA #4 to work on the same hall as the resident due to staffing shortages further compromised the resident's safety. The facility lacked a clear policy on rehiring employees, which contributed to the oversight in handling the situation appropriately.
Removal Plan
- Resident was interviewed by social services director and requested to talk to a psychiatrist and have a psychiatric evaluation. Evaluation is scheduled.
- Resident currently attends a day group program at Ozark Community Hospital with a psychiatric Advanced Nurse Practitioner 2 times a week.
- All current and future admitted residents will have a safety provided at all times.
- CNA has been terminated.
- DON/Designee will in-service all staff on abuse and neglect as well as psychosocial well-being and will continue to in-service all employees prior to next start of shift.
- This in-service will be done with all new hires and at least annually.
- Any behaviors documented on resident will be reviewed daily in stand-up ensuring that resident feels safe, and needs are being met.
- QA committee will monitor in morning meeting to ensure new hire education on Abuse, neglect and psychosocial well-being will be reviewed, to ensure employees received education. All staff will be reviewed annually.
Failure to Administer CPR to Full Code Resident
Penalty
Summary
The facility failed to administer Cardiopulmonary Resuscitation (CPR) to a resident who was a full code, as per their care plan and Physician Order for Life Sustaining Treatment (POLST). The resident, who was cognitively intact and had diagnoses of heart failure and morbid obesity, was found pulseless and breathless. Despite the resident's full code status, CPR was not initiated by the staff upon discovery. The last recorded vital signs were taken prior to the incident, and there was no documentation of CPR being administered when the resident was found in distress. Interviews revealed that the Director of Nursing (DON) acknowledged the resident's full code status and the lack of documentation regarding CPR administration. The EMS dispatcher reported that upon arrival, two staff members were present at the resident's bedside without administering CPR, and one staff member claimed to have received an order to withhold CPR from a physician. However, the physician later stated he did not recall giving such an order. An LPN who arrived during the incident confirmed that no CPR was being performed and that the resident was cold to touch. The facility lacked a policy on when to withhold CPR, contributing to the confusion and inaction during the emergency situation.
Removal Plan
- A cardiopulmonary (CPR) in-service was initiated by the Director of Nursing (DON).
- DON reviewed all physician orders, care plans, and signed Do Not Resuscitate (DNR) documents for code status.
- Color coded name plates were placed outside resident doors, green for full code and red for DNR.
- An in-service was provided to staff and new hires regarding color coded name plates.
- Quality Assurance and Performance Improvement (QAPI) is to ensure continued employee education.
- Staff interviews were conducted with staff from all positions to verify training had been completed.
- Staff interviewed verified they had been trained on CPR initiation and how to identify DNR or full code residents.
- A review of in-service sheets provided indicated staff had been provided training.
- Those staff who were not physically present to receive the in-services were messaged via telephone by the Administrator, with the in-service information provided and the employee acknowledging receipt and voicing understanding.
Staffing Deficiency Leads to Missed Resident Showers
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the residents' needs over several shifts in September 2024. Interviews and record reviews revealed that residents, including one who was scheduled for showers on specific days, did not receive showers as planned due to understaffing. The grievance logs showed multiple complaints about missed showers in August, September, and October 2024. Staffing schedules and timecards indicated that on several occasions, there were insufficient CNAs and nurses on duty, with some shifts having only two staff members or none at all. Interviews with staff members confirmed the understaffing issues, with CNAs and LPNs expressing concerns about not having enough time to complete their duties, including scheduled showers. The facility's assessment did not include a contingency plan for staffing shortages. The administrator acknowledged the staffing issues and mentioned efforts to hire more CNAs but did not provide details on retention strategies.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information, which is required to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. This deficiency was identified through observation, interview, and record review, and had the potential to affect all 60 residents in the facility. Specifically, the shift staffing schedule for the 7:00 AM to 3:00 PM shift on 10/28/2024 was missing the facility's name, the number and actual hours worked by staff, the resident census, and the licensed staff scheduled to work. Additionally, the staffing schedule for the 11:00 PM to 7:00 AM shift on the same date only listed one Certified Nursing Assistant's (CNA's) name. During an interview on 11/01/2024, the Director of Nursing (DON) stated that the staffing sheets, which should include the facility name, date, census, and total and actual number of hours worked per shift for nursing staff, were no longer required and therefore were not completed.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and sanitation standards, as observed during a survey. In the walk-in freezer, several opened boxes of food items such as cookie dough, garlic bread sticks, and Salisbury steak were not covered or sealed. Additionally, containers of sugar and flour were left uncovered under the food preparation counter. The spice rack contained expired items, including cinnamon, ground ginger, and poultry seasoning. In the nourishment room refrigerator, various food items lacked labels indicating when they were received or opened, and some were expired or discolored. The ice machine was found to have wet black residue on its plastic panels, indicating inadequate cleaning. The Dietary Manager confirmed that the machine is used by CNAs for residents' water pitchers and acknowledged the residue. Furthermore, dietary staff failed to adhere to hand hygiene protocols. Instances were observed where staff handled clean dishes, food preparation equipment, and meal trays without washing their hands after performing tasks that could lead to contamination. The facility's handwashing policy, initiated in 2018, was not followed by dietary staff, as evidenced by multiple observations of staff failing to wash hands between tasks. This included handling clean and dirty items without proper hand hygiene, which could compromise the safety and quality of food served to residents. The Dietary Manager confirmed the lapses in hand hygiene and food storage practices during interviews.
Lack of Governing Body Involvement in Facility Assessment
Penalty
Summary
The facility failed to establish and implement a policy for the governing body responsible for managing and operating the facility. The governing body was not active in the development and implementation of the facility assessment. During an interview, the Administrator admitted that no member of the governing body assisted with the completion of the facility assessment. Additionally, the facility did not have a documented policy for the governing body, as confirmed by the Administrator when asked to provide one.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to ensure that its facility-wide assessment contained essential information to allocate necessary care and resources to meet the needs of its residents. The assessment, approved on 08/08/2024 and reviewed on 10/28/2024, was missing critical components such as details about the resident population, facility resources, a facility-based and community risk assessment with an all-hazards approach, and the staff responsible for completing the assessment. Additionally, it lacked information on staffing needs, staff training and competencies, policies and procedures for care provision, physical environment and building information, contracts and third-party agreements, and health information technology resources. The Administrator, who was interviewed on 11/01/2024, acknowledged responsibility for completing the assessment and stated that this was his first time doing so. He admitted that neither the governing body member nor the medical director had input in the completion of the facility assessment. This deficiency had the potential to affect all 60 residents of the facility.
Arbitration Agreement Deficiency
Penalty
Summary
The facility failed to ensure that the arbitration agreement included all necessary components, specifically the right for residents or their representatives to rescind the agreement within the first 30 days of admission. During a review of the facility's admission agreement, it was found that the arbitration provision allowed revocation within 21 days of signing, rather than the required 30 days. The facility's administrator confirmed this discrepancy and acknowledged that there was no existing policy regarding arbitration agreements. This oversight had the potential to affect all residents who had signed the arbitration agreement.
Arbitration Agreement Lacks Neutral Arbitrator and Location Details
Penalty
Summary
The facility failed to ensure that its arbitration documentation included the selection of a neutral arbitrator and a convenient location for arbitration, potentially affecting all 47 residents. During interviews, both the Administrator and the Admission Director were unable to identify language in the admission agreement that described the process for selecting an arbitrator and a neutral location. The Administrator acknowledged the absence of a policy for arbitration agreements. A review of the facility's arbitration agreement confirmed that section f of the admission agreement, which pertains to arbitration, did not contain the necessary information regarding the selection of an arbitrator and location.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to implement consistent infection surveillance to prevent the spread of possible communicable diseases and did not develop a water management plan to prevent the growth and spread of waterborne pathogens. During a review on 10/30/2024, it was found that the Infection Control Log analysis forms were incomplete, lacking trends and root cause analysis, and the facility diagrams were blank for each month. Additionally, the facility did not have any policy, procedures, or management plan for Legionella, as confirmed by the Administrator and the Infection Control Nurse. The Infection Control Nurse admitted to not conducting an infection surveillance process at the time, despite the facility's policy stating that a facility-wide surveillance should be performed to identify opportunities to prevent or reduce infection rates among residents, employees, and visitors.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure a consistent antibiotic stewardship program to determine if antibiotics were indicated or if adjustments to therapy should be made. This deficiency was identified through interviews, record reviews, and facility policy reviews. A resident, who was cognitively intact with a BIMS score of 15, had a diagnosis of a cutaneous abscess on the right foot and was prescribed an intravenous antibiotic every 24 hours. However, infection control assessment tools were not completed for August, September, and October, as confirmed by the Infection Control Nurse. The nurse admitted to having no paper evidence to verify whether the antibiotic was necessary or if adjustments were needed, and stated that without conducting investigations, it was impossible to confirm if the resident had a true infection. The Director of Nursing also indicated a lack of involvement in the process, stating they were told not to interfere. The facility's policy on antibiotic stewardship aimed to optimize antimicrobial use, improve clinical outcomes, and control antimicrobial resistance, but these objectives were not met due to the lack of proper assessments and documentation.
Failure to Conduct Required Communication Training
Penalty
Summary
The facility failed to ensure that required annual in-service trainings were conducted, specifically in the area of communication, for direct care staff members. During a review of in-service records from September 30, 2023, to October 27, 2024, it was found that no communication training had been completed. The Administrator was only able to provide documentation of an in-service on resident rights. The Director of Nursing (DON) stated that the Administrator was responsible for conducting mandatory in-services and was unaware of why some had not been completed. The DON had been working on completing the in-services since her tenure began and provided a monthly all-staff in-service dated October 16, 2024, which covered resident rights/abuse and neglect and enhanced barrier precautions.
Failure to Conduct Compliance and Ethics In-Services
Penalty
Summary
The facility failed to conduct the required annual in-service trainings on compliance and ethics for staff over a period from September 30, 2023, to October 27, 2024. During a review on November 1, 2024, the Administrator was unable to provide documentation of these in-services, except for one related to resident rights. The Director of Nursing (DON) indicated that the Administrator was responsible for conducting these mandatory in-services and expressed unawareness of why they had not been completed. The DON mentioned efforts to complete the in-services since her tenure began, but the deficiency remained unaddressed at the time of the survey.
Failure to Conduct Behavioral Health In-Service Trainings
Penalty
Summary
The facility failed to conduct required annual in-service trainings for staff, specifically in the area of behavioral health services. The Facility Assessment, dated August 8, 2024, lacked information on how staff were prepared to care for residents requiring behavioral health services. Upon review of the in-service records from September 30, 2023, to October 27, 2024, it was found that no in-services were completed for behavioral health. The Administrator could only provide evidence of an in-service on resident rights. During an interview, the Director of Nursing stated that the Administrator was responsible for conducting mandatory in-services and was unaware of why some had not been completed, although she had been working on completing them since her tenure began.
Deficiency in Staff Training on Dementia Care
Penalty
Summary
The facility failed to ensure that required annual in-service trainings were conducted, specifically in the areas of dementia care and abuse prevention. During a review of in-service records from September 30, 2023, to October 27, 2024, it was found that no in-services were completed for dementia care. The Administrator was only able to provide documentation of an in-service on resident rights. The Director of Nursing, when interviewed, stated that the Administrator was responsible for conducting these mandatory in-services and was unaware of the reason for their incompletion. She mentioned that she had been working on completing the in-services since her tenure began.
Failure to Maintain Lint-Free Dryer Traps
Penalty
Summary
The facility failed to ensure that lint traps in the laundry area were free from excessive lint build-up, which could pose a fire hazard. During an inspection, the Surveyor observed that all three clothes dryers had excessive lint accumulation. The clipboard used for documenting lint removal showed the last entry was made on the previous morning, indicating that the lint traps had not been cleaned since then. The Housekeeping Supervisor confirmed that lint was supposed to be removed after every three loads of laundry and documented accordingly. However, the employee responsible for the evening shift on the previous day admitted to not removing the lint or making an entry. The facility's Fire Policy and Procedure did not address this specific issue.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its established abuse policies and procedures following an allegation of abuse involving a resident. The facility's Abuse & Neglect Policy and Procedure, revised in 2017, mandates the protection, response, reporting, and investigation of any abuse allegations. However, after an incident involving a Certified Nursing Assistant (CNA) showing inappropriate pictures to a resident, the facility did not adequately protect the resident from further contact with the alleged abuser. The CNA involved in the incident was not immediately suspended or removed from the resident's vicinity, as she continued to work on the same hall where the resident resided, despite the administrator's initial intention to suspend her. The resident involved, who has a moderate cognitive impairment and other medical conditions, expressed distress over the incident, which led to self-harm. The resident reported being shown an inappropriate picture by the CNA, which caused significant agitation and led to the resident biting himself. Despite the administrator's awareness of the situation, the CNA was allowed to work in proximity to the resident due to staffing issues, and no new background checks were conducted upon her return. The facility lacked a policy on rehiring employees, which contributed to the oversight in handling the situation appropriately.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a written discharge summary for a resident included a comprehensive summary of the stay, a reconciliation of medications, and the resident's status at discharge. The discharge summary for the resident, who was admitted and later discharged home with family, noted participation in physical, occupational, and speech therapy, as well as wound care. However, it lacked details on the resident's pre- and post-discharge medications and the resident's status at discharge. Additionally, the discharge summary was not signed by a physician. During an interview, the Director of Nursing acknowledged that the discharge summary was incomplete and should have included information on the disposition of the resident's medications and belongings. The facility's policy on discharge/transfer of residents, which was undated, required that the discharge summary include a list of medications with instructions, post-discharge care instructions, and signatures from the resident or their representative. The policy also stated that the signed original form should be placed in the medical record, which was not adhered to in this case.
Failure to Provide Scheduled Showers Due to Understaffing
Penalty
Summary
The facility failed to ensure that a resident received scheduled baths/showers, which compromised personal hygiene and grooming. The deficiency was identified for a resident who was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. On one occasion, the resident did not receive a shower due to understaffing, with only one CNA available to assist on the resident's hall. The resident, who was cognitively intact and required substantial assistance with bathing due to chronic obstructive pulmonary disease and spastic hemiplegia, reported the issue during an interview. The facility's grievance logs revealed multiple complaints about missed baths/showers over several months. The staffing schedule confirmed inadequate CNA coverage on the day in question, and the DON acknowledged the issue, noting that grievances had been filed. Despite in-service training provided to staff, the facility's records showed inconsistencies in documenting completed baths/showers, further highlighting the deficiency in maintaining scheduled personal hygiene care for residents.
Inadequate Incontinence Care for Resident with Dementia
Penalty
Summary
The facility failed to provide proper and timely incontinence care for a resident with memory problems and frequent incontinence of bowel and bladder. The resident, diagnosed with Alzheimer's disease and non-Alzheimer's dementia, was observed multiple times throughout the day sitting in a wheelchair in the hallway common area and dining room. Despite the resident's care plan, which included ensuring an unobstructed path to the bathroom, the resident was not provided with timely incontinence care. During an observation, Certified Nursing Assistants (CNAs) #4 and #7 provided incontinence care to the resident, who had been incontinent of bowel and bladder. CNA #7 failed to clean all areas of the perineal and buttock regions exposed to urine. CNA #7 admitted that the resident's pants were wet when removed and acknowledged not cleaning certain parts of the perineal area. The Director of Nursing confirmed that staff should clean every surface of the perineal area to prevent skin breakdown, bacteria buildup, and urinary tract infections. The facility's incontinence care policy emphasizes keeping the skin clean, dry, and free of irritation to prevent infections.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that bed rails were used only after a proper assessment for the risk of entrapment was completed for a resident. The resident in question had memory problems, frequent incontinence, and diagnoses of Alzheimer's disease and non-Alzheimer's dementia. Despite the care plan indicating that the resident should have an unobstructed path to the bathroom, a surveyor observed a Certified Nursing Assistant lowering a side rail that obstructed the resident's path. The Director of Nursing acknowledged that the side rail restrained the resident's movement and confirmed that no assessment for entrapment had been completed prior to its use.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure that medication was available for a resident during a medication administration observation. On two separate occasions, staff members were unable to locate Lactulose, a medication prescribed for constipation, for a specific resident. On the first occasion, an LPN discovered the absence of Lactulose in the medication cart and indicated the need to contact the pharmacy. On the second occasion, an RN confirmed that the available Lactulose was intended for another resident, and there was none available for the resident in question. The resident's order summary and electronic medication administration record both indicated the need for Lactulose to be administered twice daily. Progress notes revealed that the medication was out of supply on two consecutive days, and staff were awaiting delivery from the pharmacy. The Director of Nursing stated that nurses were responsible for ordering medication refills, while the Administrator handled over-the-counter medication orders. The facility's Medication Administration Guidelines policy outlined the process for medication administration, which includes verifying the medication with the physician's orders and recording the information promptly. However, the failure to have the medication available resulted in the resident missing scheduled doses.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.41% during an observation of medication administration. This deficiency involved two residents and was observed during the administration of medications by two RNs and three LPNs. Specifically, Resident #46 did not receive their prescribed Lactulose medication on two consecutive days due to it being out of supply, as noted in the progress notes. The medication was not available in the medication cart, and staff were waiting for delivery from the pharmacy, which led to missed doses. Additionally, Resident #7 received an incorrect dosage of a probiotic medication. An LPN prepared and administered only one capsule of Saccharomyces Boulardii instead of the prescribed two capsules. The error was confirmed upon review of the resident's electronic medication administration record. The facility's policy requires that medications be administered timely and according to established guidelines, which was not adhered to in these instances.
Failure to Adhere to Planned Menu During Meal Service
Penalty
Summary
The facility failed to ensure that food items were prepared and served according to the planned written menu during the noon meal service on 10/28/2024. Specifically, residents on Minced Moist Soft diets were supposed to receive 1 cup of chicken spaghetti using 2 #8 scoops, but instead, they were served 3/4 cup using a 6-ounce ladle. Additionally, these residents were served pureed vegetable blend instead of the prescribed soft mash vegetables. Furthermore, residents on pureed diets were supposed to receive 1 cup of pureed chicken spaghetti using 2 #8 scoops, but they were served 2/3 cup using a #6 scoop. These discrepancies were observed during the meal service and indicate a failure to adhere to the planned menu, which was not followed as required.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 42 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rogers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Innisfree Health And Rehab, Llc | 1.7 mi | ★★★★★ | 0 | 0 |
| Bradford House Nursing And Rehab, Llc | 2.3 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Rogers Rehab & Nursing Center | 2.5 mi | ★★★★★ | 3 | 0 |
| Promenade Health And Rehabilitation | 2.6 mi | ★★★★★ | 5 | 0 |
| The Green House Cottages Of Northwest Arkansas | 3 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.