Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Brooken Hill Health And Rehab, Llc during CMS and state inspections, most recent first.
Two residents who required substantial/maximal assistance with ADLs did not receive consistent nail care, use of protective geri-sleeves, and shaving as outlined in their care plans. One resident with Parkinson’s disease, severe cognitive impairment, and a history of arm skin tears was repeatedly observed with overgrown fingernails and exposed arms without geri-sleeves, despite ADL records indicating weekly nail checks and encouragement of geri-sleeves. Staff interviews revealed uncertainty about who was responsible for applying geri-sleeves and providing nail care, and ADL documentation lacked staff initials. Another resident with tremors and moderate cognitive impairment was observed multiple times with visible chin hair and reported not being offered shaving, even though ADL records showed facial hair checks and shaving as needed were documented as completed without initials. A CNA acknowledged seeing the facial hair earlier and intending to shave the resident later, and the DON confirmed CNAs were responsible for checking and removing facial hair and that documentation should not indicate tasks were done when they were not.
A resident with respiratory failure, heart failure, type 2 diabetes, and COPD was approved to self-administer inhaled medications, but surveyors observed the resident’s corticosteroid and beta2-agonist inhalers left unattended on the over-bed table on multiple occasions, and a medication lockbox kept on the over-bed table with the key left in the lock. The resident reported being told they could use their own inhalers. An LPN stated the resident was approved for unsupervised self-administration but admitted not being familiar with the self-administration policy, while also acknowledging that medications should not be left on the over-bed table and that the lockbox should not have the key in it. The DON and another LPN described that the facility’s process and expectations required assessment of the resident’s ability to self-administer, demonstration of correct use, and secure locked storage out of reach of other residents, and CNAs stated that medications should not be left out in resident rooms.
A resident with terminal Parkinson’s disease and severe cognitive impairment was enrolled in hospice, with hospice aides providing baths and an updated care plan specifying hospice CNA, RN, social services, and chaplain visits. However, no hospice physician order was present in the EHR at the time, no hospice notes appeared in progress notes, and the MDS still reflected that the resident was not on hospice. The MDS Coordinator reported she did not complete a Significant Change in Status Assessment because there was no hospice order in the system to trigger it, later finding that the hospice admission order had been dated earlier but not entered until much later. The DON stated that the nurse on duty at hospice admission should have entered the hospice order and believed nurses knew they were responsible for doing so.
A nonverbal resident with a history of brain stem hemorrhage and intact cognition was admitted with documented unclear speech, rare ability to make themself understood, and reliance on nodding, head shaking, and sign language for communication, yet no communication deficit with individualized interventions was initiated on the comprehensive care plan. Multiple assessments and progress notes by nursing, social services, APRN, and SLP consistently described the resident as nonverbal and using alternative communication methods, but these findings were not incorporated into a person-centered care plan. CNAs, an RNA, and an LPN reported using yes/no questions, body language, facial cues, and the resident’s hand signals to communicate, while also stating they did not know sign language and had not seen communication boards or structured tools, and leadership acknowledged that a communication deficit should have been care planned and that there were no facility policies guiding communication care planning for nonverbal residents.
A resident with neuropathy, non‑weight‑bearing status on one leg, multiple comorbidities, and a known history of falls was care planned as high fall risk and required two‑person assistance with a gait belt for all transfers. After prior incidents where the resident’s legs had given out during transfers, two staff attempted a wheelchair‑to‑toilet transfer by standing and pivoting the resident using the stronger leg while the resident held grab bars, but they did so without a gait belt. The resident’s legs collapsed, the resident went down to the knees, and an abrasion to the knee occurred. Staff and leadership interviews, along with policies and job descriptions, confirmed that a gait belt was required for all assisted transfers and that staff were expected to follow this procedure, but the involved staff admitted they forgot to use the gait belt during this transfer.
A resident with respiratory failure and other comorbidities received O2 via nasal cannula under an order that lacked a start date and was not set up as a scheduled order in the electronic record, even though oxygen use was documented on multiple days. Over several days, the resident’s humidifier bottle was repeatedly observed to be undated or dated but empty while the resident was on 2 L O2, and the resident reported persistent nasal dryness and that the bottle had been empty despite asking staff to change it. An LPN confirmed the order issue and acknowledged the empty, dated humidifier bottle, and leadership reported expectations for changing tubing and humidifier bottles but had no policy addressing oxygen equipment or humidified water.
A resident reported that a CNA tossed personal items onto the bed where the resident was lying and repeatedly patted the resident’s buttocks. The DON documented the allegation and reported it up the chain of command, and the DON and Administrator both recalled discussing the incident and the involved CNA. The Administrator, who stated she was familiar with the facility’s abuse policy requiring prompt external reporting of alleged maltreatment, chose not to report the allegation to the state agency because she did not believe it met the definition of abuse, and there was no documentation of any interview with the CNA. This resulted in a failure to report an allegation of mistreatment as required.
A resident reported that a CNA had tossed items onto the bed and repeatedly patted the resident’s buttocks, and facility records showed the DON documented this allegation. The facility’s abuse policy required an immediate, thorough investigation including interviews with staff, the alleged victim, other residents, and others with knowledge of the incident. The Administrator recalled speaking with the resident and believed she spoke with the CNA involved but did not document the CNA interview and did not interview other employees, leaving no evidence that a complete investigation was conducted as required by policy.
A resident with a recent abdominal surgery was admitted with staples in place and severe pain, but the facility did not obtain or implement physician orders for wound care or assessment. Nursing staff failed to perform or document wound assessments, did not notify a provider despite significant drainage and pain, and removed surgical staples without confirming the wound's readiness. This led to wound dehiscence, rehospitalization, and emergency surgery.
Failure to Provide Regular Nail Care, Protective Sleeves, and Shaving for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide regular nail care and use of protective geri-sleeves for one resident and shaving/personal grooming for another resident, as required by their care plans and ADL needs. For Resident #91, surveyors observed on multiple occasions that the resident’s fingernails extended over the tips of the fingers, despite a care plan intervention directing staff to check nail length and trim and clean nails on bath day and as necessary. The resident had Parkinson’s disease with dyskinesia, severe cognitive impairment (BIMS score of 04), required substantial/maximal assistance with showering and personal hygiene, and had a history of skin tears on the right arm. The care plan also included an intervention to encourage use of geri-sleeves due to potential skin integrity impairment, but the resident was repeatedly observed with arms exposed and without geri-sleeves in place. Record review for Resident #91 showed ADL tasks for checking, cutting, and filing nails weekly, and for encouraging geri-sleeves as tolerated, were marked as completed on several dates; however, there were no staff initials to identify who performed these tasks. During interviews, CNAs and a MA-C demonstrated uncertainty about who was responsible for placing geri-sleeves on the resident, when they should be applied, and whether the resident was supposed to wear them at all. One CNA believed hospice aides provided nail care and that they visited three times a week, while another CNA stated she provided nail care when needed and that the resident did not wear geri-sleeves, even though she acknowledged the resident would need them due to fragile skin. The DON reported there was no facility policy for ADLs and did not provide skills check-offs for the CNAs involved. For Resident #107, surveyors twice observed visible hair on the resident’s chin, and the resident reported that staff had not offered to shave the chin. The resident had a diagnosis of other specified forms of tremors, moderate cognitive impairment (BIMS score of 09), and required substantial/maximal assistance with showering and personal hygiene. The care plan required staff assistance with bathing/showering and personal hygiene, and the ADL task list showed scheduled bath days and documented completion of a task to check for facial hair and shave as needed on several dates, again without staff initials. Progress notes did not show any refusal of shaving by the resident. A CNA stated she determined needed care by looking in the resident’s closet care plan, that CNAs were responsible for bathing/showering, and that staff checked for facial hair on shower days and should check daily. She acknowledged seeing facial hair that morning and intended to shave the resident later. The DON stated CNAs were responsible for checking and removing facial hair during showers and as needed, and that CNAs should not document facial hair removal when it had not been done.
Failure to Safely Manage Self-Administration of Inhalers and Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident approved for self-administration of medications could follow instructions so that medications were not left at the bedside. The resident had diagnoses including respiratory failure, heart failure, type 2 diabetes, and COPD, and was receiving oxygen via concentrator. Record review showed orders for a beta2-agonist inhaler and a corticosteroid inhaler, but no physician order for self-administration rights was initially found. The facility’s policy required that residents who self-administer be assessed by the IDT to ensure they could safely administer and store medications out of reach of other residents. On multiple observations, surveyors found the resident’s inhalers and lockbox not secured as required. During one observation, the resident was resting in bed with eyes closed, the oxygen concentrator running at two liters via nasal cannula, but the nasal cannula was not in place, and both the corticosteroid and beta2-agonist inhalers were left unsupervised on the over-bed table. The resident stated they had been told they could use their own inhalers. On a later observation, a lockbox with the key left in the lock was seen on the over-bed table, and the resident stated the lockbox contained prescription inhalers but could not recall when it was provided. On another observation, the lockbox with the key still in the lock remained on the over-bed table while the resident was resting with oxygen in place. Interviews with staff confirmed that the resident had been approved for self-administration but revealed gaps in adherence to policy and lack of staff familiarity with self-administration procedures. An LPN stated the resident had been approved to self-administer inhalers at the bedside unsupervised and acknowledged not being familiar with the self-administration policy, while also stating that medications should not be left unattended on the over-bed table and that the lockbox should not have the key in the lock. The DON described the process for approving self-administration, including assessment, demonstration of use, and locked storage, and stated it would not be appropriate to leave a key in the lock or medications out on the over-bed table. Another LPN reported there had not been prior residents with self-administration rights and agreed that medications should not be stored on the over-bed table or in a lockbox with the key in place. CNAs stated that any medications found on the over-bed table would be reported to a nurse and that residents were not allowed to have unstored medication out in the open in their rooms.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS within 14 days of a resident’s hospice service election, as required by the CMS RAI Manual. The resident had a terminal prognosis related to Parkinson’s disease and a quarterly MDS dated 02/20/2026 showed severe cognitive impairment (BIMS score of 4) and no hospice services. The care plan, reviewed on 03/16/2026 and revised on 04/07/2025, was updated with an intervention initiated on 04/20/2026 indicating that a named hospice provider would supply a CNA up to five times weekly, an RN weekly and PRN, social services monthly and PRN, and chaplain services monthly and PRN, with a contact number listed. A CNA reported that the resident’s baths were being provided by hospice aides who visited about three days a week. Record review showed no physician’s order for hospice services in the electronic health record at the time of survey, and progress notes from 03/01/2026 through 04/24/2026 contained no hospice notes. During interview, the MDS Coordinator stated she completes all MDS assessments and had not done a significant change MDS for this resident’s hospice admission because there was no physician’s order in the system to alert her. Upon review, she identified that an order to admit the resident to hospice services was dated 03/24/2026 but was not entered into the system until 04/23/2026, and acknowledged that the ARD should have been set within 14 days of hospice election, by 04/07/2026. The DON stated that the nurse on duty when the resident was admitted to hospice should have entered an admission order for hospice and expressed that she believed nurses understood they were responsible for adding such orders, treating them like any other order.
Failure to Care Plan Communication Deficit for Nonverbal Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a communication deficit for a nonverbal resident. The resident had been admitted with diagnoses including nontraumatic intracerebral hemorrhage in the brain stem, major depressive disorder, and anxiety disorder, and was unable to move the right side of the body, including the face and mouth, due to a stroke. The admission MDS documented unclear speech, that the resident rarely or never made themself understood, sometimes understood others, and responded adequately only to simple, direct communication, while the BIMS score was 15, indicating intact cognition. The Baseline Care Plan noted the resident did not communicate easily with staff, but on review of the Comprehensive Care Plan initiated at admission, no communication deficit with corresponding interventions had been initiated. Record review showed multiple assessments and notes documenting the resident’s nonverbal status and alternative communication methods, but these findings were not translated into a specific communication care plan problem with individualized interventions. The Nursing Admit/Readmit/Quarterly Assessment described the resident as soft spoken and mouthing words, and progress notes indicated the resident was very soft spoken, nonverbal, able to shake the head yes and no, and utilized sign language. A social services admission assessment documented that the resident’s speech was clear, that the resident was nonverbal, used sign language as another mode of communication, and rarely or never was able to make themself understood but could understand others. An APRN note and an SLP evaluation further confirmed that the resident communicated by nodding or shaking the head and had impaired communication skills. Interviews with staff demonstrated that, in the absence of a care-planned communication deficit with defined interventions, staff relied on general approaches and did not have consistent tools or guidance for communicating with the resident. CNAs and an RNA reported communicating with the resident by asking yes/no questions, observing body language and facial cues, and noting that the resident used the left hand to indicate numbers or point to areas of pain, while also stating they did not know sign language and had not seen communication boards or other aids. An LPN reported talking to nonverbal residents as to verbal residents, using facial expressions to interpret needs, and was unaware of any communication boards or specific interventions for nonverbal residents. The MDS coordinator and DON acknowledged that a communication deficit should have been triggered and care planned at admission for a nonverbal resident, and the DON further stated the facility did not have policies for care plans, comprehensive care plans, communication, or communicating with nonverbal residents.
Failure to Use Required Gait Belt During Transfer Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to utilize appropriate transfer equipment, specifically a gait belt, during a toilet transfer for one resident, resulting in a fall and knee abrasion. The resident had medical diagnoses including a left lower leg blood clot, stage 4 kidney disease, type 2 diabetes, neuropathy, and was care planned as high risk for falls with gait and balance problems and limited mobility related to weakness. The resident was also non‑weight bearing on the left lower extremity and required assistance of two staff members with all transfers. The admission MDS showed the resident was cognitively intact and had a history of a fall in the prior months. Prior to the cited incident, the resident had experienced multiple falls at the facility. An unwitnessed incident report documented that the resident slid out of a wheelchair while trying to pick up a ring from the floor, with no injury. A later witnessed incident documented that the resident’s legs gave out during a transfer, and the resident was assisted to the floor without injury and then transferred back to the wheelchair using a gait belt and two staff. These events established that the resident had recurrent episodes of legs “giving out” and required two‑person assistance and a gait belt for safe transfers. On the date of the deficiency, during a transfer from wheelchair to toilet in the bathroom, two staff members (a MA‑C and a CNA) attempted to stand and pivot the resident using the right leg while the resident held onto grab bars, but they did not use a gait belt. The resident’s legs collapsed, and the resident went down to the knees, sustaining an abrasion to the right kneecap, which the resident attributed to the lack of a gait belt. Interviews with the resident, nursing staff, therapy staff, and administration confirmed that the resident was non‑weight bearing on the left leg, required two‑person assistance and a gait belt for transfers, and that facility expectations and policy required use of a gait belt for all assisted transfers. Staff involved acknowledged they “forgot” to use the gait belt during this transfer, and other staff confirmed that gait belts were expected to be used with every transfer when assistance was needed.
Failure to Maintain Active Oxygen Orders and Humidified Oxygen for Resident Comfort
Penalty
Summary
The deficiency involves the facility’s failure to ensure that oxygen therapy orders were properly scheduled and active before administration and to provide humidified oxygen in accordance with a resident’s preferences and comfort needs. Resident #125, who had diagnoses including respiratory failure, heart failure, and type II diabetes, had an active order entered on 04/15/2026 for oxygen at 2–4 liters via nasal cannula, but the order lacked a start date and did not appear as a scheduled order in the electronic record. The admission MDS in progress with an ARD of 04/20/2026 did not indicate that the resident was receiving oxygen therapy, despite documentation on the resident’s oxygen saturation summary that the resident was on oxygen on multiple dates in April. An LPN confirmed that the oxygen order had been present since 04/15/2026 but was not set up as a scheduled order and had no active date. The facility also failed to provide and maintain humidified water for the resident’s nasal comfort over several days. On multiple observations from 04/20/2026 through 04/22/2026, the resident’s humidifier bottle was found undated or dated but empty, while the resident was receiving 2 liters of oxygen via nasal cannula. The resident repeatedly reported that their nose was very dry and that the humidifier bottle had been empty since Monday, and stated they had asked staff to change the water bottle but could not identify to whom. An LPN acknowledged that the humidified water bottle dated 04/21/2026 was empty and stated it should not have been empty at 2 liters of oxygen, suspecting that someone may have dated an empty bottle without actually changing it. The administrator and DON stated their expectation that humidified water bottles be changed on Tuesday evenings with the tubing or when empty, but there was no facility policy addressing oxygen tubing, storage, or humidified water bottles, and the existing oxygen safety policy only addressed handling oxygen, not equipment.
Failure to Report Allegation of Mistreatment to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of mistreatment to the state agency as required by its abuse policy and regulation. The facility’s abuse policy, revised 10/18/2022, required all personnel to immediately report all alleged, witnessed, or suspected maltreatment to the Administrator or designee, who would then report events as required by state law. The policy specified that all alleged violations must be reported immediately, but not later than two hours if abuse or serious bodily injury is involved, or within 24 hours if the events do not involve abuse or serious bodily injury. Despite this policy, an allegation of mistreatment involving one resident was not reported to the state agency. The resident reported that a CNA came into the room, spent time there without working, and had hit the resident in the past, describing the CNA as “out of line” and “unusual.” Documentation in a folder provided by the Administrator showed that on 09/09/2025 the resident had reported to the then‑ADON (now DON) that a CNA, later identified as CNA #16, came to get the resident’s tray, threw items from the resident’s table onto the bed where the resident was lying, and hit the resident on the butt, not hard, but continued to do that. The DON’s witness statement reflected this report, and the DON recalled that the incident was initially reported to a social worker, after which she went to the resident to investigate. The DON stated she then reported the incident to the then‑DON (DON #17) and also reported it to the Administrator. Interviews with leadership confirmed that the allegation was never reported to the state agency. The Administrator acknowledged that she was made aware of the allegation, spoke with the resident, and understood that the CNA had tossed items onto the bed and patted the resident’s bottom. She stated she was familiar with the abuse policy but did not report the allegation externally because, based on her own investigation, she did not believe it constituted abuse. The Administrator also indicated that any interview with CNA #16 was not documented, as no such documentation was found in the incident folder. DON #17 recalled being informed of an incident involving a CNA tossing items on the bed and patting the resident’s behind and discussing it with the Administrator, and he stated he suspended the CNA, but he did not recall specific details or times. These actions and omissions resulted in the facility’s failure to report an allegation of mistreatment to the proper state agency for this resident.
Failure to Thoroughly Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to maintain evidence that an allegation of mistreatment was thoroughly investigated for one resident. The facility’s abuse policy, revised on 10/18/2022, required the Administrator or designee to conduct an immediate investigation of all alleged, witnessed, or suspected maltreatment, including abuse, and to consider interviews with employees, the alleged victim, other residents, family members, and others who might have knowledge of the incident. During an interview on 04/20/2026, Resident #74 reported that a female staff member used to come into the room, waste time, and not do any work, and that the staff member may have hit the resident, though the resident stated the incident was a long time ago and details were not clearly remembered. The resident indicated the incident had been reported and believed the staff member was no longer working there. Record review of a folder provided by the Administrator on 04/21/2026 showed a witness statement from the DON (who was the ADON at the time of the incident) documenting that on 09/09/2025, Resident #74 reported a CNA, later identified as CNA #16, came to retrieve the resident’s tray and threw items from the resident’s table onto the bed with the resident, and that the CNA hit the resident on the butt, not hard, but continued to do so. The resident was initially unable to identify the CNA. In an interview on 04/23/2026, the Administrator stated she became aware of the allegation around 09/11/2025 and that the resident reported the incident had occurred a couple of days earlier. The Administrator recalled speaking with the resident, who described the CNA tossing items onto the bed and patting the resident’s bottom, and the resident reported the pat did not hurt. The Administrator stated she was familiar with the abuse policy and believed she spoke with CNA #16, but there was no documentation of this interview in the investigation file. When asked if other employees were interviewed, the Administrator stated she did not interview other staff and could not recall why, leaving no documented evidence that all required investigative steps, including staff interviews, were completed in accordance with facility policy.
Failure to Obtain and Implement Physician Orders for Post-Operative Wound Care
Penalty
Summary
The facility failed to obtain and implement physician orders for the care of a post-operative surgical wound for one resident, resulting in significant complications. Upon admission, the resident had a recent abdominal surgery with staples in place and was experiencing severe, nearly constant pain. The hospital discharge instructions indicated that staples were to be removed on post-operative day ten, but did not provide specific instructions for wound assessment, care, documentation, or criteria for physician notification. Facility documentation and care plans lacked any plan of care or interventions for the surgical wound, and there were no orders or documentation related to wound care, assessment, or monitoring for complications. Nursing staff did not perform or document appropriate wound assessments or dressing changes during the initial days following admission. The resident's pain was not effectively managed, and staff failed to notify a physician or seek further guidance despite the presence of significant drainage and an unhealed incision. The wound was not assessed by an RN, and the LPN who provided care did not contact the on-call provider. When the staples were eventually removed, the wound dehisced, leading to rehospitalization and emergency surgery. Interviews with staff revealed a lack of clarity regarding responsibilities for wound care and assessment, and a reliance on incomplete or absent orders from the hospital. The resident's family reported concerns about uncontrolled pain and saturated dressings, and staff interviews confirmed that wound assessments were not performed as required. The treatment nurse removed the staples based solely on the discharge paperwork, without confirming the wound's readiness or consulting the surgeon or provider. The lack of a coordinated approach to wound care, absence of physician orders, and failure to document or communicate changes in the resident's condition directly contributed to the resident's wound dehiscence and subsequent complications.
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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.
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Nursing homes near Fort Smith
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fianna Hills Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 1 | 0 |
| Covington Court Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 5 | 0 |
| The Blossoms At Fort Smith Rehab & Nursing Center | 3.2 mi | ★★★★★ | 9 | 0 |
| Riverside Health Services | 4.6 mi | ★★★★★ | 6 | 0 |
| Ashton Place Health And Rehab, Llc | 4.6 mi | ★★★★★ | 0 | 0 |
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