Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Cavalier Healthcare Of England during CMS and state inspections, most recent first.
The facility did not consistently review or update care plans after assessments or changes in condition for several residents, including those with severe cognitive impairment, recent falls, new hospice services, and recent admissions. In multiple cases, care plans were not revised to reflect significant events or interventions, and required assessments were not completed within the specified timeframes.
Dietary staff did not follow hand hygiene protocols during meal service, including handling food and food service equipment with bare hands and failing to wash hands between tasks that could cause cross contamination, as required by facility policy.
A resident with severe cognitive impairment and a diagnosis of Alzheimer’s and dementia was not provided with a care plan meeting involving their designated POA, despite facility policy requiring such involvement and care plan interventions that included family participation. Staff interviews confirmed that no care plan meeting had occurred since admission, and the POA was not invited to participate.
A resident with severe cognitive impairment had conflicting advance directive documentation regarding life-sustaining treatment, with forms signed by a family member who was not the legal healthcare POA. The facility did not have a valid POA on file, resulting in unclear and potentially invalid code status for the resident.
A resident who was re-admitted on hospice services after multiple hospitalizations did not have a significant change MDS assessment completed within the required 14-day period. The MDS was started but remained incomplete for over two months, and the care plan was not updated to reflect the resident’s hospice status. The MDS Coordinator confirmed the assessment should have been completed and was unaware of the delay.
A facility did not complete and transmit required MDS assessments, including entry, significant change, and quarterly MDS, within the mandated timeframes for a resident with COPD and pneumonia who experienced changes in care, such as hospice admission. The care plan was not updated to reflect these changes, and the MDS Coordinator confirmed the assessments were incomplete and not submitted as required.
A resident with severe cognitive impairment and incontinence was not checked or changed for an extended period, resulting in saturated clothing and a soiled brief. Despite facility policy and staff training requiring checks every two hours, CNAs admitted the resident was overlooked due to other duties. Nursing staff interviews confirmed expectations for regular incontinence care and repositioning were not met.
The facility failed to maintain proper food temperatures, leading to resident dissatisfaction and potential nutritional issues. Observations revealed that food carts were left open, causing temperature drops in meals served. Residents reported receiving cold food, and staff admitted to procedural lapses. The Dietary Manager acknowledged equipment issues, and facility policies on food temperatures were not adhered to.
The facility failed to ensure proper food storage, hand hygiene, and kitchen cleanliness. Observations included uncovered and undated food items, improper hand hygiene by dietary staff, and unclean kitchen and dishwashing areas. Additionally, a hot food item was found to be below the required temperature, posing a risk of foodborne illness to residents.
The facility failed to ensure that a diabetic resident's nails were clean and trimmed as per her care plan. Despite the responsibility lying with the nurses, the resident was observed multiple times with long nails and a black substance underneath them. The resident indicated that her nails were only cleaned when there was enough help.
The facility failed to ensure a safe and hazard-free environment for two residents. One resident with severe cognitive impairment had hazardous items left accessible in their room, while another resident with moderate cognitive impairment was observed vaping indoors despite a policy prohibiting it. The facility's inconsistent enforcement and communication of safety policies led to these deficiencies.
The facility failed to ensure that refrigerated narcotic medications were stored in a permanently affixed compartment, potentially leading to misappropriation. An LPN confirmed the narcotic box was not affixed, and the DON acknowledged it should be. Facility policy mandates secure storage of medications.
The facility failed to ensure meals were served at acceptable temperatures, affecting residents who received meal trays in their rooms. Residents reported that hot food items were often cold, and cold items were warm. Temperature checks confirmed these observations, with unheated food carts resulting in food items not being maintained at safe and appetizing temperatures.
The facility failed to ensure pureed food items were blended to a smooth, lump-free consistency, posing a risk to residents requiring pureed diets. Observations revealed that pureed lasagna, garlic bread, vegetable blend, bread, and sausage were not prepared correctly, affecting six residents.
The facility failed to ensure that the biohazard and oxygen rooms remained locked at all times, potentially affecting all 57 residents. Unattended keys were found in the Biohazard Room door, and another room containing oxygen cylinders and used syringes was found unlocked. The DON and Administrator confirmed these findings.
The facility failed to ensure that residents had knowledge of the State Inspection Book and that it was accessible to them. Residents were unaware of the book's existence or location, and the survey results binder was found to be kept behind the nurse's station, making it inaccessible to residents and their representatives. The Administrator admitted the book was not returned to its proper location after painting.
Failure to Review and Revise Care Plans After Assessments and Changes in Condition
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment or change in condition for four out of five sampled residents. For one resident with severe cognitive impairment and a history of falls, the care plan had not been updated following multiple falls and hospitalizations, despite documentation of these events in progress notes. Observations also revealed the resident continued to attempt to get out of bed, and interventions such as an extra mattress were implemented without corresponding updates to the care plan. Another resident was admitted with multiple complex diagnoses, but a comprehensive care plan was not developed following admission, nor was a baseline care plan completed within the required timeframe. The MDS Coordinator confirmed that the care plan was overdue and not available for staff reference. Additionally, a resident who was started on hospice services did not have this significant change reflected in their care plan, as the last revision predated the hospice order. A further resident experienced multiple falls over several months, with some falls lacking documented interventions and others having interventions that were not incorporated into the care plan. The care plan did not reflect the resident's recent falls or the interventions implemented, and a significant change MDS assessment was not completed within the required timeframe. The facility's policy required care plans to be reviewed and revised after comprehensive assessments and significant changes, but this was not consistently followed for the sampled residents.
Failure to Perform Hand Hygiene During Food Service
Penalty
Summary
Dietary staff failed to perform proper hand hygiene during meal service, as observed on two separate occasions. On one occasion, a dietary staff member opened a box of rolls without gloves, reached into the box with bare hands, and handled the rolls without washing hands after touching the outside of the box. The staff member acknowledged during an interview that hand washing should have occurred after opening the box and before touching the food to prevent cross contamination. In another instance, the same staff member opened and closed the lids of hot plate warmer containers with bare hands, retrieved plates, and proceeded to the tray line to serve food without performing hand hygiene between these tasks. The facility's policy requires hand washing before food preparation and after handling soiled equipment or utensils, as well as as often as necessary to prevent cross contamination. The administrator and another dietary aide confirmed that the top of the plate warmer was considered dirty, and that staff hands would be considered contaminated after touching it, yet hand hygiene was not performed before returning to food service.
Failure to Involve POA in Care Plan Development for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident’s designated Power of Attorney (POA) was invited to participate in the development and implementation of the resident’s person-centered care plan. The resident, who was admitted with Alzheimer’s and dementia and had severe cognitive impairment as indicated by a Brief Interview for Mental Status score of 04, had a care plan that included interventions requiring family involvement, particularly in nutritional evaluation. Despite this, the POA reported never being invited to a care plan meeting since the resident’s admission. Interviews with facility staff revealed that care plan meetings were supposed to be held quarterly, upon admission, and with changes in condition. However, the MDS Coordinator confirmed that no care plan meeting had been conducted for the resident since admission. The Nurse Manager stated there was no one available to conduct care plan meetings at the time, and the Administrator was unsure if the POA had been contacted, noting that two of the resident’s family members worked at the facility. The DON also acknowledged that care plan meetings should have occurred but could not explain why they had not been held for this resident.
Conflicting Advance Directive Documentation and Lack of Legal Authorization
Penalty
Summary
The facility failed to ensure that a resident's advance directive documentation accurately reflected the resident's wishes regarding life-sustaining treatment. Record review revealed that the resident, who was admitted with severe cognitive impairment and multiple medical diagnoses including dementia and chronic kidney disease, had conflicting information documented regarding their code status. Specifically, two separate acknowledgment forms were signed by a family member—one indicating a Do Not Resuscitate (DNR) order and another indicating a desire for all life-sustaining treatments. Additionally, the family member who signed these documents was not documented as having legal authority as the resident's healthcare Power of Attorney (POA). Further review and interviews confirmed that the facility did not have a healthcare POA on file for the resident, and the family member who signed the forms stated they did not possess POA authority, as the resident was not competent to appoint one. The facility's policy requires that advance directives be honored only if completed prior to a resident being deemed incompetent, and that such directives must be legally valid. The presence of conflicting documentation and lack of a legally authorized decision-maker resulted in unclear and potentially invalid advance directive status for the resident.
Failure to Complete Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after determining a significant change in a resident’s physical or mental condition. The resident in question was initially admitted with abnormal blood chemistry and pneumonia, and was later re-admitted from the hospital on hospice services with a diagnosis of acute kidney injury, following multiple hospitalizations in the previous month. Documentation showed that the significant change MDS was started three days after the resident’s re-admission and transition to hospice care, but as of more than two months later, the assessment remained incomplete and pending with the MDS Coordinator. Further review revealed that the resident’s care plan had not been updated to reflect the hospice admission, and the MDS Coordinator confirmed that the significant change MDS should have been completed within 14 days of initiation. The coordinator was unaware of why the assessment did not appear on their dashboard, resulting in the failure to complete the required assessment and update the care plan accordingly. Orders and documentation from the hospice company and physician confirmed the resident’s hospice status, but the necessary MDS and care plan updates were not completed as required.
Failure to Complete and Transmit MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to ensure that a comprehensive entry Minimum Data Set (MDS) assessment was encoded and transmitted within the required timeframe for one resident. Record review showed that the resident was admitted with chronic obstructive pulmonary disease and pneumonia, and later had significant changes in care, including admission to hospice services. Examination of the electronic health record revealed that several MDS assessments, including a discharge MDS, an entry MDS, a significant change MDS, and a quarterly MDS, were either not completed or not transmitted as required. The care plan had not been updated to reflect the resident's changes in care. During interview, the MDS Coordinator confirmed that the significant change MDS and other required assessments were incomplete and not submitted within the mandated timeframes, and that the facility did not have a specific policy for MDS timing, relying instead on the RAI OBRA guidelines.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
A deficiency occurred when staff failed to provide timely perineal care and repositioning for a resident with severe cognitive impairment, stroke, dementia, and depression. The resident was observed to have been left in a saturated brief containing stool and soaked clothing, with the last change reportedly occurring early in the morning. Certified Nursing Assistants (CNAs) admitted the resident had been overlooked due to being asked to assist with other residents, and were unsure of the exact time the resident was last changed. The resident was dependent on staff for all activities of daily living and was always incontinent of bladder and frequently incontinent of bowel, as documented in the Minimum Data Set (MDS) and care plan. Facility policy and the resident's care plan required that incontinent residents be checked and changed at least every two hours, and that staff monitor for signs of infection and skin breakdown. The care plan also directed frequent hourly rounds while the resident was in a wheelchair. Interviews with nursing staff, including the RN, treatment nurse, DON, and administrator, confirmed that staff were expected to check and change residents every two hours, especially those with incontinence, to maintain skin integrity and prevent infection. Despite these policies and staff training, the resident was not checked or changed as required, resulting in prolonged exposure to urine and feces. The incident was directly observed by the surveyor, and staff interviews confirmed a lapse in following established protocols for incontinence care and repositioning. Facility documents and in-service records showed that the involved CNAs had been educated on these requirements prior to the incident.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures, which compromised the palatability and nutritional intake of residents. During observations, it was noted that food carts were left open while being loaded and transported, causing significant temperature drops in both hot and cold food items. For instance, cream corn and chili were served at temperatures well below the required 150 degrees Fahrenheit for hot foods, and milk was served above the acceptable 40 degrees Fahrenheit for cold foods. This issue was observed during multiple meal services across different halls. Residents expressed dissatisfaction with the temperature of their meals, with some reporting that their food was cold by the time it reached them. Staff interviews revealed a lack of adherence to proper procedures for maintaining food temperatures, with several CNAs admitting that leaving the cart doors open was faster but resulted in temperature drops. The Dietary Manager acknowledged that the steam table and food carts were not functioning optimally, contributing to the problem. The facility's policies on food temperatures were not followed, as evidenced by the repeated instances of food being served at incorrect temperatures. Despite previous grievances and complaints from residents about cold meals, the facility continued to struggle with maintaining appropriate food temperatures during service. The failure to address these issues effectively led to ongoing resident dissatisfaction and potential impacts on their nutritional intake.
Multiple Deficiencies in Food Storage, Hand Hygiene, and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure food items stored in the refrigerator were covered and dated, and the kitchen vents were cleaned to provide a sanitary environment for food preparation. Observations included an open gallon of enchilada sauce and an opened box of bacon in the refrigerator without proper covering or dating. Additionally, the ceiling tile above the refrigerator had peeling paint, exposing the wood. Similar issues were found in the meat and vegetable freezer, where opened zip lock bags containing onion rings and chicken fried steak were not sealed properly. Dietary staff failed to follow proper hand hygiene protocols, leading to potential contamination. One dietary employee washed his hands but then turned off the faucet with his hands, contaminating them before handling food items. Another dietary employee was observed handling utensils and food items without changing gloves or washing hands after touching dirty objects. These actions were repeated by multiple dietary employees, indicating a systemic issue with hand hygiene practices. The facility also failed to maintain the cleanliness and integrity of the kitchen and dishwashing areas. Observations included peeling paint, water damage, and stains on the ceiling tiles, floors, and walls. The dishwashing room had black/brown stains on the floor, rust stains on the baseboards, and white sediment accumulations on dish racks. Additionally, the temperature of a hot food item on the steam table was found to be below the required 135 degrees Fahrenheit, posing a risk of foodborne illness to residents.
Failure to Maintain Nail Hygiene for Diabetic Resident
Penalty
Summary
The facility failed to ensure that the nails of Resident #2, who has a diagnosis of Type 2 Diabetes mellitus, were clean and trimmed. The resident's care plan specified that nails should be checked, trimmed, and cleaned on bath days and as necessary, with changes reported to the nurse. On multiple occasions, Resident #2 was observed with long fingernails and a black substance underneath them. The resident mentioned that her nails were only cleaned when there was enough help. Both a CNA and an LPN confirmed that nurses were responsible for cutting and cleaning the resident's nails due to her diabetic condition. However, the LPN admitted that there was no excuse for the nails being dirty, even if the resident sometimes refused to have them cut.
Failure to Ensure a Safe and Hazard-Free Environment
Penalty
Summary
The facility failed to ensure a safe and hazard-free environment for two residents, leading to deficiencies in their care. Resident #50, who has severe cognitive impairment due to dementia, was observed multiple times with potentially hazardous items such as aftershave, shaving gel, shave cream, and body lotion left on the dresser by the door. Despite the care plan indicating that staff should ensure a safe environment, these items were not removed. A Certified Nursing Assistant (CNA) acknowledged that these items should not be there and that it was the aides' responsibility to put them away. The Director of Nursing (DON) confirmed that these items should not be accessible to demented and confused residents, as per the facility's policy on avoiding accidents and incidents involving patients. Resident #43, who has moderate cognitive impairment and impaired physical mobility due to a stroke, was observed vaping in their room. The facility's smoking policy was updated to prohibit vaping indoors and only allow it in designated outdoor areas. However, Resident #43 indicated that they were previously allowed to vape in their room and were only informed of the new policy after being observed vaping. The Administrator could not provide a clear answer on when the facility became vape-free, indicating a lack of consistent enforcement and communication of the policy. The updated smoking policy was provided to the resident after the incident, but the initial failure to enforce the policy created a hazardous environment.
Failure to Securely Store Refrigerated Narcotic Medications
Penalty
Summary
The facility failed to ensure that refrigerated narcotic medications were stored in a permanently affixed compartment, which could potentially lead to the misappropriation of resident property. During an observation, an LPN was seen pulling a narcotic medication box out of the refrigerator and placing it on the counter; the box was not affixed to the refrigerator. The LPN confirmed that the narcotic box was not permanently affixed. When questioned, the Director of Nurses was unaware of the reason but acknowledged that the box should be affixed. The facility's policy on drug acquisition, storage, and inspection mandates that medications be stored securely.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents. This deficiency was observed during two meals, affecting residents who received meal trays in their rooms on the A, B, and C halls. Specifically, residents reported that hot food items were often cold, and cold items were warm. For instance, Resident #41 and Resident #30 both indicated dissatisfaction with the temperature of their meals, noting that the food was not served at appropriate temperatures, which impacted their dining experience and nutritional intake. Temperature checks conducted by the surveyors confirmed these observations. On multiple occasions, unheated food carts were used to deliver meal trays, resulting in food items not being maintained at safe and appetizing temperatures. For example, milk temperatures ranged from 45 to 53 degrees Fahrenheit, and hot food items like biscuits with gravy and scrambled eggs were recorded at temperatures between 102.7 and 115 degrees Fahrenheit. These findings indicate a systemic issue with the facility's meal delivery process, affecting the quality and palatability of the food served to the residents.
Improper Preparation of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is essential to minimize the risk of choking or other complications for residents requiring pureed diets. During observations, it was noted that the pureed lasagna prepared by Dietary Employee (DE) #3 was gritty and not smooth. Similarly, the pureed garlic bread was thick, lumpy, and contained pieces of bread. The pureed vegetable blend was initially runny, and even after adding thickener, it remained lumpy and not smooth. These observations were made during two separate meals, indicating a consistent issue with the preparation of pureed foods in the facility. Further observations on the steam table revealed that the pureed bread and pureed sausage intended for residents on pureed diets were also not prepared to the required consistency. The pureed bread was thick, and the pureed sausage was gritty. When asked to describe the consistency of the pureed food items, DE #1 confirmed that the pureed bread was thick and the pureed sausage was gritty, acknowledging that they needed to be smooth. This deficiency had the potential to affect six residents who were on pureed diets, posing a significant risk to their safety and well-being.
Failure to Secure Biohazard and Oxygen Rooms
Penalty
Summary
The facility failed to ensure that the biohazard and oxygen rooms remained locked at all times, which had the potential to affect all 57 residents. On 04/02/2024 at 03:09 PM, the Surveyor observed an unattended set of keys in the doorknob to the Biohazard Room on 300 Hall. The Maintenance staff later removed the keys, admitting they had only been gone for a couple of minutes. The Administrator confirmed the keys were left in the door unattended. Additionally, on 04/03/2024 at 10:11 AM, the Surveyor observed a door on Hall 3 with a sign indicating it should be kept closed at all times, but it was found unlocked and open. The room contained oxygen cylinders, used syringes and needles, disinfecting wipes, a small refrigerator, and multiple PPE items. The DON and Administrator confirmed the room's contents and that the door was unlocked. A document provided by the Administrator titled 'Incident and Accident Reporting' effective 05/15/2024, with a revised date of 08/22/2017, indicated that everything possible should be done to avoid accidents or incidents involving patients. Despite this policy, the facility's failure to keep the biohazard and oxygen rooms locked at all times was observed on multiple occasions, posing a potential risk to the safety of all residents.
Failure to Ensure Accessibility of State Inspection Book
Penalty
Summary
The facility failed to ensure that residents had knowledge of the State Inspection Book and that it was accessible to them. During a Resident Council meeting, four residents stated they were unaware of the State Inspections Book or its location. The surveyor was unable to locate the survey results binder in the facility. The Activity Director indicated that the state inspection results were kept behind the nurse's station, making them inaccessible to residents and their representatives. The Administrator acknowledged that the state inspection book was not returned to its proper location after painting.
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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 England
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lonoke Health And Rehab Center, Llc | 15.7 mi | ★★★★★ | 7 | 0 |
| Barnes Healthcare | 17.3 mi | ★★★★★ | 0 | 0 |
| The Blossoms At White Hall Rehab & Nursing Center | 19.9 mi | ★★★★★ | 0 | 0 |
| Chambers Health And Rehabilitation | 20.4 mi | ★★★★★ | 5 | 0 |
| The Blossoms At West Dixon Rehab & Nursing Center | 20.5 mi | ★★★★★ | 7 | 0 |
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