Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Crestpark Forrest City, Llc during CMS and state inspections, most recent first.
Failure to timely report alleged abuse and narcotic diversion: two cognitively intact residents had narcotic book entries showing pain meds administered by an RN, but both denied receiving them, and the DON confirmed the diversions were not reported to OLTC. In a separate incident, a cognitively intact resident reported a CNA grabbed the resident’s arm and caused a bruise, and the DON stated the allegation was not brought to her attention until the next morning; the facility policy required immediate investigation and OLTC notification by 11:00 AM the next day.
Failure to protect a resident after alleged CNA abuse: A cognitively intact resident with diabetes, PVD, bilateral AKA, osteomyelitis, and sepsis reported that a CNA grabbed the resident's arm, caused bruising/redness, and threw clothes at the resident after finding the resident naked. The RN reassigned the resident to another CNA but did not immediately notify the DON or remove the CNA from duty, and the allegation was not reported to the DON until the next morning.
An LPN prepared discharge paperwork and pulled medications for one resident but mixed up two residents and sent another resident’s medications home with the wrong family/representative. An RN then handed over the medications without checking them and did not review the discharge instructions or medication list with the family/representative. The DON confirmed the wrong medications were issued and the discharge instructions were not gone over.
Misappropriation of resident controlled medications occurred when an RN accepted a pharmacy narcotic delivery while the charge nurse was busy, signed the invoice, and logged the count, then another nurse opened the locked narcotic box and allowed access to the medication card. The count later did not match the pharmacy delivery, and the DON stated two other residents also had drug diversion investigations involving the same RN. The DON further stated the facility lacked policies on pharmacy deliveries and on nurses working while taking controlled drugs, and the investigations were not reported to the state agency.
The facility failed to maintain ice machines in a sanitary condition, improperly stored and managed food items, and did not adhere to proper handwashing protocols. Ice machines had visible dirt, food items were expired or improperly stored, and staff did not wash hands correctly, risking contamination. Additionally, food was not reheated to safe temperatures.
The facility did not secure refrigerated narcotics properly, as observed by a surveyor who found the controlled medication lockbox was not affixed inside the refrigerator. An LPN acknowledged the ease of removing the unsecured box from the facility. The facility's policy requires narcotics to be stored in a locked container affixed inside a locked cabinet, which was not followed.
The facility did not serve meals according to the planned menu, failing to provide the required 4 ounces of fried chicken to residents. Instead, residents received either 2 chicken legs weighing 2.5 ounces or 2 chicken wings weighing 1.2 ounces. A dietary aide confirmed the shortfall, acknowledging that more chicken should have been served.
The facility failed to maintain appropriate food temperatures, affecting meal palatability and nutritional intake. Observations showed unheated food carts delivering meals with temperatures below acceptable levels, such as scrambled eggs at 103.6°F and ground sausage at 84.5°F. Residents reported receiving cold food, indicating a consistent issue across meals.
The facility failed to prepare pureed foods to the required smooth, lump-free consistency for residents on pureed diets. Observations revealed that pureed items, including strawberry cake, English peas, vegetable blend, chicken, and sausage, were improperly prepared, with textures ranging from runny and lumpy to gritty. Staff interviews confirmed these inconsistencies, which did not align with the facility's policy for pureed food preparation.
The facility failed to ensure a safe environment and adequate supervision, as evidenced by improper handling of falls involving two residents. One resident experienced a fall resulting in bruising and hip pain, but necessary notifications to hospice or the provider were not made, and the resident was not evaluated. Another fall occurred two days prior with similar inaction. The DON was unaware of these incidents, indicating a breakdown in communication and adherence to protocols.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a feeding tube. An LPN was observed flushing the tube without wearing the required PPE, despite a dresser outside the room indicating EBP. Interviews revealed the facility lacked EBP signage and a formal policy, although staff were expected to wear PPE during high-contact activities. The facility had conducted in-service training on EBP, but no specific policy was in place.
The facility failed to revise care plans to address wandering behaviors for two residents with moderate cognitive impairment, despite being identified as at risk for elopement. Both residents' care plans lacked documented interventions to prevent potential elopement, highlighting a deficiency in the care planning process.
A resident with moderate cognitive impairment and exit-seeking behaviors left the facility unsupervised due to inadequate supervision and lack of documented interventions in their care plan. Despite being identified as an elopement risk, the resident's wandering behavior was not effectively managed, resulting in the resident being found outside the facility after triggering a door alarm.
Failure to Timely Report Alleged Abuse and Narcotic Diversion
Penalty
Summary
The facility failed to report alleged abuse and misappropriation involving narcotic pain medication to the proper state agency within the required time frame for three residents. For Resident #18, the quarterly MDS showed a BIMS score of 15 and no scheduled or PRN pain medication, yet the narcotic book documented pain medication administration on multiple dates by RN #1. The DON stated the resident was interviewed and denied requesting or receiving pain medication on those dates, and the resident later stated pain medication had not been administered in a while and that they used over-the-counter medication instead. For Resident #39, the quarterly MDS also showed a BIMS score of 15 and indicated PRN pain medication use, while the narcotic book documented pain medication administration on multiple dates by RN #1. The DON stated the resident denied requesting or receiving pain medication on those dates, and the resident stated they received pain medication only at times and usually took regular over-the-counter medication for aches. The DON confirmed the two residents had narcotic diversions by the nurse named in the allegation and stated the facility did not report it to OLTC; she also stated there was no documentation other than flagging it in the narcotic book. For Resident #43, the admission MDS showed a BIMS score of 15 and partial to moderate assistance needs for transfers. A facility incident report documented that the resident reported CNA #8 grabbed the resident’s arm causing a bruise, threw shorts at the resident, and threw a trash can in the room. The DON stated the allegation was reported to her the next morning, that she reported it to OLTC, contacted police and the physician, and attempted to contact the family, but also stated the RN should have called her, the administrator, and sent the CNA home when the allegation was first reported. The facility policy stated suspected abuse required an immediate internal investigation and OLTC notification by 11:00 AM the next day.
Failure to Protect Resident After Alleged CNA Abuse
Penalty
Summary
The facility failed to ensure immediate protective measures were implemented and maintained until a thorough investigation was initiated after a resident reported alleged abuse by CNA #8. Resident #43 was admitted with diagnoses including type II diabetes, peripheral vascular disease, bilateral above-knee amputations, osteomyelitis, and sepsis, and the admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact. The resident required partial to moderate assistance with toilet transfer and chair/bed-to-chair transfer. According to the facility incident report, the resident told the DON that CNA #8 grabbed the resident's arm causing a bruise, called the resident disrespectful for not having shorts on, threw shorts at the resident, and threw a trash can. The incident was discovered on 08/25/2025 at 9:30 AM and submitted to OLTC the next day. A witness statement from RN #6 indicated the resident had reported that CNA #8 came into the room the night before, found the resident naked, told the resident it was indecent exposure, and threw clothes at the resident. RN #6 also learned from another CNA that the resident said CNA #8 grabbed the resident's left arm, leaving redness. RN #6 reassigned the resident to another CNA but did not send CNA #8 home or immediately report the allegation to the DON. The DON stated the allegation was not brought to her attention until the next morning and that the RN should have called her, sent the CNA home, and started the reportable process. The employee detail report showed CNA #8 worked two overnight shifts before being suspended pending investigation. The facility policy stated suspected abuse required immediate internal investigation and continual observation or relocation of the resident during the investigation.
Wrong Medications Sent at Discharge and Discharge Instructions Not Reviewed
Penalty
Summary
The facility failed to ensure the Five Rights of Medication were performed before nursing staff gave a resident’s family/representative the wrong medications at discharge, and failed to ensure discharge instructions were reviewed with the family/representative. Resident #42 was discharged with medications that actually belonged to Resident #12, whose medication regimen included treatment for hypertension, congestive heart failure, dementia, high cholesterol, and atrial fibrillation. The family/representative of Resident #42 later contacted the facility to question the discharge instructions and medications issued at discharge, stating the charge nurse gave the medications and discharge paperwork and instructed the family member to sign the discharge instruction form without reviewing the medications. The initial investigation found the 3:00 PM to 11:00 PM charge nurse prepared the discharge paperwork and pulled the medications, but pulled the medications of another resident and placed the wrong medication regimen information on the discharge instruction form. The 7:00 AM to 3:00 PM charge nurse admitted she did not review the medications with the family/representative. During interviews, the LPN stated she got the residents mixed up while preparing the discharge items and acknowledged she should have slowed down and paid better attention, while the RN stated she did not check the medications herself to ensure they were correct. The DON confirmed the medications were sent home with the wrong resident and that the discharge instructions and medications were not reviewed with the family/representative.
Misappropriation of Resident Controlled Medications
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of resident property involving controlled medications for three residents. Resident #18’s MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and no pain medication was listed. Resident #19’s annual MDS showed a BIMS score of 03, indicating severe cognitive impairment, and no scheduled or PRN pain medication was listed. Resident #39’s quarterly MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and the resident had received PRN pain medication and non-medication interventions. The incident centered on a pharmacy delivery of narcotics for Resident #19. LPN #3 was the nurse responsible for the medication cart and narcotic box, but she was busy with medication pass when the delivery arrived. RN #1 accepted the delivery, signed the invoice and electronic device, and logged the narcotic count. LPN #3 later opened the locked narcotic box and allowed RN #1 to place the narcotic card inside. When LPN #3 later checked the narcotic count, she found the count did not match the pharmacy delivery, with the narcotic book showing 19 tablets and one punched out, while the pharmacy verified 20 tablets had been delivered. The DON stated the signed invoice and outer wrapping for the medication could not be located, and the facility’s investigation found RN #1 had signed in the narcotic as 20 on the invoice copy but the narcotic book reflected 19. RN #1 was terminated, but the DON stated LPN #3 was not disciplined for allowing another staff member access to the narcotic box. The DON also stated the facility did not have a policy on pharmacy deliveries or on nurses working while taking controlled drugs, and that two other residents, Resident #18 and Resident #39, had additional drug diversion investigations involving RN #1 that were not reported to the state agency. The facility policy reviewed stated the facility would take steps to prevent, detect, and report abuse and misappropriation of resident property, including reporting alleged violations to the Administrator and state agencies.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain two ice machines in a clean and sanitary condition, which could lead to food and beverage contamination. Observations revealed that the ice machine panels in both the kitchen and the 400 Hall had brown and black dirt, which easily transferred to tissue when wiped. The ice from these machines was used for beverages served to residents and for water pitchers in residents' rooms. The Dietary Manager and Maintenance Supervisor confirmed the cleaning schedules, which were not sufficient to prevent the accumulation of dirt. Additionally, the facility did not properly store and manage food items, increasing the risk of foodborne illness. An opened bag of cheese slices was found unsealed in the refrigerator, and several expired food items, including dairy products and seasonings, were not discarded promptly. The kitchen ceiling tiles were also observed to have an accumulation of black and grayish dust, further compromising the sanitary environment for food preparation. The facility's dietary staff did not adhere to proper handwashing protocols, which is crucial for preventing contamination. Instances were observed where staff members failed to wash their hands after handling dirty objects and before handling food or clean equipment. This included a dietary staff member who contaminated gloves before deboning chicken and another who contaminated her hands after washing them and before handling a blender blade. Furthermore, a dietary aide failed to reheat broccoli with cheese that was not at the appropriate serving temperature, indicating a lapse in food safety practices.
Failure to Secure Refrigerated Narcotics
Penalty
Summary
The facility failed to ensure that refrigerated narcotics were stored securely to prevent misappropriation. During an observation of the medication storage area, a surveyor noted that the red controlled medication lockbox containing narcotics was not secured inside the refrigerator. This observation was made on 8/07/2024 at 9:30 AM. Subsequently, during an interview with an LPN, it was admitted that the unsecured lockbox could easily be concealed and removed from the facility due to its size. The facility's policy, which was undated but received on 8/07/2024, specifies that narcotics should be kept in a locked container affixed inside a locked cabinet within the medication room. This policy was not adhered to, leading to the deficiency noted by the surveyor.
Failure to Serve Meals According to Planned Menu
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu, which was intended to meet the nutritional needs of the residents. On August 5, 2024, during the noon meal service, residents who were supposed to receive 4 ounces of fried chicken as per the menu were instead served 2 fried chicken legs or 2 chicken wings. Upon weighing, it was found that the 2 chicken legs weighed 2.5 ounces and the 2 chicken wings weighed 1.2 ounces, both falling short of the 4-ounce requirement. Dietary Aide #4 acknowledged the discrepancy, stating that more chicken should have been provided.
Inadequate Food Temperature Maintenance
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures, which affected the palatability and nutritional intake of residents. During an observation, it was noted that an unheated food cart containing 17 lunch trays was delivered to the dining room, and the temperatures of the food items were significantly below acceptable levels. For instance, the vegetable blend was at 97.7 degrees Fahrenheit, English peas at 92.4 degrees Fahrenheit, and ground fried chicken at 92.6 degrees Fahrenheit. This issue was corroborated by a resident who reported that the food was cold by the time it reached them. Further observations revealed similar issues during breakfast service. Unheated food carts were used to deliver breakfast trays to various halls, and the temperatures of the food items were again below acceptable levels. For example, milk was at 46.9 degrees Fahrenheit, sausage links at 91.9 degrees Fahrenheit, scrambled eggs at 103.6 degrees Fahrenheit, and ground sausage at 84.5 degrees Fahrenheit. Another resident confirmed that the hot food was not hot during lunch, indicating a consistent problem with maintaining appropriate food temperatures across different meals and locations within the facility.
Improper Consistency of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed food items were prepared to a smooth, lump-free consistency, as required for residents on pureed diets. During observations, it was noted that the pureed strawberry cake was runny and lumpy with pieces of strawberries, and the pureed English peas and vegetable blend were runny and contained pieces of carrots. Additionally, the pureed chicken was gritty with visible pieces of chicken, and the pureed bread with milk was too thick. These inconsistencies were observed during meal preparations and servings, indicating a failure to adhere to the facility's policy on pureed food consistency. Interviews with dietary staff and a certified nursing assistant confirmed the improper consistency of the pureed foods. The dietary manager and aides described the pureed sausage as resembling mechanical soft meat rather than the required smooth, pudding-like texture. The facility's policy on mechanically altered foods clearly states that pureed items should be completely smooth, similar to pudding or mashed potatoes, and should require little to no effort to chew. The failure to meet these standards posed a potential risk to residents requiring pureed diets.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents, as evidenced by the handling of falls involving two residents. Resident #48 experienced a fall from bed, resulting in extensive bruising to the face and pain in the left hip. Despite the resident's report of frequent falls and current pain, the necessary notifications to hospice or the provider were not made, and the resident was not sent for evaluation. The LPN on duty was aware of the fall but did not follow the protocol to notify the appropriate parties or ensure continued monitoring. Similarly, Resident #48 had another fall two days prior, which was also not reported to hospice or the provider, and no hospital evaluation was conducted. The LPN involved in this incident did not notify the necessary parties, operating under the assumption that notification was unnecessary if no injuries were visible. The Director of Nursing was unaware of these incidents until informed during the survey, indicating a breakdown in communication and adherence to the facility's policies and procedures for managing falls.
Failure to Implement Enhanced Barrier Precautions for Resident with Feeding Tube
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during the care of a resident with a feeding tube. The resident, who has diagnoses including Parkinson's, depression, and PEG tube management, was observed to have a feeding tube. During an observation, an LPN was seen checking the resident's feeding tube and flushing it with water without wearing the required EBP, except for gloves. The LPN confirmed that the resident was not on EBP and did not see the need for additional PPE, despite the presence of a small dresser outside the room indicating EBP, with visible blue gowns. Interviews with the Director of Nursing and the Administrator revealed that the facility did not have EBP signage, but used a small dresser outside the room as an indicator for EBP. The Administrator confirmed that staff were expected to wear PPE during high-contact activities like flushing a feeding tube. However, the facility lacked a specific policy on EBP, and the provided Gastrostomy Feedings policy did not address EBP. An in-service training had been conducted, which included EBP recommendations for residents with feeding tubes, but the facility had not implemented a formal policy on EBP at the time of the survey.
Failure to Revise Care Plans for Wandering Behaviors
Penalty
Summary
The facility failed to ensure that care plans were revised to accurately reflect wandering behaviors and include interventions to prevent potential elopement for two residents. Resident #1 was admitted with diagnoses including unspecified dementia and had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. Despite being identified as at risk for elopement and wandering, Resident #1's baseline care plan and Nursing Assistant Care Plan did not document any interventions. The MDS Coordinator confirmed that a comprehensive care plan was not completed during the resident's 13-day stay. Similarly, Resident #3, admitted with diagnoses including unspecified dementia and Alzheimer's disease, was also identified as at risk for elopement and wandering. However, both the baseline care plan and the comprehensive care plan for Resident #3 failed to indicate these risks or include any interventions. The absence of documented interventions for these residents' wandering behaviors represents a deficiency in the facility's care planning process.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with moderate cognitive impairment and exit-seeking behaviors from leaving the facility unsupervised. The resident, diagnosed with unspecified dementia and other conditions, had a history of wandering behavior as noted in the Minimum Data Set (MDS) and was identified as an elopement risk. Despite this, the resident's baseline care plan and nursing assistant care plan lacked documented interventions to address the risk of wandering and elopement. The facility's policy on wandering residents indicated the use of door alarm systems to alert staff of unauthorized exits, but it appears these measures were insufficient in this case. The resident was observed on multiple occasions exhibiting wandering behavior, including entering other residents' rooms and expressing confusion about their location. On one occasion, the resident triggered a door alarm but was found outside the facility approximately seven minutes later, about 60 feet from the exit. The resident's room was located near the double doors they exited, and the administrator confirmed the resident's unsupervised absence. This incident highlights the facility's failure to implement effective interventions and supervision to prevent the resident's elopement, as required by their own policies.
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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 Forrest City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Ridge Rehabilitation And Care Center | 13.4 mi | ★★★★★ | 0 | 0 |
| Crestpark Wynne, Llc | 13.7 mi | ★★★★★ | 0 | 0 |
| Crestpark Marianna, L L C | 17.1 mi | ★★★★★ | 4 | 0 |
| The Springs Of Brinkley | 25.4 mi | ★★★★★ | 9 | 1 |
| Woodruff County Health Center | 29.4 mi | ★★★★★ | 8 | 0 |
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