Average — CMS composite of the measures below.
The next survey window likely opens 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 Fayetteville Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to follow physician orders for medication administration and bed positioning. A resident with severe cognitive impairment did not receive an ordered contraceptive injection on schedule, and an LPN and DON confirmed the dose was missed because it was not ordered. Another resident with severe cognitive impairment and tube feeding was repeatedly observed lying flat in bed despite an order for HOB elevation, and staff, the DON, and the MD confirmed the order required the HOB to be raised 30-45 degrees.
A resident with dementia, heart disease, diabetes, and Hospice services had a significant decline with lethargy, increased respirations, and later no respirations, but the family was not notified by either the facility or Hospice. The ADON and Administrator agreed the family should have been informed, while staff interviews showed confusion about whether Hospice or the facility was responsible for making the call.
Failure to implement the care plan for skin tear prevention: A resident with dementia, COPD, and cerebrovascular disease was observed ambulating without long sleeves or protective sleeves despite a care plan directing staff to ensure such protection for fragile skin. The resident had a partially healed skin tear that was actively bleeding, and the MDS showed severe cognitive impairment, dependence for dressing and hygiene, a history of falls with injury, and use of an antiplatelet medication. Staff stated the care plan guided care, and the DON expected staff to follow each resident’s plan of care.
Failure to follow EBP during wound care: a Treatment Nurse entered a resident’s room wearing gloves but no gown, then provided wound care for a resident with an open foot wound and severe cognitive impairment. The nurse’s clothing touched the bed while she leaned over the wound, and the Medical Director and DON verified that gown and gloves should have been worn for direct care.
The facility failed to properly label and date food items, leading to expired and unlabeled food in storage. Staff, including the Dietary Manager, did not follow proper hand hygiene practices, using hand sanitizer instead of washing hands before handling food. Additionally, the kitchen and storage areas were not adequately cleaned, with residues found on the ice machine and expired food items in storage.
The facility failed to maintain resident dignity during meal times, as observed in several instances. A resident's clothing fell during a transfer, exposing them in a public setting, while another resident was fed by standing CNAs, contrary to dignity training. Additionally, several residents experienced delays in receiving meal trays, leading to dissatisfaction and anxiety. These actions did not align with the facility's policy on treating residents with respect and dignity.
The facility failed to update care plans for two residents, one with severe intellectual disabilities and another with ALS. The first resident's care plan lacked interventions after the removal of a call light, leaving them without a means to signal for help. The second resident's care plan did not address limited range of motion, despite observations of contracted hands. Staff interviews confirmed the absence of necessary interventions in the care plans.
The facility failed to maintain a transfer lift properly, with missing attachments posing a risk to two residents during transfers. Staff were inadequately trained on lift usage, and maintenance logs were not kept. Additionally, a resident with dementia was at risk due to disinfecting wipes left on their nightstand, contrary to safety protocols.
The facility failed to remove expired medications from carts, improperly handled controlled substances, and left medications within a resident's reach. Expired medications were found on multiple carts, and broken seals on controlled substances were not addressed. A resident with cognitive impairment had unauthorized medications in their room, posing a hazard.
The facility did not adhere to the planned menus for resident meals, affecting those on pureed, regular, and mechanical soft diets. During meal services, residents received incorrect portions or substitutions, such as mashed potatoes instead of pureed macaroni salad and missing pureed dinner rolls. Dietary staff admitted to not following or reviewing the menu, leading to these discrepancies.
The facility failed to maintain appropriate food temperatures, affecting residents' meal palatability and nutritional intake. Observations revealed that meals delivered to residents on B Hall and A Hall were served at inadequate temperatures, with hot foods like ground ham and riblets served below recommended levels. Unheated carts were used for meal delivery, contributing to the deficiency.
The facility failed to prepare pureed food items to a smooth, lump-free consistency, as observed during multiple meals. Various pureed foods, including chicken, beef sauce, and sausage, were not properly blended, posing a risk to residents requiring pureed diets. The Dietary Manager confirmed these inconsistencies.
The facility failed to ensure proper hand hygiene by staff, leading to potential cross-contamination among residents. A CNA was observed handling meal trays and assisting residents without sanitizing hands. Additionally, a resident was exposed to pests in their room, with flies present on their blanket and in the room, indicating inadequate pest control measures.
The facility failed to provide a safe and sanitary environment, with surveyors observing damaged furniture, exposed electrical outlets, and unsanitary conditions in various rooms. Interviews revealed a lack of systematic reporting and overwhelmed maintenance staff, leading to delayed repairs and potential hazards.
The facility failed to maintain effective pest control, leading to flies in the kitchen and dining areas. Despite treatments, flies were observed on food and in the dining room, with staff acknowledging the issue due to open doors near a dumpster.
The facility failed to maintain a safe and homelike environment, with damaged walls, chipped paint, and stained toilet seats observed in residents' rooms. Loose doorknobs and missing tiles posed safety risks, while maintenance logs were missing, and repairs were delayed if residents refused access. Staff acknowledged the need for repairs, and the administrator was aware of the potential hazards.
A resident with ALS had an inaccurately coded MDS, showing limited range of motion in one upper extremity, while both hands were contracted. The care plan lacked interventions for these contractures, and staff interviews confirmed no consistent interventions or charting. The MDS Coordinator and DON acknowledged the importance of accurate MDS for care planning.
A resident with hemiplegia, hemiparesis, and dementia was observed multiple times sitting in a specialized chair without a required pressure-reducing cushion, despite their care plan indicating the need for such a device. Interviews with CNAs and the DON revealed a lack of awareness and responsibility regarding the resident's need for a cushion, leading to a failure in preventing potential skin breakdown.
A resident with ALS and memory issues was observed with labored breathing due to incorrect oxygen therapy settings, contrary to physician orders. The oxygen concentrator was set to 1 LPM instead of the prescribed 2 LPM. Staff interviews confirmed the oversight, emphasizing the importance of adhering to physician orders, especially for hospice care residents.
Failure to Follow Medication and Positioning Orders
Penalty
Summary
The facility failed to ensure Resident #94 received an ordered [Name Brand Contraceptive] injection and failed to ensure a physician's order was followed for Resident #4's head-of-bed positioning. Resident #94 had diagnoses including unspecified intellectual disabilities, depression, and generalized anxiety disorder, and a quarterly MDS indicated the resident was severely cognitively impaired and never or rarely made decisions. The physician order directed [Name Brand Contraceptive] 150 mg intramuscularly every three months, but the June MAR did not show the injection was administered. An LPN stated the resident received the medication in March but did not receive the scheduled June dose, and the DON stated the dose was not given because it was not ordered. For Resident #94, the DON stated the medication should have been scheduled with the pharmacy and that the June dose was reordered for September, with the guardian aware. The DON also stated no in-service was completed after the facility determined the resident did not receive the ordered injection. The Medical Director stated the resident should receive the injection every three months to maintain the medication's effect. The Administrator stated staff should follow physician orders and ensure medications are documented on the MAR. Resident #4 had a physician order for the head of bed to be positioned at 30-45 degrees while in bed, and the care plan included an intervention for head of bed elevated. The resident's annual MDS indicated severe cognitive impairment and dependence on staff for bed mobility. During multiple observations, the resident was seen lying flat in bed with the head of bed not elevated as ordered. Staff interviews confirmed the order required elevation, the care plan did not specify the degree, and the DON and Medical Director both stated the order should be followed while the resident was in bed.
Failure to Notify Family of Resident’s Significant Decline
Penalty
Summary
The facility failed to ensure the family was notified of a significant change in condition for one resident who had diagnoses including Alzheimer's disease, non-Alzheimer's dementia, heart disease, and type II diabetes mellitus, and who was under Hospice care with severe cognitive impairment. The resident's care plan and Hospice care plan indicated that Hospice and facility staff would assist the family in having an active role in care planning and would keep the family informed of care and changes in disease progression. Progress notes documented that the resident had a significant decline, becoming much less responsive and lethargic with increased respirations. Hospice was notified and gave medication recommendations, and later the resident was found without respirations. A family member stated that neither the facility nor Hospice called any family member when the resident suddenly declined and died in the facility about 12 hours later. The family member declined to answer further questions. During interviews, the ADON and Administrator stated that Hospice and the facility were responsible for notifying the family when there was a change in condition, and both agreed the family should have been contacted regarding the resident's decline. Staff interviews showed differing understandings of who was responsible for calling the family, with some staff believing Hospice would notify the family and others stating they would call only if Hospice asked them to. The record also included a Hospice nurse note describing the resident's labored respirations, low pulse, and low oxygen saturation, with instructions to give medication and call back with concerns.
Failure to Implement Care Plan for Skin Tear Prevention
Penalty
Summary
The facility failed to ensure interventions in Resident #22’s comprehensive care plan were implemented to prevent possible skin tears. On 09/22/2025 at 2:07 PM, Resident #22 was observed ambulating in the hallway of the secure neighborhood wearing a short sleeve top and had a partially healed skin tear on the outer aspect of the right elbow that was actively bleeding, along with a bandage to the area below the thumb of the right hand. The resident was not wearing any protective sleeves at that time. Additional observations on 09/23/2025 at 8:56 AM and 1:43 PM, and on 09/24/2025 at 11:50 AM, showed the resident wearing clothing without long sleeves and without any type of protective sleeve. Resident #22 was admitted on 09/18/2023 with diagnoses including dementia, COPD, and cerebrovascular disease. The significant change MDS with an ARD of 08/13/2025 indicated a mental status score of 03, showing the resident was severely cognitively impaired and never or rarely made decisions. The MDS also showed the resident ambulated without assistance, required moderate to maximal assistance with hygiene and maximal assistance with dressing, had experienced two or more falls with injury, and took an antiplatelet medication. The care plan, edited 04/15/2025, identified the resident as at risk for bruises and skin tears related to fragile skin and directed staff to ensure the resident wore long sleeves or protective sleeves. CNA #4 stated staff used the care plan to guide resident care and that following the care plan was part of orientation, and the DON stated she expected staff to follow each resident’s plan of care.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure staff followed Enhanced Barrier Precautions during wound care for one resident with an open wound to the right foot. During observation, an EBP sign was posted outside the resident’s room, and the Treatment Nurse entered the room wearing gloves but without a gown before providing wound care. The nurse removed a bandage from the resident’s right outer heel, noted yellowish drainage on the bandage, cleaned the wound with wound cleanser, and patted it dry. The resident had been admitted with an unspecified open wound to the right foot and had severe cognitive impairment on the quarterly MDS. Physician orders documented Enhanced Barrier Precautions related to the wound. During the treatment, the nurse was kneeling beside a low bed, and when she leaned over the resident’s wound, her shirt and pants touched the resident’s bed. In interviews, the Treatment Nurse stated she should have worn a gown but forgot, and the Medical Director and DON both verified that a gown and gloves should be worn during wound care for the resident.
Deficiencies in Food Storage, Hand Hygiene, and Cleanliness
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in the refrigerator, freezer, and storage room, leading to the presence of expired and unlabeled food. Observations revealed multiple containers of food, such as gravy, chocolate frosting, and spaghetti sauce, that were either unlabeled or past the three-day usage period. Additionally, open containers of Italian dressing and coleslaw were found without proper dating, and the Dietary Manager acknowledged that these items should have been discarded. The facility also failed to maintain proper hand hygiene practices during food distribution. The Dietary Manager was observed using a cell phone and then applying hand sanitizer instead of washing hands before handling food items. This practice was repeated multiple times, and the Dietary Manager continued to prepare and serve food without proper handwashing. Other staff members, including Dietary Aides and Certified Nursing Assistants, were also observed handling food and clean equipment without washing their hands after touching unsanitary objects or surfaces. Furthermore, the facility did not maintain cleanliness in the kitchen and storage areas. The ice machine and scoop holder were found with orange and black residues, indicating inadequate cleaning. Expired food items, such as bread and pinto beans, were found in the storage room, and opened boxes of biscuits and hamburger patties were left uncovered in the freezer. The Dietary Manager and other staff members admitted to not following proper procedures for food storage and cleanliness, contributing to the deficiencies observed during the survey.
Failure to Maintain Resident Dignity During Meal Times
Penalty
Summary
The facility failed to maintain the dignity of several residents during meal times, as observed in multiple instances. Resident #39, who was moderately impaired and at risk for skin breakdown, experienced an incident where their pants fell down during a transfer in the dining room, exposing their brief and buttocks. This occurred in a public setting, and staff acknowledged that the resident's clothing was too loose due to weight loss, which should have been addressed beforehand. The Director of Nursing confirmed that it is the staff's responsibility to ensure residents' dignity during such transfers. Resident #95, who had moderate cognitive impairment and required assistance with meals, was observed being fed by CNAs who stood over them rather than sitting at eye level. This practice was noted during multiple observations, and staff interviews revealed a lack of consistent adherence to dignity training, which emphasized the importance of sitting while assisting residents with meals. The Director of Nursing stated that staff should sit when providing meal assistance to maintain the resident's dignity. Additionally, residents #3, #46, #55, and #68, all with varying degrees of cognitive impairment, were observed waiting for their meal trays while others were already eating. This delay in serving meals led to Resident #68 expressing dissatisfaction and anxiety while waiting. Staff interviews confirmed that trays should be passed table by table to prevent residents from watching others eat, which could affect their dignity. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, which was not upheld in these instances.
Failure to Revise Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to revise care plans for two residents, leading to deficiencies in their care. Resident #78, diagnosed with severe intellectual disabilities and developmental disorders, had a care plan that did not include interventions for the removal of the call light, which was taken away due to the resident's behavior of wrapping it around their neck. Despite the removal, the call light was observed going off continuously, and the resident was left without a call light for several days. Interviews with staff revealed that the resident's non-verbal status required frequent rounds and observation for care needs, but the care plan lacked updated interventions to address the absence of the call light. Resident #89, diagnosed with Amyotrophic Lateral Sclerosis (ALS), had a care plan that did not include interventions for limited range of motion, despite observations of contracted hands. Staff interviews indicated that initial interventions such as rolled washcloths and stretches were used but were not documented in the care plan. The MDS Coordinator confirmed the absence of interventions for contractures, emphasizing the importance of an accurate care plan to guide staff in providing appropriate care and preventing further deterioration of the resident's condition.
Deficiencies in Lift Maintenance and Chemical Storage
Penalty
Summary
The facility failed to ensure a transfer lift was properly working, which posed a potential risk of harm to two residents. The transfer lift on D hall was observed missing the upper right and lower right metal moveable attachments. Despite this, the lift was used to transfer residents, with staff unaware of the missing parts. Interviews with CNAs revealed that their last training on lift usage was during their schooling or several months ago, and they reported issues to maintenance verbally or through a maintenance book. Maintenance confirmed the missing clips and stated that the lift was inspected monthly, but the logs were not retained. The facility's policy and the lift's user manual both emphasize the importance of ensuring all attachments are properly in place before moving a patient. Additionally, the facility failed to ensure chemicals were stored safely, as evidenced by a canister of disinfecting wipes left on a resident's nightstand. The resident, diagnosed with dementia and exhibiting moderate cognitive impairment, was at risk of ingesting the chemicals. The LPN acknowledged the hazard, and the DON confirmed that such items should be stored out of reach. These deficiencies highlight lapses in equipment maintenance and chemical safety protocols, potentially endangering residents.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that expired medications were removed from medication carts, as observed during a survey. On multiple occasions, expired medications were found on different medication carts, including Ibuprofen, Hyoscyamine, Ondansetron, Hydrochlorothiazide, Hydroxyzine, and Oxybutynin. Licensed Practical Nurses (LPNs) stated that medication carts are checked periodically, but expired medications were still present, indicating a lapse in the process of removing outdated medications. Additionally, the facility did not properly handle controlled substances, as evidenced by broken seals on medication cards for Clonazepam, Morphine, Diazepam, and Tramadol. The broken seals were not appropriately addressed, which could lead to potential misappropriation of medications. The Director of Nursing (DON) acknowledged that nurses should check for breaks in seals and either waste the medication or secure the break, but this procedure was not consistently followed. Furthermore, the facility failed to ensure that medications were stored out of residents' reach. A resident with moderate cognitive impairment was found with a bottle of eye solution and an unlabeled medicine cup containing a cream in their room, neither of which were prescribed or identified. LPNs confirmed that these items should not have been left in the resident's room, as they pose a hazard. The DON stated that medications should be stored securely in designated areas to prevent unauthorized access.
Failure to Follow Planned Menus for Resident Meals
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, which compromised the nutritional needs of the residents. During the supper meal service on June 25, 2024, it was observed that residents on pureed diets were served mashed potatoes instead of the planned pureed country macaroni salad. Additionally, residents on regular diets received a smaller portion of tossed salad than specified in the menu. Dietary staff admitted to not following the menu and not reviewing it before serving, which led to these discrepancies. On June 26, 2024, during the noon meal service, residents on pureed diets did not receive the planned pureed dinner rolls. When questioned, the dietary staff member responsible for the oversight admitted to forgetting to serve the pureed dinner rolls. These failures in meal preparation and service affected residents on various diets, including pureed, regular, and mechanical soft diets, highlighting a lack of adherence to the planned menu and dietary guidelines.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food was prepared and served at appropriate temperatures, affecting the palatability and nutritional intake of residents. During observations, it was noted that food served to residents on B Hall and A Hall was not maintained at safe and appetizing temperatures. On one occasion, a resident reported that their food was always cold when received. Subsequent checks by the Dietary Manager and staff revealed that food items such as ground ham with gravy, yams, green beans, and ham were served at temperatures ranging from 80 to 100 degrees Fahrenheit, which are below the recommended hot food serving temperature. Similarly, during another meal service, items like potato salad and riblets were also found to be served at inadequate temperatures, with readings as low as 60 degrees Fahrenheit for cold items and 90 to 99 degrees Fahrenheit for hot items. These observations were made after meals were delivered using unheated carts, indicating a failure in maintaining food temperature during delivery to residents' rooms.
Inadequate Preparation of Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed food items were prepared to a smooth, lump-free consistency, which is necessary to minimize the risk of choking or other complications for residents requiring pureed diets. During observations on two separate days, the surveyor noted that various pureed food items, including green beans, chicken, beef sauce, oatmeal, biscuits, sausage, cream of wheat, ham, yams, and spinach with eggs, were not prepared to the appropriate consistency. The pureed chicken was described as gritty, the beef sauce and green beans as runny, and the sausage as gritty with visible pieces of bread. These inconsistencies were confirmed by the Dietary Manager during interviews. The deficiency was observed during multiple meals, affecting seven residents who required pureed diets and one resident who required pureed meat only. The Dietary Manager and Dietary staff were involved in the preparation and serving of these meals. Despite the use of blenders and the addition of liquids such as broth and water, the pureed foods did not meet the required consistency standards, posing a potential risk to the residents' safety.
Inadequate Hand Hygiene and Pest Control
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were implemented by staff, leading to potential cross-contamination among residents. Certified Nursing Assistant (CNA) #17 was observed on multiple occasions handling meal trays and assisting residents without performing hand hygiene. Specifically, CNA #17 touched a resident's head, served meal trays, and assisted with a gait belt without sanitizing hands between tasks. Interviews with CNA #17, CNA #12, and the Director of Nursing confirmed that hand hygiene should be performed during meal service to prevent the spread of germs, yet it was not adhered to in these instances. Additionally, the facility failed to maintain a sanitary environment for a resident who was exposed to pests in their room. Resident #73, who had moderate cognitive impairment and an indwelling catheter, was found with multiple flies on their blanket and in the room. The trash can was full, contributing to the pest issue. Although maintenance was notified, the problem persisted, as evidenced by the presence of flies during subsequent observations. The facility's pest control service reports indicated ongoing issues with large flies, with glue boards being 75% full, suggesting inadequate pest management.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple observations and interviews. On several occasions, surveyors noted damaged furniture, such as bedside tables with torn vinyl and sharp edges, which were not reported or repaired. Additionally, a loose doorknob, exposed wood on an armchair, and a bathroom with grime and missing drain covers were observed. The dining room had missing drywall, a brown substance on walls and furniture, and an overflowing dustpan with trash. In one room, a wall behind a bed had missing paint and drywall, with debris under the bed and a live spider present. An electrical outlet was partially exposed, posing a potential hazard. Interviews with staff, including the Maintenance Director and a CNA, revealed a lack of a systematic process for reporting and addressing maintenance issues. The Maintenance Director admitted to not keeping a log of reported issues and being overwhelmed with the volume of repairs needed. He also mentioned working a second job, which limited his availability to address maintenance concerns. Despite being aware of some issues, such as the dining room's condition, repairs were delayed due to the presence of residents. The facility's policy requires a safe, clean, and comfortable environment, which was not upheld in these instances.
Pest Control Deficiency in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in the kitchen and dining areas. Pest control invoices from April and May 2024 documented treatments for mice, cockroaches, and flies, indicating ongoing pest issues. Despite these treatments, observations on June 26, 2024, revealed multiple instances of flies in the kitchen and dining areas. Flies were seen in the storage room, on a plate warmer, on a pan of baked apples, and on a scoop by the steam table. Additionally, a fly was observed in a resident's salad bowl immediately after being served. Staff interviews confirmed the persistent fly problem, with one dietary staff member acknowledging the issue and attributing it to doors being left open, allowing flies to enter from a nearby dumpster. A CNA also noted that flies enter when doors are held open for residents who smoke. An invoice from June 26, 2024, documented further pest control measures, including interior and exterior fly treatments and the addition of fly lights and baited panels, but these actions were not sufficient to prevent the observed deficiencies.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents in two observed halls, B Hall and D Hall. Observations revealed multiple deficiencies, including damaged walls with exposed gypsum compound, chipped paint, and rough cracked areas on bathroom doors, as well as peeling and stained toilet seats. Additionally, a loose doorknob and an improperly seated escutcheon plate interfered with door operation, while missing tiles and cracked patterns on the floor posed a fall risk. The bathroom sink was missing a drain cover and had cracks with a brownish-black gritty substance, further compromising cleanliness and safety. Interviews with staff highlighted a lack of an effective maintenance program, with maintenance rounds conducted monthly and repairs prioritized from worst to least. However, maintenance logs were not located, and repairs were delayed if residents refused room access. Maintenance staff acknowledged the need for repairs, such as replacing loose door handles and addressing floor damage, which could destabilize residents' walkers. The administrator confirmed awareness of these issues and the potential hazards they posed, indicating that repairs would be addressed if residents agreed to relocation.
Inaccurate MDS Coding and Lack of Interventions for Resident Contractures
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident diagnosed with amyotrophic lateral sclerosis (ALS). The resident's MDS was incorrectly coded, indicating limited range of motion in only one upper extremity, while observations revealed contractures in both hands. The care plan did not include interventions for these contractures, and staff interviews confirmed the absence of charting or consistent interventions for the contractures. The MDS Coordinator, who recently assumed the position, acknowledged the coding error after observing the resident and confirmed that the MDS is crucial for accurate care planning. The Director of Nursing emphasized the importance of an accurate MDS for proper resident care. The facility's policy mandates comprehensive and accurate assessments to identify care needs and develop care plans, which was not adhered to in this case.
Failure to Utilize Pressure-Relieving Devices for Resident
Penalty
Summary
The facility failed to ensure that interventions to prevent pressure ulcers were utilized for a resident with hemiplegia, hemiparesis, and dementia. The resident was assessed as moderately impaired in daily decision-making and required pressure-relieving devices for both chair and bed. Despite the care plan indicating the need for a pressure-reducing cushion while the resident was in a chair, observations over several days revealed that the resident was repeatedly seated in a specialized chair without the necessary cushion, instead sitting directly on plastic straps. Interviews with various CNAs revealed a lack of awareness and understanding regarding the resident's need for a cushion in the specialized chair. One CNA admitted to not knowing if the resident required a cushion, while another acknowledged that most specialized chairs had cushions but was unsure why this resident did not. The Director of Nursing also expressed a lack of knowledge about the absence of the cushion, indicating a breakdown in communication and responsibility among the care staff to ensure pressure-relieving devices were in place.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to physician orders for oxygen therapy for a resident diagnosed with amyotrophic lateral sclerosis (ALS), who also had memory problems affecting both long-term and short-term recall. The care plan for this resident included a goal to prevent shortness of breath, with an intervention to administer oxygen therapy as ordered. However, observations by a surveyor revealed that the resident's oxygen concentrator was set to 1 liter per minute (LPM) instead of the prescribed 2 LPM, resulting in uneven labored respirations and a red, cracked oral cavity from mouth breathing. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed the discrepancy between the physician's order and the actual oxygen administration. The LPN acknowledged the importance of following physician orders, especially for a resident on hospice care where comfort is the primary goal. The facility's policy on oxygen administration mandates that oxygen should be administered according to the attending physician's orders, highlighting the failure to comply with this policy in the case of the resident.
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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 Fayetteville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Butterfield Trail Village | 0.8 mi | ★★★★★ | 3 | 0 |
| North Hills Life Care And Rehab | 1.2 mi | ★★★★★ | 1 | 0 |
| Arkansas Veterans Home At Fayetteville | 2.4 mi | ★★★★★ | 0 | 0 |
| Edgewood Health And Rehab | 3.2 mi | ★★★★★ | 0 | 0 |
| Westwood Health And Rehab, Inc | 4.8 mi | ★★★★★ | 1 | 0 |
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