Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Lake Hamilton Health And Rehab during CMS and state inspections, most recent first.
Staff failed to ensure privacy for two residents during personal care and medication administration. In one case, an LPN left a resident exposed while placing them on a bedpan with the door open and no privacy curtain. In another, the ADON administered medication via PEG tube with the door and blinds open, exposing the resident to view from the hallway and dining area. Both incidents were acknowledged by staff as privacy issues.
Surveyors found that the facility failed to maintain sanitary conditions in food service, including mold in the ice machine, expired food items left in storage, improper food covering, and refrigeration temperatures above recommended levels. Dietary staff did not consistently follow hand hygiene or glove use protocols, handling food and food contact surfaces with contaminated hands or gloves, contrary to facility policy.
Surveyors found that staff failed to follow Enhanced Barrier Precautions, proper hand hygiene, and PPE use for three residents requiring infection control measures. An LPN provided care to a resident with a VRE infection using only gloves, a CNA performed incontinence care without changing gloves and contaminated multiple surfaces, and a treatment nurse conducted wound care without a gown or proper hand hygiene. Facility leadership confirmed the expectations for infection control, but there was no specific EBP policy in place.
A resident with severe bilateral hand contractures did not consistently have prescribed finger separators and a palmar grasp splint applied as ordered, with multiple observations showing the resident without these devices and no documentation of refusal or notification to medical staff. Staff interviews revealed confusion about responsibility for device application and documentation, and the care plan was not updated to reflect any refusal.
The facility failed to ensure food items in the freezer were covered, sealed, and dated, and dietary staff did not follow proper hand hygiene protocols. Multiple opened boxes of food items were found uncovered and undated, and a dietary employee was observed handling clean equipment without washing hands after touching dirty objects. These practices had the potential to affect 73 residents.
The facility failed to develop care plans for three residents receiving antibiotics, anticoagulants, and insulin, leading to a lack of appropriate coordination of care. The MDS Coordinator and Nurse confirmed the omissions and emphasized the importance of documenting these treatments in care plans.
The facility failed to ensure accurate documentation and counting of stock narcotics, leading to discrepancies in the narcotic book. An LPN confirmed that Ativan oral syringes and an injectable vial were not properly recorded, and the facility lacked a medication storage policy.
The facility failed to maintain a medication error rate below 5%, as an LPN administered incorrect dosages to two residents. The errors were confirmed by the LPN and the DON, highlighting the need to follow physician orders for resident safety.
The facility failed to ensure medications were not stored at the bedside for residents without self-administration rights, left a resident unattended during a nebulizer treatment, and did not store refrigerated narcotics in a permanently affixed storage box. These deficiencies were observed with a resident who had an albuterol inhaler at the bedside, was left alone during a nebulizer treatment, and the emergency narcotic box was not permanently affixed in the refrigerator.
The facility failed to serve meals at acceptable temperatures, potentially affecting residents' nutritional intake. Observations showed that breakfast trays delivered to various halls had food items with temperatures below acceptable levels, impacting meal palatability.
The facility failed to ensure staff were sitting face to face with a resident during meal service to promote dignity. A CNA was observed standing while feeding a resident due to a missing table and chairs, despite an empty chair being available nearby. The facility's documentation and staff interviews confirmed that staff should sit at eye level with residents during feeding, but the facility lacks a policy on feeding assistance.
The facility failed to protect a resident's privacy by leaving medication cards with identifiable information visible on an unattended medication cart in the hallway. An LPN and the DON confirmed this as a HIPAA violation and against facility policy. The resident rights documentation did not adequately address privacy concerns.
The facility failed to ensure an unlocked public bathroom near a common resident area was equipped with a pull cord on the call light, essential for resident safety and fall prevention. An LPN confirmed that residents use this bathroom and would not be able to reach the call button if they fell. The DON and Nurse Consultant were unaware of the absence of the pull cord and admitted to miscalculating the distance from the floor to the call light button.
A facility failed to ensure that only licensed nursing staff provided oxygen as ordered by the physician for a resident. A CNA was observed adjusting the resident's oxygen flow without involving licensed personnel, contrary to the facility's policy. Interviews confirmed that CNAs should not administer oxygen, and the facility's policy did not specify which staff members are licensed to do so.
Failure to Provide Privacy During Personal Care and Medication Administration
Penalty
Summary
Surveyors identified that staff failed to provide adequate privacy during personal care for two residents. In the first instance, a resident with severely impaired cognition and limited mobility was observed having their covers and underwear removed and being placed on a bedpan by an LPN, while the door to the room was open and the privacy curtain was not drawn. This left the resident exposed and visible to people passing by in the hallway. The LPN confirmed during an interview that the door was open during care, acknowledging the privacy issue. In the second instance, a resident with moderately impaired cognition and a feeding tube was observed receiving medication via a PEG tube from the ADON. During this procedure, the resident's shirt was raised, the door was open, the privacy curtain was not drawn, and the blinds were raised, making the resident visible to staff and other residents outside the room and in the dining area. The ADON confirmed she did not close the door or blinds. The DON stated that staff are expected to close doors, pull curtains, and close blinds to protect resident privacy, and that failure to do so is a dignity issue. Facility policy also states that residents have the right to be treated with dignity and respect.
Multiple Food Service Sanitation and Safe Handling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including unsanitary conditions and improper food handling practices. The ice machine, used for residents' drinks and ice chests, was found to have grayish and black residues identified as mold, indicating it was not maintained in a sanitary condition. Expired food items, such as seasonings and French dressing, were observed on storage shelves and had not been promptly removed or discarded. Additionally, loose tea bags were left uncovered, and food stored in the freezer was not properly covered. Refrigeration issues were also noted, with the 2-door glass refrigerator registering a temperature of 44 degrees Fahrenheit, above the recommended 41 degrees or below. Dairy products such as buttermilk and half and half were found at even higher temperatures after being left out for meal preparation. These conditions suggest a failure to maintain proper cold storage for perishable items, as required by professional standards. Dietary staff were observed repeatedly failing to follow safe food handling practices, including not washing hands or changing gloves between tasks, handling food with contaminated gloves, and touching food contact surfaces after touching potentially dirty objects. Staff also touched the rims of glasses and food items with bare or contaminated hands before serving them to residents. Facility policies reviewed by surveyors required regular cleaning of the ice machine and strict hand hygiene, but these were not consistently followed.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Control Practices
Penalty
Summary
Surveyors identified that the facility failed to implement and follow Enhanced Barrier Precautions (EBP), proper hand hygiene, and appropriate use of Personal Protective Equipment (PPE) for residents requiring infection control measures. One resident with severely impaired cognition and an unstageable sacral pressure injury, who also had a confirmed Vancomycin-Resistant Enterococci (VRE) infection and was on strict contact isolation, received care from an LPN who only wore gloves and did not don a gown as required. The LPN acknowledged during interview that a gown should have been worn in addition to gloves. Another resident with moderately impaired cognition and total incontinence of bowel and bladder was observed receiving incontinence care from a CNA who failed to change gloves during the care process. The CNA touched multiple surfaces in the resident's environment, including the bed rail, nightstand, sheets, trash bag, and pillow, with contaminated gloves, resulting in cross-contamination. The CNA admitted to not changing gloves and recognized that this practice led to contamination of the environment. A third resident with a sacral pressure ulcer, chronic obstructive pulmonary disease, and benign prostatic hyperplasia received wound care from a treatment nurse who entered the room with gloves already on, did not wear a gown, and failed to perform hand hygiene between glove changes. The nurse's body brushed against the resident's bed during the procedure, and she later acknowledged that hand hygiene and gown use were required due to the resident being on EBP. Facility leadership confirmed expectations for PPE use and hand hygiene, but the facility did not have a specific policy on EBP, instead referencing CDC guidelines.
Failure to Consistently Apply Contracture Prevention Devices
Penalty
Summary
Facility staff failed to ensure that a resident with severe bilateral hand contractures consistently had prescribed devices in place to prevent further contracture and skin breakdown. The resident's care plan and physician orders required continuous use of finger separators on both hands and a palmar grasp splint on the right hand, with staff instructed to monitor and document device placement every shift. Multiple observations over several days revealed that the resident was frequently without any hand devices, both in common areas and in bed, despite the presence of the devices on the bedside table or nightstand. Documentation did not indicate that the resident refused the devices, and there was no evidence that the medical provider was notified of any non-compliance or refusal. Interviews with CNAs, the ADON, and the DON revealed confusion regarding responsibility for device application and documentation. Staff reported that only the treatment nurse or restorative aides applied the devices, and that refusals or skin issues should be documented and reported, but there was no documentation of refusals or notification to nursing or medical staff. The DON confirmed that the lack of device use rendered the intervention ineffective and that the care plan had not been updated to reflect any refusal. The facility's policy required provision of rehabilitative nursing care as ordered, but this was not consistently implemented for the resident in question.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure food items stored in the freezer were covered, sealed, and dated, which could minimize the potential for foodborne illness. Observations on 04/10/2024 revealed multiple opened boxes of food items, such as biscuits, cheese omelets, chocolate chip cookies, bread sticks, chicken and cheese tortillas filling, breaded beef, bean burritos, hamburger patties, beef steak, and beef fritters, that were not covered, sealed, or dated. Additionally, an opened gallon of soy sauce was found on a rack in the kitchen without being refrigerated as per the manufacturer's specifications. Dietary staff also failed to follow proper hand hygiene protocols. On 04/10/2024, a dietary employee was observed handling tray cards and plates without washing his hands after touching dirty objects. Later the same day, the same employee was seen pulling up his pants and then handling clean equipment, such as a scoop for ice, without washing his hands, thereby contaminating the glove and the ice. These practices had the potential to affect 73 residents who received meals from the kitchen.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop care plans to address specific medical treatments for three residents, leading to a lack of appropriate coordination of care. Resident #34, diagnosed with Non-Alzheimer's dementia and a urinary tract infection, was receiving antibiotics for the prevention of recurring urinary tract infections. However, the care plan did not include this information, which was confirmed by the MDS Coordinator upon review. Similarly, Resident #22, who had Non-Alzheimer's dementia and was receiving anticoagulant medication for orthopedic aftercare, did not have this treatment documented in their care plan. The MDS Coordinator acknowledged the omission and its importance for monitoring potential side effects and ensuring staff awareness of the resident's baseline condition. Additionally, Resident #68, diagnosed with type 2 diabetes mellitus, was receiving long-acting insulin but this was not reflected in their care plan. The MDS Nurse confirmed the absence of this critical information and emphasized the importance of documenting insulin use and diabetes management in the care plan. The Assistant Administrator noted that there was no specific policy on care plans, and the facility referred to the Resident Assessment Instrument (RAI) manual for guidance. These deficiencies in care planning had the potential to affect multiple residents receiving similar treatments, highlighting a significant gap in the facility's care coordination processes.
Failure to Accurately Document and Count Stock Narcotics
Penalty
Summary
The facility failed to ensure that stock narcotics were accurately counted and documented when received from the pharmacy. This deficiency was identified during an observation where an LPN confirmed discrepancies in the narcotic book. Specifically, the concentration of Ativan oral syringes on hand did not match the documentation, and an Ativan injectable vial was not recorded in the narcotic book upon receipt. The LPN acknowledged that the procedure for documenting narcotics was not followed, and the delivery sheet was not signed by the receiving nurse, leading to an inaccurate count of medications on hand. Further investigation revealed that the Ativan injectable was delivered on 04/04/2024 but was not documented until 04/10/2024, after the surveyor's inquiry. The Director of Nursing and the Nurse Consultant confirmed the importance of timely and accurate documentation to prevent diversion and ensure proper medication counts. However, it was noted that the facility lacked a medication storage policy, contributing to the oversight in narcotic documentation and counting procedures.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, as evidenced by the administration of incorrect dosages of medications to two residents. Resident #229 was prescribed Calcium plus Vitamin D3 500-15 mg-mcg, but was administered Calcium with Vitamin D 600 mg 10 mcg. Resident #67 was prescribed Fluticasone Propionate Nasal Suspension 50 mcg/act, one spray in each nostril twice a day, but was administered two sprays in each nostril. These errors were observed during medication administration by LPN #1, who confirmed the incorrect dosages and acknowledged that a new physician order should have been obtained since the correct dosages were not available. The Director of Nursing also confirmed the medication errors and emphasized the importance of following physician orders for resident safety.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were not stored at the bedside for residents without self-administration rights approved by the Interdisciplinary team. This was observed with Resident #226, who had an albuterol sulfate inhalation aerosol on the bedside table. The resident was unsure if the inhaler was from home or provided by the facility and had been using it since admission. Licensed Practical Nurse (LPN) #3 confirmed finding the inhaler and removing it, noting that it was unknown if the resident had self-administration rights. The nurse explained that medications should not be left at the bedside due to the risk of forgetfulness and potential double dosing by residents. The Nurse Consultant confirmed that medications should not be left at the bedside without self-administration rights and acknowledged that families occasionally bring in medications without staff knowledge. The facility did not have a specific medication storage policy to address this issue. Additionally, the facility's policy on administering updrafts was not followed, as observed with Resident #226, who was left unattended during a nebulizer treatment. The resident complained about the inhaler being on too long, and the fluid chamber was empty. LPN #3 stated that the nurse administering the updraft should stay in the resident's room until the treatment is completed and the equipment should be cleaned and stored to prevent infection. The Nurse Consultant confirmed this procedure but noted that it was not followed in this instance. Furthermore, the facility failed to ensure refrigerated narcotics were stored in a permanently affixed storage box. LPN #2 showed the Surveyor a purple case containing the emergency narcotic box, which was easily removable and not permanently affixed in the refrigerator. The Nurse Consultant and Director of Nursing (DON) confirmed that narcotics should be behind two locks but did not address the requirement for the emergency kit to be permanently affixed. The Surveyor found that the facility did not have a policy addressing the storage of refrigerated narcotics in a permanently affixed compartment. The Nurse Consultant provided a policy on self-administration of medications and a general guideline on controlled substances, but neither addressed the specific issue of refrigerated narcotics storage. The facility also lacked a relevant in-service documentation on medication storage, relying more on one-on-one interventions than formal in-services.
Failure to Serve Meals at Acceptable Temperatures
Penalty
Summary
The facility failed to ensure meals were served at acceptable temperatures to residents, which could affect their nutritional intake and meal palatability. During an observation on 04/11/2024, unheated food carts containing breakfast trays were delivered to various halls. The temperature of the food items on these trays was measured immediately after the last resident was served. On the 200 Hall, the temperatures of ground sausage with gravy, scrambled eggs, and sausage were 116°F, 109°F, and 105.7°F, respectively. On the 400 Hall, scrambled eggs and sausage were measured at 113°F and 109°F, respectively. On the 100 Hall, scrambled eggs and sausage were 105.6°F and 108°F, respectively. On the 300 Hall, scrambled eggs and sausage were 111°F and 108.2°F, respectively. These temperatures were below acceptable levels, indicating that the meals were not served in a manner that maintained their appearance and temperature, potentially affecting the residents' willingness to eat and their overall nutritional intake. The deficiency was observed across multiple halls, affecting a significant number of residents who received meal trays in their rooms. The observations were made by the Dietary Supervisor and involved multiple Certified Nursing Assistants (CNAs) delivering the trays.
Failure to Maintain Dignity During Meal Service
Penalty
Summary
The facility failed to ensure staff were sitting face to face with residents during meal service to promote dignity for one resident requiring feeding assistance. On 04/09/2024, a CNA was observed standing above a resident while feeding them mixed vegetables, and remained standing throughout the meal service. The CNA explained that the absence of a table and chairs led to this situation, although an empty chair was observed nearby. The facility's documentation and staff interviews confirmed that the expected procedure is for staff to sit at eye level with residents during feeding to maintain dignity. The facility does not have a policy on feeding assistance.
HIPAA Violation Due to Unattended Medication Cart
Penalty
Summary
The facility failed to protect a resident's privacy by leaving medication cards with identifiable information visible on an unattended medication cart in the hallway. The surveyor observed the medication cart with the resident's name, room number, and medication details clearly readable. An LPN confirmed that the medication cards should not be left visible and acknowledged this as a HIPAA violation. The Director of Nursing also confirmed that leaving patient information visible is inappropriate and against the facility's policy. The resident rights documentation provided by the facility did not address privacy concerns adequately.
Failure to Equip Bathroom with Pull Cord on Call Light
Penalty
Summary
The facility failed to ensure that an unlocked public bathroom near a common resident area was equipped with a pull cord on the call light, which is essential for resident safety and to prevent falls. This deficiency was observed by the Surveyor on 04/11/2024 at 09:48 AM. The call light in the bathroom did not have a pull cord, and the bathroom was located in a hallway between the nurse's station area. The area across the hall was identified as a space used for various activities, including rehab dining, group therapy, and family visits. Licensed Practical Nurse (LPN) #1 confirmed that residents use this bathroom and acknowledged that if a resident fell, they would not be able to reach the call button located above the grab bar to the right of the toilet, as there was no pull cord present. Further investigation revealed that the Director of Nursing (DON) and the Nurse Consultant were unaware of the absence of the pull cord. The Nurse Consultant initially claimed that the bathrooms were designed to regulation and code, and the distance from the floor to the call light button was appropriate. However, upon further questioning, the Nurse Consultant admitted to miscalculating the distance and confirmed that there was no call light policy available. This failed practice had the potential to affect nine residents who ambulated and/or self-propelled in the facility, as they would not be able to call for help if they fell in the bathroom.
Unlicensed Staff Administering Oxygen
Penalty
Summary
The facility failed to ensure that only licensed nursing staff provided oxygen as ordered by the physician for Resident #45. On 04/10/2024, a CNA was observed removing the resident's nasal cannula and connecting the resident to a portable oxygen tank, adjusting the oxygen flow to 2 liters per minute. The CNA confirmed that she determined the oxygen flow rate by checking the concentrator and then adjusted the portable tank accordingly. This action was performed without the involvement of licensed nursing staff, contrary to the facility's policy that oxygen is considered a medication and should only be administered by licensed personnel. Further interviews revealed that the LPN and the Nurse Consultant were aware of the protocol that CNAs should not administer oxygen. The Nurse Consultant confirmed that CNAs are required to get a nurse to assist with oxygen administration. The facility's policy on portable oxygen and oxygen safety did not address oxygen as a medication or specify which staff members are licensed to administer it. The Order Summary for Resident #45 indicated that the resident required 2-3 liters of oxygen per minute via nasal cannula as needed, highlighting the importance of proper administration by licensed staff to prevent respiratory complications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 30 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hot Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quapaw Care And Rehabilitation Center Llc | 4.4 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Hot Springs Rehab And Nursing Cent | 7.1 mi | ★★★★★ | 0 | 0 |
| The Springs Of Red Oak | 7.9 mi | ★★★★★ | 2 | 0 |
| The Pines Nursing And Rehabilitation Center | 8.4 mi | ★★★★★ | 0 | 0 |
| The Springs Of Park Ave | 9.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lake Hamilton Health And Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.