Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Village Rehabilitation And Care Center during CMS and state inspections, most recent first.
Unsafe handling of a resident during a behavioral incident led to a fall and femur fracture. An RN entered the resident’s room to give medication, the resident became agitated and chased the RN, and a laundry cart was placed between them in the hallway. Staff accounts differed, but multiple witnesses described the RN and resident pushing the cart back and forth before the resident fell to the floor. The resident had multiple diagnoses including PTSD, dementia, schizophrenia, gait instability, and a recent hip replacement revision.
Medication administration errors were observed involving two residents and two LPNs, resulting in an error rate above the allowed threshold. One resident received an incorrect diuretic dose after the LPN relied on a medication card that did not match the physician order or eMAR, and the nurse acknowledged giving four 20 mg tablets instead of the ordered three. Another resident with cerebral atherosclerosis missed a scheduled antiplatelet dose because the medication was unavailable, and the eMAR lacked documentation explaining the omission.
A facility failed to have physician supervision documented for antibiotic stewardship and medication review for three residents. Pharmacist MRR recommendations for residents with conditions including CKD, respiratory failure, diabetes, lung disease, wounds, and infections were signed by an ADON/LPN instead of the physician, and progress notes did not show verbal orders for those reviews. Interviews confirmed staff expected physician signatures or documented verbal orders, but the reviews were handled through the nurse signature process.
Failure to Use EBP During Trach Care: A nurse provided trach care to a resident without wearing a gown, despite physician orders and care plan directions for EBP related to the resident’s trach and PEG tube. The resident had severe cognitive impairment and required trach care. During interview, the nurse stated the resident was on standard precautions, then acknowledged a gown should have been worn after seeing the EBP signage. The ADON confirmed the resident was on EBP and that gown and gloves were required for trach care.
The facility failed to properly store and date food items, potentially affecting 52 residents. Observations revealed open spice containers, undated corn meal, and a jug of vinegar without markings in the pantry. Additionally, an opened jar of grape jelly in the cooler lacked an open date. The facility's Food and Nutrition Services document did not address these issues, leading to the deficiency.
The facility exceeded the acceptable medication error rate, with errors involving incorrect dosages of Famotidine and Fluticasone nasal spray administered by an RN and an LPN, respectively. The errors occurred due to failure to adhere to the facility's policy of checking medication orders against the MAR before administration.
The facility failed to return a deceased resident's trust account balance of $145.21 to the estate administrator within the required 30-day period. The BOM confirmed the policy to return funds within one month, but the facility's document did not address this procedure, resulting in the oversight.
A resident with moderate cognitive impairment and physical limitations was unable to self-hydrate due to the facility's failure to consistently keep fluids within reach. Despite the care plan's directive to keep personal items accessible, the resident was observed multiple times with a water pitcher placed out of reach, lacking a cup or straw. A CNA confirmed the resident's inability to access water independently and the absence of a facility policy to ensure items were within reach.
A facility failed to update a resident's care plan to include an antipsychotic medication prescribed for Schizophrenia. The care plan only mentioned the use of an antidepressant, despite the antipsychotic being ordered. This was confirmed by the DON, and the facility lacked a resident care plan policy.
A resident with severe cognitive impairment and an indwelling urinary catheter was observed with improper catheter management. The catheter collection bag was not positioned correctly, and the tubing was wrapped around the resident's ankle and draped over the wheelchair lock, causing kinking and urine accumulation. The facility lacked a specific catheter care policy, relying on the Lippincott Manual of Nursing.
An LPN failed to properly disinfect a glucometer after use on a resident, contrary to the manufacturer's guidelines. The LPN admitted to not receiving proper instruction on the cleaning procedure, leading to a deficiency in the facility's infection prevention and control program.
Unsafe handling of a resident during a behavioral incident led to a fall and fracture
Penalty
Summary
The facility failed to ensure that the resident environment remained free of avoidable accidents and hazards for one resident who had diagnoses including heart disease, osteoarthritis, muscle weakness, difficulty walking, unsteady gait, schizophrenia, dementia, auditory hallucinations, PTSD, and a prior femur fracture. The resident’s record showed a significant change MDS with a BIMS score of 13, indicating cognitive intactness at that time, and the care plan noted the resident liked to be left alone in the room and would place objects in front of the door while sleeping for security. The resident was also care planned for an actual fall with major injury to the left hip and had a recent total left hip replacement revision. On the day of the incident, an RN entered the resident’s room to administer medication and reported that the resident jumped up, slammed a cup from the RN’s hand, and then grabbed a cane or stick and ran after the RN. The RN stated she ran from the room and placed a laundry cart between herself and the resident. According to the RN, the resident grabbed the cart, lost balance, and fell into the door frame and then onto the floor. Other staff interviews described seeing the RN and the resident pushing the laundry cart back and forth in the hall, with the cart being pushed toward the resident and the resident ending up on the floor. The resident’s hospital record documented a femoral neck fracture, and the CT report described a comminuted displaced and angulated fracture of the neck of the left femur. Staff interviews also showed the RN was not familiar with the resident’s diagnosis of PTSD and had not received training on how to handle the situation. The facility record and interviews indicated the incident involved the resident and RN in the hallway, with the laundry cart used as a barrier during the confrontation.
Medication Administration Errors and Omitted Dose
Penalty
Summary
The facility failed to ensure the medication error rate remained below five percent during a medication administration observation involving two residents and two LPNs. Surveyors observed 25 medication administration opportunities, and two medications were not administered according to physician orders, resulting in an eight percent medication error rate. The facility guidance reviewed stated that medication administration required the right dosage and checking the label three times against the order. For one resident, an LPN administered a diuretic incorrectly during the morning medication pass. The physician order and eMAR indicated three 20 mg tablets twice daily, but the medication card used by the nurse showed instructions for four 20 mg tablets in the day and three in the evening, and the nurse acknowledged giving four 20 mg tablets. The surveyor also observed the nurse count 10 and a half pills in the cup before administration. Another LPN later retrieved a different medication card from the cart that showed one 80 mg tablet twice daily, while a third LPN stated she had removed the last three pills from a card and placed it in the shred box, but the card retrieved from the shred bin did not match what she said she had used. For the second resident, who had cerebral atherosclerosis and was ordered an antiplatelet medication at bedtime, the medication was not given during the observed pass. The LPN stated the medication was not available and had been reordered after the last pill was administered the night before. The eMAR showed a code indicating hold/see progress notes, but there was no documentation explaining why the dose was not administered. The ADON stated omitted doses should be reported to the medical provider, and as of the end of the survey review, the facility had not provided a skills check-off for medication administration for one of the involved LPNs.
Physician Oversight Missing for Antibiotic Stewardship Reviews
Penalty
Summary
The facility failed to have the medical care of three residents supervised by a physician for review of unnecessary medications and antibiotic stewardship. Facility policy stated the medical director provides oversight for the antibiotic stewardship program and that the consultant pharmacist’s written or electronic findings and recommendations are to be given to the attending physician, DON, medical director, and others as appropriate, with a process to ensure the findings are acted upon. However, for the three residents reviewed, pharmacist medication regimen review recommendations were signed by the ADON/LPN in place of the physician’s signature, and the corresponding progress notes did not document verbal orders for those entries. Resident #3 was admitted with diagnoses including chronic kidney disease, respiratory failure, pressure ulcer of the sacral region, and urinary tract infections. The resident had severe cognitive impairment and an open wound care plan with enhanced barrier precautions. Pharmacist antibiotic stewardship recommendations for this resident were completed multiple times and were signed by the ADON/LPN instead of the physician, with no verbal orders documented in the progress notes for those reviews. Resident #6 was admitted with diagnoses including type 2 diabetes, enlarged heart, bronchitis, skin and subcutaneous tissue infection, urinary retention, and bacterial bone infection. The resident was cognitively intact but dependent for self-care and mobility and received hemodialysis. Multiple pharmacist antibiotic stewardship reviews for this resident, including two on the same date with different antibiotics listed, were signed by the ADON/LPN in place of the physician, and no verbal orders were documented. Resident #20 was admitted with diagnoses including lung disease, type 2 diabetes, and stroke, was cognitively intact, and was completely dependent for self-care and mobility. Pharmacist antibiotic stewardship reviews for this resident were also signed by the ADON/LPN instead of the physician, with no verbal orders documented for those reviews.
Failure to Use EBP During Trach Care
Penalty
Summary
Enhanced Barrier Precautions were not implemented during tracheostomy care for one resident. On 03/06/2026 at 9:22 AM, a surveyor observed RN #3 provide trach care to Resident #1 without putting on a gown before or during the procedure. The resident had physician orders for EBP related to the trach and gastrostomy tube, with a revision date of 02/08/2026, and also had an order to change the inner cannula every day. Resident #1’s quarterly MDS with an ARD of 02/04/2026 showed severe cognitive impairment and that the resident received tracheostomy care. The care plan, revised 02/20/2026, directed staff to use disposable gloves and gowns when providing high-contact care for PEG tube feedings and tracheostomy. During interview, RN #3 stated the resident was on standard precautions and not EBP, then acknowledged after seeing the EBP signage that a gown should have been worn for trach care. The ADON stated the resident was on EBP and that the nurse should wear a disposable gown and gloves for trach care. A facility in-service dated 07/02/2025 listed tracheostomy care as a high-contact activity requiring gloves and a gown, but RN #3’s name did not appear on the sign-in sheet.
Improper Food Storage and Dating in Pantry
Penalty
Summary
The facility failed to ensure proper storage and dating of food items in the pantry, which could potentially affect 52 residents receiving meals from the kitchen. During an observation, it was noted that a shelf above the food processor next to the stove had bottles of spices, including a container of onion powder with dried matter on the open and a container of salt with the lid open. The Dietary Manager (DM) confirmed that the lids should be closed, indicating a lapse in following proper storage procedures. Further observations in the dry storage pantry revealed a 20-liter container labeled as corn meal without any date indicating when it was placed in the container or when it should be used by. Additionally, a 1-gallon jug, identified by the DM as white vinegar, had no markings or date of opening. In the walk-in cooler, a 48-ounce jar of grape jelly was found opened without an open date, with only about 3 ounces left. The facility's document titled Food and Nutrition Services did not address the requirement for dating opened food items or ensuring proper closure, contributing to the deficiency.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.45%. During an observation, a registered nurse (RN) administered an incorrect dosage of Famotidine to a resident. The RN retrieved 10 mg tablets instead of the prescribed 20 mg tablets, resulting in a total dose of 20 mg instead of the ordered 40 mg. Upon review, the RN confirmed the discrepancy between the administered dose and the physician's order. In another instance, a licensed practical nurse (LPN) administered an incorrect number of sprays of Fluticasone nasal spray to a resident. The LPN gave two sprays in each nostril instead of the prescribed one spray per nostril. The LPN acknowledged the error upon reviewing the medication orders and stated the importance of double-checking orders before administration. The facility's policy requires checking the medication administration record (MAR) against the medication label before administration, which was not adhered to in these cases.
Failure to Convey Deceased Resident's Funds Timely
Penalty
Summary
The facility failed to convey a deceased resident's personal funds to the individual or representative administering the individual's estate within the required 30-day period. The deficiency involved a resident who had passed away, leaving a trust account balance of $145.21. The Business Office Manager (BOM) confirmed that the facility's policy, in accordance with DHS guidelines, mandates the return of resident funds within one month of death or discharge. However, the facility's document titled 'Management of Resident and Elder Trust Accounts' did not address the procedure for returning funds upon a resident's discharge or death, leading to the oversight in handling the deceased resident's trust account funds.
Failure to Ensure Resident Self-Hydration
Penalty
Summary
The facility failed to ensure that a resident was able to self-hydrate by consistently keeping fluids within reach. Resident #48, who had diagnoses of poly osteoarthritis and intervertebral disc degeneration, was observed multiple times with a water pitcher placed out of reach. The resident had a moderate cognitive impairment and required setup assistance with eating, as noted in a quarterly Minimum Data Set. Despite the care plan indicating the need to keep personal items within reach and encourage hydration, the resident was repeatedly found unable to access water independently. On several occasions, the resident was observed reaching for a water pitcher that was placed on a bedside table or nightstand out of reach. The resident confirmed the intent to drink water, but there was no cup or straw available. A CNA confirmed that the resident needed a cup to drink and that CNAs were responsible for placing the cup in the room. The CNA also acknowledged that the water pitcher was out of reach and that the resident would waste water if attempting to use the pitcher directly. The facility did not have a policy regarding the accommodation of residents' needs for items to be within reach.
Failure to Revise Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to revise the care plan for a resident after completing a quarterly assessment. The resident, who had a diagnosis of Schizophrenia and depression, was taking both an antipsychotic and an antidepressant medication. However, the care plan, last revised on 05/21/2024, only referenced the use of an antidepressant and did not include the antipsychotic medication, which was ordered to treat Schizophrenia starting on 6/27/2024. This oversight was confirmed by the Director of Nursing during an interview on 9/06/2024. Additionally, the facility did not have a resident care plan policy in place.
Improper Catheter Care for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide proper catheter care for a resident with an indwelling urinary catheter. The resident, who had severe cognitive impairment and a history of urinary retention, overactive bladder, and benign prostatic hyperplasia, was observed multiple times with improper catheter management. On one occasion, the catheter collection bag was hooked to the back of the wheelchair and not positioned below the bladder level, hindering urine flow. Additionally, the catheter tubing was observed wrapped around the resident's ankle and touching the floor, and on another occasion, it was draped over the wheelchair lock, causing kinking and urine accumulation in the tubing. The Assistant Director of Nursing acknowledged that the facility did not have a specific policy on catheter care and instead followed the Lippincott Manual of Nursing.
Improper Disinfection of Glucometer
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed during a glucometer check for a resident. On the specified date, an LPN was observed performing a blood sugar test on a resident using a glucometer. After completing the test, the LPN sanitized her hands and briefly rubbed the glucometer with her hands for less than five seconds before placing it back in the medication cart. This action did not align with the manufacturer's guidelines for cleaning and disinfecting the glucometer, which required the use of a specific disinfecting wipe to keep the device wet for a designated period between patient uses. During an interview, the LPN admitted that she was not instructed on the proper procedure for cleaning the glucometer. The Director of Nursing later provided the manufacturer's guidelines, which clearly outlined the necessary steps for disinfecting the device. The failure to follow these guidelines resulted in a deficiency in the facility's infection prevention and control program, as the glucometer was not properly disinfected between uses on different residents.
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What surveyors actually found near you
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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 Lake Village
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Heights Healthcare Center | 15.1 mi | ★★★★★ | 9 | 0 |
| Legacy Manor Nursing And Rehabilitation Center | 15.4 mi | ★★★★★ | 2 | 0 |
| Ms Care Center Of Greenville | 16 mi | ★★★★★ | 0 | 0 |
| Arbor Walk Healthcare Center | 16.4 mi | ★★★★★ | 2 | 0 |
| Dermott City Nursing Home | 16.7 mi | ★★★★★ | 3 | 1 |
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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.