Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Legacy Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to prepare and serve meals according to the planned menu for residents on pureed diets. During a lunch service, dietary staff used water instead of broth or gravy for pureed pork patties, resulting in a bland taste. Incorrect scoop sizes were used for serving pureed green beans, and residents did not receive gravy or pureed dinner rolls as required. The dietary staff was unaware of these requirements, leading to deficiencies in meeting residents' nutritional needs.
The facility failed to maintain sanitation and food safety standards, with issues including unclean ice machines, uncovered food items, and unsanitary kitchen conditions. Dietary staff did not follow handwashing protocols, leading to potential contamination. The facility's handwashing policy was not adhered to by staff.
The facility failed to ensure proper hand hygiene and PPE use during medication administration, as an LPN was observed not performing hand hygiene between residents and using a dirty gown. Additionally, the facility did not implement transmission-based precautions for a parasitic infestation, and the infection preventionist admitted to not knowing the policy for head lice. Furthermore, the facility did not provide re-education to staff despite identifying infection trends, contributing to inadequate infection control practices.
Two residents were subjected to physical abuse by another resident with a known history of aggression, despite existing care plans and supervision interventions. Staff witnessed the incidents, and the aggressor had previously exhibited aggressive behaviors toward others.
A facility failed to maintain an accurate account of a controlled medication due to an LPN forgetting to sign out a dose of antianxiety medication at the time of administration. The discrepancy was discovered when the medication count did not match the controlled medication book, which was confirmed by the DON.
A resident with significant weight loss and a physician's order for double portions was not served the required portions during breakfast. Despite the dietary order, the CNA did not provide double portions, and the Dietary Manager was unaware of the resident's weight loss. Interviews with facility staff highlighted a lack of compliance with the dietary order, emphasizing the importance of serving prescribed portions.
A CNA accepted cash from a resident for transportation to a nail salon and solicited additional loans after discussing personal financial issues, despite facility policy prohibiting staff from accepting money or gifts from residents. The resident, who was cognitively intact but had significant medical history, reported the transactions, and facility records confirmed the withdrawal of funds. The CNA's actions were found to violate the facility's abuse and exploitation policies.
A resident with severe cognitive impairment and a known tendency to drink any available liquids was found with an open bottle of cleaning agent in their room, which had been left accessible despite facility policy requiring chemicals to be locked away. Staff interviews revealed uncertainty about who left the cleaner, with suggestions it may have been left by staff during evening cleaning or brought from home. The resident was assessed and sent to the hospital but did not develop symptoms from the possible ingestion.
The facility failed to ensure the dignity of three residents by not pulling the curtain or closing the door, leaving them exposed for any visitors to see from the hallway. The CNAs and the Director of Nursing acknowledged that the doors and curtains should have been closed to maintain the residents' privacy and dignity.
Deficiency in Meal Preparation and Service for Pureed Diets
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of residents requiring pureed diets. During the lunch service on January 27, 2025, the dietary staff did not follow the recipe for pureed breaded pork patties, as they used water instead of broth or gravy, resulting in a bland taste. Additionally, the dietary staff used an incorrect scoop size to serve pureed green beans, providing only 1/3 cup instead of the required 1/2 cup. Furthermore, residents did not receive gravy or pureed dinner rolls as specified in the menu. The dietary staff member, identified as DC #11, was unaware that gravy was supposed to be served with the meal and forgot to prepare pureed dinner rolls. These actions led to the residents not receiving the appropriate nutritional content as outlined in the planned menu. The observations and interviews conducted during the meal service highlighted these deficiencies in meal preparation and service, which did not meet the nutritional needs of the residents on pureed diets.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in several areas. Observations revealed that one of the ice machines in the kitchen had wet pink and black residues, which were easily wiped off, indicating inadequate cleaning. The ice from this machine was used for resident beverages and water pitchers. Additionally, various food items in the refrigerator, freezer, and storage room were found uncovered or unsealed, including boxes of vegetables, cookies, hamburger patties, dinner rolls, sausage, chicken fried steak, and chips. An opened bag of coffee was also left unsealed on a counter, and a partially used bottle of lemon juice was not refrigerated as required by the manufacturer's instructions. The facility also failed to maintain cleanliness in the kitchen and surrounding areas. Cobwebs were observed hanging from walls above door frames and other areas, and several walls and door frames were chipped, exposing concrete and rust. The wooden shelves and countertops had loose food crumbs and were chipped, exposing the wood. The floor tiles in the dishwashing area were missing, and the exposed areas were covered with dirt and debris. The floor between the ice machine and the sink had a wet accumulation of black residue, and the pipes and walls in this area were stained. Furthermore, dietary staff did not adhere to proper handwashing protocols. One dietary staff member contaminated her hands while preparing mashed potatoes and then handled clean equipment without washing her hands. Another staff member, while wearing gloves, contaminated them by handling a block of butter and then proceeded to prepare food without changing gloves or washing hands. The facility's handwashing policy, which requires handwashing upon entering the kitchen, at the beginning of shifts, and after touching unsanitary objects, was not followed by the staff.
Inadequate Infection Control Practices and Lack of Staff Re-education
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) during medication administration. An LPN was observed administering medications to multiple residents without performing hand hygiene between residents. Additionally, the LPN used a dirty gown that had fallen on the floor during the administration of insulin to a resident on enhanced barrier precautions due to a feeding tube. This action was acknowledged by the LPN, who admitted to the mistake. The facility also failed to implement transmission-based precautions in response to a parasitic infestation. A resident was identified with head lice, but no signage or PPE was available on the secure unit to indicate transmission-based precautions. The infection preventionist confirmed that the entire unit should have been placed on isolation when the first case was identified, but this was not done until several days later. The infection preventionist also admitted to not knowing the facility's policy regarding head lice and confirmed that no precautions were taken for residents' laundry or personal items. Furthermore, the facility did not provide re-education to staff when infection trends were identified. The infection preventionist reviewed infection control tracking logs and identified trends in various infections, including urinary tract infections and respiratory infections. Despite these findings, no re-education was provided to staff, which the infection preventionist confirmed should have been done. This lack of action contributed to the facility's failure to address and prevent the spread of infections effectively.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. One resident with severe cognitive impairment was struck on the side of the head by a cognitively intact resident after being told to move out of the way. In a separate incident, another cognitively intact resident was hit on the leg by the same aggressor during a smoke break after a disagreement about lighting a cigarette. Both incidents were witnessed by staff, and the aggressor had a documented history of aggressive and agitated behaviors toward others, with interventions in place such as 1:1 staff supervision and behavioral monitoring. Despite the care plan outlining the need for close supervision and specific interventions for the resident with aggressive tendencies, the incidents of physical abuse occurred. Staff interviews confirmed that resident-to-resident aggression had been observed, and the aggressor was known to have hit other residents. The facility's policy stated residents have the right to be free from abuse and neglect, but these events demonstrate that the measures in place were insufficient to prevent resident-to-resident abuse in these cases.
Controlled Medication Reconciliation Failure
Penalty
Summary
The facility failed to maintain an accurate account of a controlled medication for one of the three medication carts reviewed. According to the facility's policy, controlled substances must be handled, stored, disposed of, and recorded in compliance with federal and state regulations. The policy requires that when a controlled medication is administered, the licensed nurse must immediately document the date and time of removal, the amount removed, and their signature in the controlled drug record. However, during an observation, it was found that the reconciliation count in the controlled medication book did not match the actual count of tablets for a resident's antianxiety medication. The discrepancy was discovered when an LPN removed the medication card and found 63 tablets, while the controlled medication book indicated 64 tablets. The last entry in the book was made approximately 12 hours prior, and the LPN admitted to forgetting to sign out the dose administered at 9:00 AM. This oversight was confirmed during an interview with the DON, who stated that nurses are required to sign out controlled medications at the time of administration to ensure accurate record-keeping.
Failure to Serve Double Portions as Ordered
Penalty
Summary
The facility failed to adhere to a physician's dietary order for a resident requiring double portions as part of a therapeutic diet. The resident, diagnosed with Huntington's disease, major depressive disorder, and other conditions, was identified with significant weight loss, having lost 5% or more in the last month and 10% or more in the last six months. Despite a dietary order for a regular diet with pureed consistency and double portions, the resident was not served double portions during breakfast, as observed by surveyors. The resident's meal card indicated the need for double portions, but the Certified Nursing Assistant (CNA) assisting the resident did not provide them, stating that the resident did not request more food. Interviews with facility staff, including the CNA, Licensed Practical Nurse (LPN), Dietary Manager (DM), and Director of Nursing (DON), revealed a lack of compliance with the dietary order. The CNA admitted to not serving double portions, and the DM, who prepared the breakfast tray, acknowledged not being aware of the resident's weight loss and the importance of serving the ordered portions. The LPN confirmed the resident's dietary needs and weight loss, emphasizing the necessity of serving the prescribed portions. The DON reiterated the importance of following physician orders, noting that failure to do so could contribute to further weight loss.
Staff Member Exploited Resident for Money and Personal Favors
Penalty
Summary
A staff member, specifically a Certified Nursing Assistant (CNA), accepted money from a resident in exchange for personal favors and borrowed additional funds from the resident. The CNA took the resident out in her private vehicle to a nail salon on multiple occasions, accepting cash for gas money. On at least two occasions, the CNA solicited and received loans from the resident, totaling $70, after discussing personal financial difficulties related to a custody situation. The resident, who was cognitively intact but had a history of cerebrovascular disease and other medical conditions, reported these transactions and stated that the CNA was aware of the resident's access to funds from a federal benefits back payment. Facility policy explicitly prohibits staff from accepting gifts or money from residents, as well as from using resident funds for personal purposes. The CNA had acknowledged receipt and understanding of these policies during orientation. Despite this, the CNA engaged in prohibited conduct by accepting money and transporting the resident in her personal vehicle, actions which were later confirmed through interviews and facility documentation. The CNA initially denied borrowing money but admitted to accepting gas money from the resident. The facility's investigation included interviews with the resident, staff, and a review of financial records, which confirmed the resident's withdrawal of a large sum of cash around the time of the incidents. The Director of Nursing confirmed that it was not facility policy to allow staff to take residents out in their personal vehicles or to accept money from them. The CNA's actions were found to be in violation of the facility's abuse, neglect, and exploitation policies, as well as the employee code of conduct.
Failure to Secure Cleaning Agents Resulting in Resident Access
Penalty
Summary
A resident with severe cognitive impairment and a history of attempting to drink any available liquids was found in their room with an open bottle of cleaning agent up to their mouth, appearing to drink from it. The resident required partial to moderate assistance with activities of daily living and was able to self-propel a wheelchair. The incident was discovered by a CNA, who intervened and reported the event to a nurse. The resident was assessed and sent to the hospital for evaluation, but did not develop any symptoms from the possible ingestion. Interviews and record reviews revealed that the cleaning agent was left in the resident's room, accessible to the resident, despite facility policy requiring such chemicals to be locked and out of reach. Staff interviews indicated uncertainty about who left the cleaning agent, with some suggesting it may have been left by staff during evening cleaning or brought from home. The housekeeping supervisor confirmed that the type of cleaner found matched what was used by staff, but the bottle size differed from those kept in supply closets. The resident's family denied bringing cleaning agents to the facility and confirmed the resident's known behavior of attempting to drink any available liquids.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity of three residents by not pulling the curtain or closing the door, leaving them exposed for any visitors to see from the hallway. Resident #72, who has severe cognitive impairment and is dependent for transfers, was observed sitting fully naked in a shower chair with the shower room door open. Both CNAs involved acknowledged that the curtain and door should have been closed for the resident's privacy and dignity. Similarly, Resident #61, who has severe dementia and a history of falling, and Resident #304, who has Alzheimer's disease and anxiety, were observed being changed in the women's bathroom with the stall doors open, making them visible from the hallway. The CNAs involved admitted that the doors should have been closed to maintain the residents' privacy. The Director of Nursing confirmed that curtains and doors should be closed when transferring residents or providing care to ensure their privacy and dignity. The facility's policy titled 'Federal Rights of Resident/Guest(s)' also states that residents have the right to be treated with respect and dignity. Despite this policy, the facility failed to uphold these standards, resulting in the exposure of the residents during personal care activities.
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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 Fort Smith
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Blossoms At Van Buren Rehab And Nursing Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Chapel Ridge Health And Rehab | 3 mi | ★★★★★ | 0 | 0 |
| Valley Springs Rehabilitation And Health Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Methodist Health And Rehab | 3.6 mi | ★★★★★ | 0 | 0 |
| Van Buren Healthcare And Rehabilitation Center | 4.1 mi | ★★★★★ | 3 | 0 |
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