Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Lonoke Health And Rehab Center, Llc during CMS and state inspections, most recent first.
The facility failed to accurately code the MDS for two residents with Level II PASRR, leading to potential impacts on their care plans and services. One resident with schizophrenia and psychotic disorder was documented as not having a mental health or intellectual disability, despite previous records indicating otherwise. Another resident with major depressive disorder, bipolar disorder, and schizophrenia was similarly misdocumented. The MDS Nurse confirmed the errors, which could affect the residents' care.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. One resident with diabetes did not have insulin management included in their care plan, despite having physician orders for insulin and Trulicity injections. Another resident using oxygen did not have this intervention reflected in their care plan. Staff were unable to locate the necessary care plans, revealing a lack of proper communication and documentation regarding the residents' care needs.
A resident with multiple diagnoses was improperly lifted using a mechanical lift with closed legs, contrary to the manufacturer's guidelines. The facility lacked a specific policy for lift use, relying on the manual, which warns against such practice to prevent accidents.
Two residents with incontinence issues received improper perineal care, failing to maintain sanitary conditions and prevent infections. One resident, with dehydration and MRSA, and another with a UTI and severe cognitive impairment, were observed receiving inadequate care from CNAs who did not use proper techniques or sufficient supplies. The DON confirmed the care did not align with staff training.
The facility failed to administer oxygen at the physician-ordered rate for two residents, leading to potential respiratory complications. One resident with severe cognitive impairment was observed receiving 3 liters of oxygen instead of the ordered 2 liters, confirmed by an LPN. The DON admitted there was no specific oxygen policy addressing the rate and signage, and nursing staff are responsible for checking orders and concentrators.
A facility failed to maintain accurate records for controlled drugs, specifically for a resident with chronic pain prescribed Hydrocodone-Acetaminophen. A surveyor found a discrepancy between the medication log and the actual count, with an LPN noting another nurse had administered the medication without signing it out. Both the LPN and DON confirmed the inaccuracy, highlighting a lapse in record-keeping that could affect resident care.
The facility failed to prepare and serve meals according to the planned menu and recipes, affecting residents on pureed and enhanced diets. Observations revealed incorrect measurements and missing items, such as pureed hashbrowns and bread, leading to incomplete meals. Dietary staff did not follow specified recipes, impacting the nutritional needs of residents.
The facility failed to prepare and serve meals according to specified recipes, affecting the palatability and consistency of pureed meals. Dietary staff did not measure ingredients accurately, leading to incorrect portion sizes and altered taste. The preparation of a pureed vegetable blend was inconsistent, resulting in a lumpy and runny product due to excessive liquid and thickener.
The facility failed to ensure pureed food items were blended to a smooth, lump-free consistency, posing a risk to residents requiring pureed diets. Observations during meal services revealed improperly blended desserts, vegetables, oatmeal, and sausage, with dietary staff acknowledging the inadequacies. CNAs also noted inconsistencies in food preparation, highlighting the importance of proper pureeing to prevent choking hazards.
The facility failed to maintain sanitation and food safety standards, affecting 71 residents. Trash cans were improperly stored near food storage, and the ice machine was unclean. Opened food items were not covered or dated, and expired items were not removed. Dietary staff did not follow hand hygiene protocols, risking cross-contamination. Hot food was not kept at required temperatures, increasing foodborne illness risk.
The facility failed to ensure proper hand hygiene during perineal care and meal service, leading to potential cross-contamination. A CNA did not use proper hand hygiene while providing care to a resident with MRSA, and two CNAs failed to sanitize hands during meal service after touching themselves or their uniforms. The DON confirmed the expectation for staff to wash hands to prevent cross-contamination.
A facility failed to provide quarterly statements to a resident managing their own trust account and did not properly record transactions. Discrepancies included a $50 withdrawal without a receipt and an undocumented $20 withdrawal. The Business Office Manager did not require residents to acknowledge receipt of statements, leading to unconfirmed transactions.
The facility failed to protect resident confidentiality, as observed when a surveyor found an unattended laptop with an unlocked screen displaying a resident's personal and medical information. An LPN confirmed the visibility of sensitive data, and the DON acknowledged the risk of exposure to unauthorized individuals. The facility's Resident Rights policy emphasizes the right to privacy and confidentiality, requiring consent for information release.
The facility failed to incorporate PASRR Level II evaluations into the care plans of two residents. One resident with schizophrenia and psychotic disorder did not have their evaluation documented, and another with major depressive disorder and bipolar disorder did not have recommended services implemented. The MDS Nurse confirmed the oversight, and the DON acknowledged the lack of a policy for MDS processes.
A resident with severe cognitive impairment and a history of unplanned weight loss did not receive prescribed nutritional supplements during meals, as observed by surveyors. Despite being listed on the meal slip, items like thickened vegetable juice and creamed soup were missing from the resident's tray. Staff confirmed that these items were crucial interventions for weight loss, and their absence could negatively impact the resident's health.
Inaccurate MDS Coding for Residents with Level II PASRR
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the preadmission screening and assessment resident record (PASRR) for two residents with a Level II PASRR. Resident #4, who has diagnoses of respiratory failure, schizophrenia, and psychotic disorder, was inaccurately documented in the MDS as not having a mental health or intellectual disability. Despite previous documentation indicating a Level II PASRR, the recent MDS did not reflect this, which was confirmed by the administrator. Similarly, Resident #44, diagnosed with major depressive disorder, bipolar disorder, and schizophrenia, was also inaccurately documented in the MDS as not having a serious mental health or intellectual disability, despite a Level II evaluation recommending a structured environment. The MDS Nurse confirmed that the MDS for both residents was not coded correctly, which could potentially affect their care plans and the receipt of recommended services. The nurse acknowledged using the RAI manual for guidance in coding the MDS, yet the discrepancies in the documentation were evident. These inaccuracies in the MDS could lead to a lack of appropriate care and services for the residents involved.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in their care. Resident #44, who has diagnoses of major depressive disorder, bipolar disorder, schizophrenia, and type II diabetes mellitus with hyperglycemia, did not have diabetes and insulin management included in their care plan. Despite having physician orders for insulin and Trulicity injections, the MDS Nurse confirmed that these were not care planned, acknowledging the importance of including such serious illnesses in the care plan. The Director of Nursing also confirmed the absence of a care plan policy and emphasized the need to follow the RAI manual for care planning. Similarly, Resident #26, with diagnoses of stroke, metabolic encephalopathy, and anxiety, was observed using oxygen, yet this was not reflected in their care plan. The resident was on 3 liters of oxygen, but the care plan did not include this intervention. Staff, including LPNs, were unable to locate the oxygen care plan, and it was revealed that the facility uses closet care plans for CNAs, while nurses are expected to use computer-based care plans. The Director of Nursing confirmed this discrepancy, indicating a lack of proper communication and documentation regarding the residents' care needs.
Improper Use of Mechanical Lift During Resident Transfer
Penalty
Summary
The facility failed to ensure the proper use of a mechanical lift when transferring a resident, leading to a deficiency in maintaining a safe environment free from accident hazards. Resident #28, who has diagnoses of polyneuropathy, heart failure, and major depression disorder, was observed being lifted in a mechanical lift with the legs in the closed position, contrary to the recommended practice. The resident's care plan indicated the need for a mechanical lift with two staff assistance for transfers, yet the observation showed non-compliance with the lift's operational guidelines. The Certified Nursing Assistant (CNA) confirmed that the mechanical lift's legs should be in the open position to ensure balance during lifting or lowering. However, the facility lacked a specific policy or procedure for mechanical lift use, relying instead on the manufacturer's manual. The manual explicitly warns that the lift's legs must be in the maximum open/locked position before lifting a patient to prevent tipping and ensure safety. This oversight in following the manufacturer's guidelines contributed to the deficiency identified by the surveyors.
Improper Perineal Care for Two Residents
Penalty
Summary
The facility failed to provide proper perineal care to two residents, leading to deficiencies in maintaining sanitary conditions and preventing infections. Resident #17, who had a diagnosis of dehydration and Methicillin-Resistant Staphylococcus Aureus Infection, was observed to have received inadequate perineal care from two CNAs. The care plan for Resident #17 indicated bowel and bladder incontinence due to immobility, and the resident was frequently incontinent of urine and always incontinent of bowel. During an observation, the CNAs did not use proper techniques or supplies to ensure cleanliness, and one CNA admitted uncertainty about whether the care was performed correctly. Similarly, Resident #14, diagnosed with a urinary tract infection and severe cognitive impairment, also received improper perineal care. The care plan noted bowel and bladder incontinence related to immobility, and the resident was always incontinent. A CNA was observed using inadequate techniques and insufficient supplies during incontinence care. The CNA later confirmed the improper technique, and the Director of Nursing acknowledged that the care provided did not align with the training given to staff.
Failure to Administer Oxygen at Ordered Rate
Penalty
Summary
The facility failed to administer oxygen at the physician-ordered rate for two residents, leading to potential respiratory complications. Resident #26, diagnosed with stroke, metabolic encephalopathy, and anxiety, was observed receiving 3 liters of oxygen via nasal cannula, despite the physician's order for 2 liters as needed for shortness of breath. This discrepancy was confirmed by LPN #17, who acknowledged that the incorrect dosage could interfere with the resident's breathing. The Director of Nursing (DON) admitted that there was no specific oxygen policy addressing the rate and signage, and confirmed that nursing staff are responsible for checking resident orders and oxygen concentrators. Similarly, Resident #50, who has severe cognitive impairment and a respiratory illness, was also observed receiving 3 liters of oxygen instead of the ordered 2 liters. The surveyor noted the absence of signage indicating oxygen use in the resident's room. LPN #11 confirmed the discrepancy in the oxygen rate and the lack of signage. These observations highlight the facility's failure to adhere to physician orders and ensure proper oxygen administration, potentially compromising resident safety.
Inaccurate Controlled Medication Record-Keeping
Penalty
Summary
The facility failed to ensure accurate record-keeping for controlled drugs, specifically for a resident with chronic pain who was prescribed Hydrocodone-Acetaminophen. During a random reconciliation of controlled medications, it was discovered that the medication log indicated 11 pills on hand, while the actual count was 10. This discrepancy was noted by a surveyor in the presence of an LPN, who mentioned that another nurse had administered the medication but failed to sign it out, potentially expecting the LPN to do so. The LPN confirmed that the controlled medication log should accurately reflect the medication on hand, which was not the case during the reconciliation. The Director of Nursing also confirmed the inaccuracy of the controlled medication log. This failure in maintaining accurate records could have implications for the resident's care, as it might lead to medication errors or unauthorized access to the medication.
Failure to Follow Dietary Menus and Recipes
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written quantified recipe and menu, which affected residents on pureed and enhanced food diets. During observations, it was noted that the dietary staff did not follow the specified measurements and ingredients for pureed diets. For instance, the angel food cake puree was prepared with incorrect measurements, and the strawberry topping was not served as per the menu. Additionally, the vegetable blend puree was improperly prepared, resulting in a lumpy and runny consistency. Further deficiencies were observed in the preparation of enhanced mashed potatoes, where the dietary staff did not use the recipe, leading to incomplete servings for residents requiring enhanced diets. The menu specified pureed hashbrowns and pureed bread for residents on pureed diets, but these were not provided as required. The dietary staff admitted to not following the menu and recipes, which resulted in residents not receiving the appropriate meals. The breakfast meal preparation also showed discrepancies, as residents on pureed diets were served regular oatmeal instead of pureed hot cereal, and pureed biscuits or toast were not provided. The dietary staff was unaware of the menu requirements, leading to the omission of necessary items. These failures in meal preparation and service had the potential to affect the nutritional needs of residents on specialized diets.
Deficiency in Meal Preparation and Consistency
Penalty
Summary
The facility failed to ensure that meals were prepared and served in a manner that maintained their nutritive value and flavor, which was acceptable to the residents. During an observation, it was noted that the dietary staff did not follow the recipe for pureed angel food cake, using incorrect measurements and failing to measure ingredients accurately. The dietary staff used a #16 scoop instead of the specified 1/4 cup for strawberry topping and did not provide the correct amount of topping as per the menu. The dietary staff admitted to not checking the menu and not using recipes, which led to incorrect portion sizes and potentially affected the palatability of the meals for residents receiving pureed meal trays. Additionally, the facility's preparation of a pureed vegetable blend was not consistent with the recipe, resulting in a product that was lumpy and runny. The dietary staff added excessive liquid and thickener without following the specified recipe, leading to a thin consistency and an altered taste. The dietary staff acknowledged using too much broth and thickener, which could affect the taste and consistency of the food, potentially posing a choking hazard. The dietary supervisor confirmed that adding extra liquid would make the puree too thin and that excessive thickener could alter the taste and consistency of the food.
Improper Puree Food Preparation in LTC Facility
Penalty
Summary
The facility failed to ensure that pureed food items were blended 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 of lunch and breakfast meal services, it was noted that pureed desserts and vegetables were not properly blended, resulting in thick, lumpy consistencies with visible pieces of strawberries and thickener. Dietary staff acknowledged that the pureed meat served was also thick and lumpy, and not smooth as required. Additionally, a Certified Nursing Assistant (CNA) admitted to mashing the dessert with strawberries, indicating a lack of adherence to proper pureeing procedures. Further observations during breakfast revealed that pureed oatmeal and sausage were served with lumpy and runny consistencies, failing to meet the smooth texture required for residents on pureed diets. Dietary staff confirmed the inadequacy of the food preparation, acknowledging the lumpy and loose texture of the oatmeal and the lumpy and runny consistency of the sausage. The staff also recognized that residents on pureed diets require such consistency because they cannot chew or swallow regular food, highlighting the importance of proper food preparation to prevent choking hazards.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen and food storage areas, which had the potential to affect 71 residents receiving meals. Observations revealed that trash cans were improperly stored near food storage racks, posing a risk of cross-contamination. Additionally, the ice machine and ice scoop were found to be unclean, with an orangish residue present, indicating inadequate cleaning practices. Opened food items in the refrigerator, freezer, and storage room were not covered, sealed, or dated, and expired food items were not promptly removed, compromising food freshness and safety. Dietary staff were observed not practicing proper hand hygiene, which could lead to cross-contamination of food and clean dishes. Specific instances included dietary aides handling food items and clean dishes without washing hands or changing gloves after touching potentially contaminated surfaces. This lack of adherence to handwashing protocols was acknowledged by the staff when questioned by the surveyor. Furthermore, hot food items were not maintained at the required temperatures on the stove and serving line, increasing the risk of foodborne illness. The facility's handwashing policy, which outlines the necessity of washing hands after certain activities, was not followed by the dietary staff, contributing to the potential for contamination and health risks to the residents.
Failure in Hand Hygiene Practices During Care and Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during the provision of perineal care and meal service, leading to potential cross-contamination. Specifically, a Certified Nursing Assistant (CNA) did not use proper hand hygiene while providing perineal care to a resident diagnosed with dehydration and methicillin-resistant Staphylococcus aureus infection. This resident was noted to have bowel and bladder incontinence related to immobility. The CNA admitted to not using proper hand hygiene and potentially contaminating furniture and reusable items during the care process. The Director of Nursing confirmed that the techniques used did not reflect proper hand hygiene. Additionally, during meal service, two CNAs were observed failing to perform hand hygiene after touching themselves or their uniforms before assisting residents with meal setup. One CNA was seen scratching their ear and resting hands on their back before handling meal items for residents, while another CNA scratched their arms and placed a thumb in their pocket before touching meal items. Both CNAs acknowledged the risk of cross-contamination due to their actions. The Director of Nursing stated that staff are expected to wash their hands during meal service and after touching themselves or their uniforms to prevent cross-contamination.
Failure to Provide Quarterly Statements and Record Transactions
Penalty
Summary
The facility failed to ensure that quarterly statements were provided to residents who manage their own trust accounts and did not properly record each transaction for a resident. This deficiency was identified during interviews and record reviews, where it was found that a resident did not receive quarterly bank statements, and discrepancies were noted in the trust transaction history. Specifically, a cash withdrawal of $50 was recorded without a receipt, and a $20 withdrawal was not documented in the trust transaction history. The Business Office Manager did not maintain individually acknowledged quarterly statements and did not require residents to sign for receipt of these statements. Instead, the statements were placed in residents' rooms without confirmation of receipt. Additionally, there was a failure to void a receipt when a resident returned money to their trust account, leading to discrepancies in the records. Despite these issues, the trust fund was reconciled without discrepancies in the total amount, but the resident could not confirm the transactions in question.
Failure to Protect Resident Confidentiality
Penalty
Summary
The facility failed to protect the personal and medical records of its residents, potentially affecting all 75 residents. On July 24, 2024, at 10:00 AM, a surveyor observed an unattended laptop with an unlocked screen displaying a resident's profile. The visible information included the resident's name, room number, date of birth, age, physician's name, allergies, code status, vital signs, and orders. At 10:14 AM, an LPN confirmed that the resident's name and date of birth were visible on the screen, acknowledging that someone could obtain the resident's information. Later, at 2:30 PM, the DON stated that nurses should ensure medication carts and computer screens are locked and that no medications are left on top of the cart before walking away. The DON confirmed that unlocked computer screens could expose information to unauthorized individuals, including other residents, family members, and staff not involved in the resident's care. The facility's Resident Rights policy was reviewed, noting the right to privacy and confidentiality, which includes the assurance of private and confidential treatment of all information in medical records. This policy requires the consent of the resident or their legal representative for the release of information to unauthorized persons.
Failure to Incorporate PASRR Level II Evaluations into Care Plans
Penalty
Summary
The facility failed to incorporate the PASRR Level II evaluations into the care plans of two residents, which was identified during a survey. Resident #4, diagnosed with respiratory failure, schizophrenia, and psychotic disorder, had a PASRR Level II evaluation that was not documented in their care plan. The MDS Nurse confirmed the absence of the Level II evaluation in the care plan and acknowledged that there was no process in place to ensure the MDS Nurse was notified when the facility received a Level II PASRR from the state designated authority. Similarly, Resident #44, who has major depressive disorder, bipolar disorder, and schizophrenia, also did not have their PASRR Level II evaluation or recommendations implemented in their care plan. The evaluation recommended a structured environment with specific mental health services, but these were not reflected in the care plan. The MDS Nurse confirmed the oversight and the Director of Nursing acknowledged the importance of care plans in resident care, noting the absence of a policy or procedure for MDS processes.
Failure to Implement Nutritional Interventions for Weight Loss
Penalty
Summary
The facility failed to implement interventions to prevent weight loss for a resident, as observed by surveyors. The resident had a history of unplanned weight loss related to acute illness and diuretic use, and was assessed to have severe cognitive impairment. The care plan and physician's orders included specific dietary supplements such as thickened vegetable juice, creamed soup, and fortified potatoes to address the nutritional needs. However, during observations, these items were missing from the resident's meal tray, despite being listed on the meal slip. Certified Nursing Assistant #1 noted that the resident did not receive the soup and shake because the resident did not like them. Social Services confirmed that the items on the meal card were interventions for weight loss and should have been included on the meal tray. The Director of Nursing also confirmed that the notes section on the meal slip was intended for listing supplements as interventions for weight loss, and their absence could negatively impact the resident's weight. This oversight in providing the prescribed nutritional interventions contributed to the deficiency identified by the surveyors.
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 46 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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 Lonoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Barnes Healthcare | 1.7 mi | ★★★★★ | 0 | 0 |
| Chambers Health And Rehabilitation | 9.8 mi | ★★★★★ | 5 | 0 |
| Woodland Hills Healthcare And Rehabilitation | 14 mi | ★★★★★ | 0 | 0 |
| Spring Creek Health & Rehab | 15.5 mi | ★★★★★ | 0 | 0 |
| Cavalier Healthcare Of England | 15.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lonoke Health And Rehab Center, Llc.
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.