Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Methodist Health And Rehab during CMS and state inspections, most recent first.
Abuse of a cognitively impaired resident occurred when a CNA was seen on video repeatedly pulling the resident back down onto a couch and pushing the resident’s arm away while the resident tried to get up. The resident had dementia and severe impairment in daily decision making, and the care plan called for one-to-one support when confused or non-verbal. The DON, security officer, and RN/CNA instructor all described the actions as abuse, while the CNA denied abuse and said she was trying to keep the resident on the couch until another staff member arrived.
Failure to Timely Report Suspected Abuse: A resident with dementia and severe cognitive impairment was involved in an incident where a CNA pulled the resident down by the clothing and pushed the resident away while the resident tried to get up on a couch in a closed unit. Staff and leadership later identified the actions as abuse, but the allegation was not reported to OLTC within the required timeframe. Interviews showed staff knew suspected abuse had to be reported immediately to the DON/administrator and proper authorities.
A resident with multiple chronic conditions and dependence on staff for transfers fell during a mechanical lift transfer when staff used an oversized bariatric sling instead of the correct medium sling. The resident slid out of the sling and onto the floor, and the record and interviews showed staff knew the sling was too large but used it anyway. The DON and Administrator stated the facility had not known there were different sling sizes at the time, and the sling instructions required the correct size to be selected based on the resident's assessment.
Survey results were not readily available for resident and family review. The admission packet and Resident Council minutes did not reference the right to see survey results, the posted resident rights did not include that right, and cognitively intact residents said they did not know where the results were kept or had not seen them. A surveyor could not find the results in common areas, and the DON ultimately produced the only survey results book, which was stored in a drawer at the security officer's desk near the side entrance.
The facility's dietary department failed to maintain food safety and hygiene standards, with staff neglecting hand washing, improper glove use, and inadequate food storage. Opened food items were found unsealed, and dietary aides and visitors lacked proper hair restraints, violating food safety protocols.
The facility failed to formulate or acknowledge advance directives for two residents. One resident with a history of Transient Ischemic Attack had no advance directive on file, while another resident with dementia and Alzheimer's disease lacked acknowledgment of advance directive information. The Admissions Director confirmed these oversights.
The facility failed to ensure a clean and homelike environment in two resident rooms. Trash was repeatedly found behind a nightstand in one room, and an unclean fan with potential respiratory risks was observed in another. Housekeepers acknowledged the need for daily cleaning, and the facility lacked a policy for fan maintenance.
The facility did not follow the planned menu for residents on pureed and mechanical soft diets, affecting their nutritional intake. Residents on pureed diets received incorrect portions and missing items during meals, while those on mechanical soft diets were served improperly prepared fish. Staff acknowledged the discrepancies in meal preparation and serving.
A medication error occurred when a resident with a statin allergy was mistakenly given another resident's medication, including Atorvastatin, due to a mix-up by a CMA during mealtime. The error was realized after administration, and the resident's blood pressure was monitored before being sent to the emergency room. The facility's policy of pulling medications for one resident at a time was not followed.
The facility failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets. Observations revealed that pureed English peas were soupy and gritty, and the gravy was lumpy. The Dietary Manager and Food and Beverage Director acknowledged these issues, noting that the peas were gritty due to the skin and should have been pureed longer, and the gravy was chunky.
Abuse of a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure one resident was free from abuse when a CNA was observed on video repeatedly pulling the resident back down onto a couch and pushing the resident’s arm away. The resident had diagnoses including dementia, osteoporosis, and epilepsy, and the annual MDS indicated severe impairment in daily decision making. The care plan identified the resident as dependent on staff for intellectual, emotional, and social needs related to cognitive impairment and included interventions to provide one-to-one support when the resident became non-verbal or confused. The incident was discovered through security camera review, which showed the CNA seated next to the resident in a closed unit while the resident tried to get up. The CNA was seen grasping the back of the resident’s pants and pulling the resident down several times, then grasping the resident’s left arm, bending it, and pushing it away when the resident reached toward the CNA. The report stated the police, family, administration, and physician were notified, and no injuries were documented. Two cognitively impaired residents interviewed denied abuse. During interviews, the DON stated the video showed the CNA pulling the resident down to the couch and pushing the resident’s arm away several times, and that this behavior was considered abuse. The CNA denied abuse and stated the resident had been agitated and hitting her, and that she was trying to keep the resident on the couch until another staff member arrived. The security officer and RN/CNA class instructor both described the video as showing the CNA repeatedly pulling the resident down and violently pushing the resident away, and the RN/CNA instructor stated the incident was abuse and should have been reported within hours of discovery.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported in a timely manner for one resident who had dementia, osteoporosis, epilepsy, and severe impairment in daily decision making. The resident’s care plan identified the resident as dependent on staff for intellectual, emotional, and social needs and noted the resident was to be one-to-one when non-verbal or confused. The incident involved a CNA pulling the resident down by the back of the resident’s clothing and pushing the resident’s arm away while the resident repeatedly tried to get up on a closed unit couch. The reportable for the incident was not submitted to OLTC within the required two-hour timeframe. Interviews showed the Administrator, DON, and other staff understood that suspected abuse should be reported immediately to administration, the DON, and the proper authorities, and that the alleged perpetrator should be separated from the resident and suspended during the investigation. The Administrator stated the incident was not reported in a two-hour period, and the DON stated she did not personally report the incident to OLTC when she was the ADON at the time. The Security Officer described reviewing video that showed the CNA repeatedly pulling the resident down from the back of the resident’s pants and/or shirt and violently pushing the resident away. The DON and the RN/CNA class instructor both identified the actions as abuse, and the RN/CNA class instructor stated the incident should have been reported within two hours from discovery. The CNA denied abuse and stated the resident had been agitated and hitting her, but the facility’s policies required abuse or suspected abuse to be reported immediately.
Improper Sling Size Used During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure Resident #67 received the proper assistive device for a safe transfer from bed to wheelchair using a mechanical lift. Resident #67 was admitted with diagnoses including atrial fibrillation, type 2 diabetes mellitus, peripheral vascular disease, left knee osteoarthritis, severe protein calorie malnutrition, and affective mood disorder. The resident's MDS showed a BIMS score of 15 and indicated dependence on staff for chair/bed-to-chair transfers. During the transfer, staff used a bariatric-sized sling even though the resident required a medium-sized sling, and the resident slid out of the sling and fell to the floor onto the buttocks. The progress note documented that the lift pad appeared too large for the resident's size. The resident stated the sling used was like an oversized sheet and that staff had said it was too big but used it anyway. CNA #3 stated she tightened the sling because it was too big, but the resident began slipping out before reaching the wheelchair. The DON and Administrator stated the facility had not known there were different sling sizes at the time of the fall, and the Administrator reported staff thought there was only one sling size. The facility policy required transfers to follow the individualized care plan and manufacturer guidelines, and the sling instructions stated the correct size sling should be used based on assessment of the resident's size and condition.
Survey Results Not Readily Available for Resident Review
Penalty
Summary
The facility failed to ensure that survey results were readily available for residents and families to easily view. Review of the admission packet provided at admission did not reference the resident's right to ready access to survey results, and the Resident Council meeting minutes did not contain any record that residents were informed of that right. During an observation, the posted resident rights on the wall did not include the right to see the results of previous surveys. During a Resident Council meeting, cognitively intact residents including Resident #71, Resident #61, Resident #86, Resident #88, Resident #92, Resident #106, and Resident #123 stated they did not know where the survey results were kept and had not seen them. A surveyor searched common areas accessible to residents and visitors and could not locate the survey results. The DON was initially unsure of the location of the results, then returned with a survey results book, which was later placed in a drawer at the security officer's desk near the coded side entrance. The DON stated this was the only copy maintained for resident and visitor review, and there was no survey results book near the front entrance.
Food Safety and Hygiene Deficiencies in Dietary Department
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards in its dietary department. Observations revealed that dietary aides frequently neglected to wash their hands after performing tasks that could contaminate their hands, such as cleaning surfaces, handling trash, and touching unsanitary items. This led to the handling of food and food service items with potentially contaminated hands, which is against the facility's hand washing and glove use policy. Additionally, dietary aides were observed using gloves improperly, such as not changing them after contamination and touching food items directly with contaminated gloves. The facility also failed to ensure that food items in the freezer and refrigerator were properly covered or sealed. Several opened food packages, including dinner rolls, pizza dough, dumplings, and hamburger buns, were found unsealed or without an opened date, which could compromise food safety. Furthermore, an opened bottle of soy sauce was stored improperly, as it was not refrigerated after opening, contrary to the manufacturer's instructions. Moreover, the facility did not enforce the use of hair restraints for dietary staff and visitors in the kitchen. Dietary aides and visitors with long hair and beards were observed without appropriate hair or beard restraints, which is a violation of food safety standards. These deficiencies indicate a lack of adherence to professional standards for food storage, preparation, and service, as well as inadequate enforcement of hygiene protocols in the dietary department.
Failure to Formulate or Acknowledge Advance Directives for Residents
Penalty
Summary
The facility failed to formulate or have an acknowledgment of an advance directive on file for two residents out of a sample of eight. Resident #108, who had a diagnosis of personal history of Transient Ischemic Attack, did not have an advance directive or an acknowledgment of one in their electronic medical record. The Admissions Director confirmed that there was no advance directive on file for Resident #108 and stated that it should have been formulated or acknowledged upon admission. Resident #10, who had a BIMS score of 6 and medical diagnoses including dementia, Alzheimer's disease, and post-traumatic stress disorder, also lacked an acknowledgment of advance directive information in their records. Although there was a Physician's Order for Life Sustaining Treatment form, no option for advance directive information was provided to the resident's representative. The Admissions Director and Administrator noted that the resident representative took the admissions packet home and failed to sign the Advance Directive Acknowledgment form. The oversight was confirmed by the Admissions Director.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in two resident rooms, as observed by surveyors. In room [ROOM NUMBER], trash was repeatedly found behind the nightstand, including items such as a white cup, an ice cream lid, peanuts, a peanut container, pencils, and paper. These observations were made at multiple times on the same day, indicating a persistent issue. Housekeepers confirmed the presence of trash and acknowledged that rooms should be cleaned daily and as needed, yet the trash remained unaddressed. In room [ROOM NUMBER] B, a black pedestal fan was observed to be unclean, with gray/beige fuzzy particles on the fan blades and protective cover, and large white/beige splatters of an unknown substance on the pedestal base. The unclean condition of the fan was confirmed by both the Administrator and the Infection Preventionist, who noted the potential respiratory risks posed by the particles. The Administrator also stated that the facility lacked a policy for fan use or cleaning, contributing to the oversight in maintaining cleanliness.
Failure to Adhere to Dietary Requirements for Residents
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, which compromised the nutritional needs of residents on pureed diets. During the lunch meal, residents were supposed to receive 4 ounces of pureed shredded lettuce salad and two #8 scoops (1 cup) of chicken and dumpling. However, only one #8 scoop (1/2 cup) of pureed chicken and dumpling was served, and no pureed salad was provided. The Dietary Aide and Food and Beverage Director acknowledged that a replacement should have been given for the missing salad. Similarly, during the supper meal, residents were to receive 6 ounces of pureed baked potato soup, but only a 4-ounce portion was served. Additionally, the facility did not adhere to the dietary requirements for residents on mechanical soft diets. The Executive Chef used a knife to dice breaded fried fish instead of grinding it, as required for mechanical soft diets. The diced fish pieces were 1 to 2 square centimeters in size and included crunchy pieces, which could be difficult to chew for residents on mechanical diets. The Food and Beverage Director confirmed that mechanical soft diets should have ground fish, and the physician order would specify if chopped meat was appropriate.
Medication Administration Error Due to Protocol Violation
Penalty
Summary
The facility failed to ensure the correct administration of medication to a resident, leading to a medication error involving two residents. Resident #76, who had an allergy to statin medications, was mistakenly given medication intended for Resident #47. This error occurred when Certified Medication Assistant (CMA) #13 mixed up the medications while administering them during mealtime. The medications were labeled with the first names of the residents, and CMA #13 inadvertently gave Resident #76 a medication cup meant for Resident #47. The error was realized immediately after Resident #76 had already swallowed the medication. The medications given to Resident #76 included Atorvastatin, which was contraindicated due to the resident's allergy. The incident was reported, and Resident #76's blood pressure was monitored, showing a reading of 140/80. The resident was later sent to the emergency room when their blood pressure dropped. The facility's policy requires that medications be pulled for one resident at a time to prevent such errors, but this protocol was not followed. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed the medication error and the failure to adhere to established protocols. CMA #13 admitted to rushing and not following the correct procedure, which led to the mix-up. The facility's policy on medication administration emphasizes verifying the resident's identity and ensuring the correct medication is given, which was not adhered to in this instance.
Failure to Ensure Proper Consistency of Pureed Foods
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 an observation on October 22, 2024, at 11:58 AM, it was noted that the pureed English peas on the steam table had a soupy consistency and were gritty, while the gravy was lumpy and not smooth. In an interview on October 23, 2024, at 1:36 PM, the Dietary Manager acknowledged that the pureed English peas were a little thin and gritty due to the skin, admitting that they should have been pureed longer. The Food and Beverage Director also confirmed these observations, stating that the peas were gritty because of the skin and should have been pureed longer, and that the gravy was chunky.
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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) |
|---|---|---|---|---|
| Chapel Ridge Health And Rehab | 1.7 mi | ★★★★★ | 0 | 0 |
| Covington Court Health And Rehabilitation Center | 2.8 mi | ★★★★★ | 5 | 0 |
| Ashton Place Health And Rehab, Llc | 3.2 mi | ★★★★★ | 0 | 0 |
| Legacy Health And Rehabilitation Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Riverside Health Services | 4.7 mi | ★★★★★ | 6 | 0 |
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