Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Nightingale At Crossett during CMS and state inspections, most recent first.
Insufficient Weekend Nursing Staffing: The facility failed to meet minimum weekend staffing levels based on PBJ data and the Facility Assessment. A Housekeeper reported times when there were not enough staff on weekends, resulting in messy rooms and unmade beds. The DON and Administrator stated they used a 3.0 HPRD staffing metric, while a 3rd party reported weekend HPRD of 3.3123, below the state criteria and below the HPRD listed in the Facility Assessment.
The facility failed to maintain proper food safety and sanitation standards, with expired and improperly stored food items found in various areas. Dietary staff did not follow hand hygiene protocols, handling food and equipment without washing hands after contamination. A resident with dysphagia had expired food in their cooler, and the facility's policy on diet and sanitation was not followed, affecting all residents receiving meals.
The facility's assessment failed to include necessary information for resource allocation, affecting all residents. It lacked documentation of the responsible governing body member, did not address staffing needs for all units, and omitted details on staff training and health information technology resources. The Administrator indicated the assessment was a group effort, but could not specify the responsible governing body member, and there were no signatures from the Medical Director or governing body member.
A facility failed to secure a catheter for a resident and did not provide proper incontinence care for another. The catheter tubing was not secured as required, and a CNA did not clean a resident's genital area during care. The facility's guidelines and policies were not followed, leading to these deficiencies.
A resident with severe cognitive impairment had discrepancies in the administration of an opioid medication for pain management. The Controlled Drug Record showed 42 administrations, while the MAR only documented 14. Staff interviews revealed inconsistencies in the documentation process, with the DON confirming the MAR did not accurately reflect the administration during the specified period.
The facility failed to serve meals according to the planned menu, affecting residents on mechanical soft, pureed, and regular diets. Observations revealed that portions of country ranch chicken and cauliflower were smaller than specified, with a 3-ounce ladle used instead of the required #8 scoop or 1/2 cup. The Dietary Service Manager confirmed the discrepancies, and the dietary staff acknowledged the need for appropriate serving utensils.
A facility failed to follow Enhanced Barrier Precautions for a resident with a PEG tube, as an LPN did not wear a gown during medication administration, despite the resident's EBP order. Additionally, a CNA did not clean a resident's genital area during incontinence care, contrary to facility policy. Both deficiencies highlight lapses in infection prevention and control practices.
A resident with severe cognitive impairment and frequent incontinence was observed receiving care without privacy, as the CNA left the bathroom door open and did not pull the curtain, compromising the resident's dignity. The CNA admitted the mistake, and the DON confirmed the expectation to ensure privacy during care, as per facility policy.
The facility failed to provide residents access to their personal funds throughout the week and on weekends, limiting requests to Monday, Wednesday, and Friday. This restriction was confirmed by residents and signage, despite federal and state laws requiring access at all times. The Social Service staff acknowledged the restricted hours were to reduce traffic, although residents could technically request money at other times.
A facility failed to notify the state authority of a resident's new bipolar disorder diagnosis. The resident, with severe cognitive impairment, was on psychotropic medications for behavior management. Despite a care plan revision in 2021, a 2022 form submitted to the state did not include the bipolar disorder diagnosis. The DON confirmed the oversight.
A resident with severe cognitive impairment and diabetes did not receive consistent nail care, resulting in poor hygiene. Observations showed a dark substance under the resident's nails, and staff interviews revealed confusion about nail care responsibilities. The facility lacked a policy on nail care, contributing to the deficiency.
A resident with a PEG tube did not have their tube placement verified before medication administration, as required by facility policy. An LPN administered medications and water without checking placement, and the facility lacked specific guidance on how to perform this verification. The DON confirmed no training or skills check-off was provided to nurses for this procedure.
Insufficient Weekend Nursing Staffing
Penalty
Summary
The facility failed to ensure the minimum staffing needs were met for residents during the weekends of October through December 2025, based on the Payroll Based Journal (PBJ) staffing data and the Facility Assessment. Review of the PBJ Staffing Data Report, with a run date of 04/09/2026, showed excessively low weekend staffing metrics during the cited period. The Facility Assessment, last updated 09/2025, listed an Average Daily Census of 60 and a Total Nursing Hours Per Resident Day (HPRD) of 3.745, and stated that federal regulations would require a minimum of 3.48 HPRD of direct care. During interviews, a Housekeeper stated there were times on weekends when there were not enough staff to care for residents, resulting in messy rooms and unmade beds. The DON stated she used a staffing metric of 3.0 HPRD and above for every day, including weekends, and said staffing usually fell in the 3.2 to 3.4 range. The Administrator also stated the facility used a 3.0 HPRD and above metric and that the facility was responsible for quarterly PBJ submission, although a 3rd party prepared and submitted the data. An email from the 3rd party stated the facility weekend HPRD was 3.3123, which was 0.1928 below the 3.5051 state criteria for the infraction period and 0.622 below the 3.745 HPRD listed in the Facility Assessment. A review of the Arkansas Administrative Code cited a minimum state requirement of 3.36 HPRD.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards, as evidenced by several observations of expired and improperly stored food items. Expired food items, including spices, breakfast drink mixes, corn chips, candy bars, milk, and nutritional supplements, were found in various storage areas. Additionally, several opened boxes of food items in the freezer, such as cobbler sheet dough, pepperoni, and chicken fingers, were not covered or sealed, increasing the risk of cross-contamination. A mushy angel food cake was also found in the freezer, indicating improper storage conditions. The facility's dietary staff did not adhere to proper hand hygiene and glove use protocols, which are critical to preventing foodborne illnesses. Instances were observed where dietary staff handled food and clean equipment without washing their hands after touching contaminated surfaces. For example, a dietary staff member was seen handling glasses and a blender blade without washing hands after touching dirty objects. Another staff member used contaminated gloves to handle food items, further compromising food safety. Resident #9, who had a diagnosis of dysphagia and required a mechanically altered diet, was found with expired food items in their bedside cooler. The cooler contained a container of vanilla pudding and non-fat yogurt, with the yogurt being past its expiration date. The facility's policy on diet, sanitation, and menu was not followed, as evidenced by the improper storage, preparation, and distribution of food under unsanitary conditions. These deficiencies had the potential to affect all residents receiving meals from the facility's kitchen.
Facility Assessment Lacks Comprehensive Resource Allocation
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included all necessary information to allocate resources effectively for resident care. The assessment, approved and reviewed by the Quality Assurance and Assessment (QAA) committee, lacked documentation of the governing body member responsible for its completion. Additionally, it did not address staffing needs for all resident units, only covering the East unit, and omitted details on staff training, education, and competency-based skill sets. The assessment also failed to include information on health information technology resources, such as managing resident records and sharing information with other organizations, and did not address food and nutrition services staff competencies in relation to resident care needs. During an interview, the Administrator indicated that the assessment was a group effort primarily led by her, but she could not specify the governing body member responsible for its completion. She mentioned that the Regional Director of Operations might be the responsible party, but there were no signatures from the Medical Director or governing body member on the assessment. The Administrator also confirmed that the Medical Director was part of the QAA committee but did not attend every meeting. The facility's purpose statement for the assessment emphasized the need for active involvement from leadership and management, including the governing body, medical director, administrator, and director of nursing, to determine necessary resources for competent resident care during daily operations and emergencies.
Deficiencies in Catheter and Incontinence Care
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling catheter. On September 16, 2024, it was observed that the catheter tubing for Resident #41 was not secured to the resident's leg, as required. The resident's care plan and order summary indicated that the catheter should be secured with a specific device every shift, but this was not done. The CNA confirmed the absence of a securing device and stated that nurses were responsible for placing it. The facility's procedure guidelines also specified that the catheter should be secured to the patient's thigh. Additionally, the facility did not provide adequate incontinence care for another resident. On September 18, 2024, a surveyor observed that CNA #7 failed to clean the genital area of Resident #25 during incontinence care. The resident had severe cognitive impairment and was frequently incontinent. The CNA acknowledged the mistake, and the Director of Nursing confirmed that proper cleaning is necessary to prevent infection and maintain dignity. The facility's policy on perineal care emphasized the importance of cleaning the genital area to prevent skin exposure to urine and feces.
Discrepancy in Opioid Administration Documentation
Penalty
Summary
The facility failed to ensure accurate administration of pharmaceutical services for a resident with severe cognitive impairment. The resident had an order for Hydrocodone-Acetaminophen, an opioid medication, to be administered as needed for pain related to osteoarthritis. However, discrepancies were found between the Controlled Drug Record and the Medication Administration Record (MAR). The Controlled Drug Record indicated that the opioid was signed out as administered on 42 occasions, while the MAR only documented 14 instances of administration. Interviews with staff revealed inconsistencies in the process of documenting the administration of as-needed controlled medications. An LPN described the procedure as checking the MAR, pulling the medication, signing it out in the controlled drug book, and then signing it off on the MAR. However, it was noted that if the administration was not documented in the MAR, the system would not prompt for the effectiveness of the medication. The Director of Nursing confirmed that the MAR did not reflect the administration of the opioid during the specified period, indicating a failure in the documentation process.
Failure to Serve Meals According to Planned Menu
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, which was intended to meet the nutritional needs of the residents. During a noon meal service, it was observed that residents on mechanical soft diets were served a smaller portion of country ranch chicken than specified in the menu. Instead of using a #8 scoop (4 ounces), a 3-ounce ladle was used, resulting in insufficient portions. Similarly, the cauliflower served to these residents was also under-portioned, with a 3-ounce ladle used instead of the required 1/2 cup. Additionally, residents on pureed diets received a smaller portion of pureed cauliflower than specified, as a 3-ounce spoon was used instead of the required #8 scoop (1/2 cup). Furthermore, residents on regular diets were served only one small serving of country ranch chicken, which was later confirmed to weigh 2.9 ounces, instead of the two pieces that should have been provided. The Dietary Service Manager confirmed the discrepancy in portion sizes, acknowledging that the residents should have received two pieces of chicken. The dietary staff member responsible for serving the meals admitted to using a 3-ounce spoon for all servings and indicated a need for more 4-ounce ladles to meet the menu requirements.
Failure to Follow Enhanced Barrier Precautions and Provide Proper Incontinence Care
Penalty
Summary
The facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. During a medication administration pass, an LPN did not wear a gown as required by EBP when administering medications through the resident's PEG tube. The LPN initially stated that the resident was not on EBP, but upon reviewing the resident's electronic health record and physician's orders, it was confirmed that the resident was indeed on EBP due to the gastrostomy tube. The facility's policy indicated that gown and glove usage is necessary during high-contact resident care activities, such as device care, to reduce the spread of multi-drug-resistant organisms. Additionally, the facility failed to provide proper incontinence care for another resident. A CNA was observed performing incontinence care but did not clean the resident's genital area, which is necessary to prevent infection and maintain cleanliness. The CNA acknowledged the oversight, and the Director of Nursing confirmed that staff should clean the genital area during incontinence care to prevent infection and maintain the dignity of the resident. The facility's policy on perineal care emphasized the importance of cleaning the genital area to prevent infection and extended skin exposure to incontinence.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #25, during the provision of care. Resident #25, who has severe cognitive impairment due to Alzheimer's and is frequently incontinent of bowel and bladder, was observed receiving incontinence care from a Certified Nursing Assistant (CNA) with the bathroom door open and the privacy curtain unpulled. This incident occurred in the presence of the resident's roommate, compromising the resident's privacy and dignity. The CNA acknowledged the oversight, and the Director of Nursing confirmed that staff are expected to pull the curtain to protect residents' privacy during care. The facility's policy emphasizes the right of residents to be treated with dignity and respect.
Facility Fails to Provide Residents Access to Personal Funds
Penalty
Summary
The facility failed to ensure residents had access to their personal funds throughout the week and on weekends, which is a violation of residents' rights to manage their financial affairs. Observations and interviews revealed that residents could only request money on specific days: Monday, Wednesday, and Friday. This limitation was confirmed by residents who stated that no one was available on weekends to assist with financial requests. Signage on the Social Service's door indicated restricted banking hours, and the Social Service staff confirmed these hours were set to reduce traffic, although residents could technically request money at other times. The deficiency was highlighted through interactions with two residents, one of whom was cognitively intact and had a diagnosis of paraplegia, and another who was also cognitively intact with diagnoses of cancer and high blood pressure. Both residents confirmed the restricted access to their funds. The Social Service staff mentioned that the change in banking hours was discussed in a resident council meeting, but not all residents with personal bank accounts managed by the facility were present. The facility's policy did not align with the federal and state law requirements that residents must have access to their bank accounts and cash at all times.
Failure to Notify State Authority of New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to notify the proper state authority when a resident was diagnosed with a new mental disorder. The resident, identified as having severe cognitive impairment, had a Brief Interview of Mental Status (BIMS) score of 05 and was diagnosed with bipolar disorder and depression. The resident's care plan, revised in 2021, indicated the use of psychotropic medications for behavior management related to bipolar disorder, mood disorder, and potential for self-injury or harm to others. However, a form submitted to the State Designated Professional Associates in 2022 did not include the bipolar disorder diagnosis. The Director of Nursing confirmed that the state authority was not informed of the resident's new diagnosis of bipolar disorder.
Failure to Provide Consistent Nail Care for Resident
Penalty
Summary
The facility failed to consistently provide nail care to promote good grooming and personal hygiene for a resident with severe cognitive impairment and multiple health conditions, including hemiplegia, hemiparesis, and type 2 diabetes mellitus. The resident was observed on multiple occasions with a dark brown substance under the fingernails and discolored nail beds, indicating a lack of proper hygiene. The resident's care plan specified that they were totally dependent on staff for personal hygiene and required diabetic nail care every Tuesday, yet these needs were not adequately met. Interviews with facility staff revealed a lack of clarity regarding responsibilities for nail care, particularly for hospice residents. A CNA described the resident's fingernails as appearing to have a bowel movement under them, and an LPN confirmed that while CNAs could clean a diabetic resident's nails, they could not trim them. The facility administrator acknowledged the absence of a policy on nail care, which contributed to the inconsistency in providing necessary hygiene care for the resident.
Failure to Verify PEG Tube Placement
Penalty
Summary
The facility failed to ensure proper verification of a Percutaneous Endoscopic Gastrostomy (PEG) tube placement before use for a resident with swallowing difficulties and a feeding tube. During an observation, an LPN administered medications and water through the resident's PEG tube without checking for proper placement, contrary to the facility's order and policy. The LPN stated that she considered the tube flushed normally as a check for placement, although she had not been instructed to verify placement in this manner. The facility's policy required verification of tube placement before feeding or medication administration, but it did not specify the method for checking placement. The Director of Nursing confirmed that no guidance or skills check-off had been provided to the nurses on how to verify PEG tube placement. The facility assessment indicated that staff training on policies and procedures was expected, but there was no evidence of such training regarding PEG tube placement verification.
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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 Crossett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nightingale At Stonegate | 1.4 mi | ★★★★★ | 0 | 0 |
| Cherry Ridge | 22 mi | ★★★★★ | 0 | 0 |
| Lagniappe Healthcare | 22.5 mi | ★★★★★ | 4 | 0 |
| Legrand Healthcare And Rehabilitation Center | 22.9 mi | ★★★★★ | 1 | 0 |
| Oak Woods Home For The Elderly | 24.3 mi | ★★★★★ | 0 | 0 |
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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.