Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Piggott Healthcare & Senior Living, Llc during CMS and state inspections, most recent first.
Incomplete and inaccurate nurse staffing information was posted in the facility. Surveyors observed CNA and nurse schedules in multiple locations, but the schedules did not include the facility name, date, census, or the total number and actual areas worked per shift for licensed and unlicensed staff. The AD stated she did not keep up with regulated staffing assignments or where each nurse or CNA was working, and the DON said staffing sheets should show staff names, hall assignments, and day or night shift.
Failure to provide quarterly statements for resident funds. The BOM stated the facility did not send quarterly statements to residents or resident representatives and only maintained a Personal Funds Receipts document listing names, cash withdrawals, and transaction amounts without receipts. She described a process where residents wrote checks to cash, employees took them to a bank, and the cash was returned to petty cash. The Administrator stated she had recently learned of the process and did not consider it a proper accounting practice.
Care plans were not person-centered for two residents. One resident’s care plan omitted several medication-related interventions despite diagnoses and active medication needs, and also listed insulin care planning even though there were no active insulin orders. Another resident’s care plan identified elopement risk but did not reflect multiple documented elopement attempts or add new interventions beyond monitoring emotional well-being. The ADON and DON confirmed care plans should be updated with changes in condition and each elopement attempt.
Failure to timely report alleged abuse and supervision-related incidents involved two residents reviewed for accidents, supervision, and abuse. One resident had anoxic brain damage, anxiety, depression, CHF, HTN, moderate cognitive impairment, and documented exit-seeking/elopement risk. Records showed the resident was found outside near the laundry and maintenance building and later walking down the road after exiting through a hall door, but several elopement events were not listed on the facility event summary. Interviews with the administrator, corporate nurse, ADON, and DON showed inconsistent awareness of the events and that reportables were not completed for all incidents as required by policy.
Failure to document discharge and provide required notices: A resident with anoxic brain injury, behavioral symptoms, CHF, HTN, depression, and anxiety was taken in police custody for ER and psych evaluation, then transferred to another hospital. The chart lacked a discharge summary, discharge order, and completed discharge details, and the facility did not provide written transfer/discharge notice to the resident or representative or notify the Ombudsman as required.
A resident with moderate cognitive impairment, ambulatory status, and documented exit-seeking/elopement risk repeatedly left the facility unsafely. The resident was found outside near a laundry/maintenance building, later walked down the road after exiting through a hall door, crawled through a smoke wall, and exited through a dining room door while assaulting staff, resulting in police transport for ER evaluation. The Medical Director stated the resident had found ways out of the facility, including outdoor codes or another route outside.
The facility failed to adhere to proper food storage and handling practices, affecting all residents receiving meals. Observations revealed uncovered food items, lack of thermometers in refrigerator/freezer units, and unsanitary kitchen conditions, including broken meal trays and sticky residues on equipment. Interviews with the DM and Administrator emphasized the importance of these practices, but the facility's actions did not align with their policies.
The facility's arbitration agreement lacked necessary components, including the right to rescind within 30 days, a declaration that arbitration is not a condition of admission, and confirmation of the right to communicate with regulatory bodies. This affected four residents who signed agreements post-ownership change.
The facility failed to provide adequate personal hygiene assistance to residents requiring help with grooming. Three residents were observed with facial hair that had not been removed despite their requests and care plans indicating the need for assistance. One resident also had long fingernails that were not trimmed. Interviews with CNAs and the DON confirmed that these tasks should be part of routine hygiene care, but they were not completed as requested.
The facility failed to provide weekend activities for all 34 residents, as observed by the surveyor and confirmed by residents and staff. The Activity Director was unaware of any staff assigned to conduct weekend activities, and the activity logs were incomplete. Interviews revealed a lack of clarity and responsibility regarding weekend activities, despite the facility's policy requiring activities seven days a week.
A surveyor found that narcotic medications were not stored in a permanently affixed compartment in the medication room's refrigerator, which lacked a locking mechanism. The ADON confirmed the box should be secured to prevent unauthorized removal. The facility's policy requires controlled substances to be locked in permanently affixed compartments, which was not followed.
The facility did not follow its planned menu, affecting the nutritional needs and meal variety for all 36 residents. The Dietary Manager cited issues with ingredient availability due to a new delivery schedule, leading to menu deviations. The Resident Council reported a lack of meal variety, with repeated servings of certain foods and limited alternatives. The Administrator acknowledged the importance of a planned menu for reducing repetition and meeting nutritional needs.
The facility failed to maintain safe food temperatures, with cold items served above 41°F and hot items below safe serving temperatures. Despite the Dietary Manager's awareness and intention to address equipment issues, residents consumed meals with improperly held food, risking foodborne illness and affecting meal enjoyment.
A facility failed to notify a resident's representative and the ombudsman in writing about the resident's transfer to the hospital, as required by policy. The resident confirmed a recent hospital visit, but no transfer or bed hold notices were documented. Staff interviews revealed a lack of awareness and execution of the notification policy.
A facility failed to notify a resident's representative in writing about the bed hold policy during a hospital transfer. The resident was hospitalized due to bleeding after a catheterization and returned to the facility without the required notices being sent. Interviews with staff revealed a lack of awareness and execution of the notification policy, despite the facility's policy requiring written notification to residents and their representatives.
A resident with a flaccid right arm due to a stroke did not receive restorative care after completing therapy, as the facility lacked a restorative program and aide. The resident's care plan indicated rehabilitation potential, but therapy was discontinued, and staff confirmed the absence of a restorative program, contrary to facility policies.
The facility failed to report and investigate allegations of abuse and misappropriation of property involving three residents. A resident with severe cognitive impairment reported rough handling by a CNA, another resident reported missing cigarettes, and a third resident was involved in an incident where a CNA was rough. These incidents were not investigated or reported as required.
The facility failed to investigate allegations of abuse and misappropriation for three residents. A resident with severe cognitive impairment reported rough handling by a CNA, but no thorough investigation was conducted. Another resident reported missing cigarettes, but the facility only locked them up without investigating the theft. A third resident was reportedly handled roughly by a CNA, who was terminated for sleeping on the job, not for the alleged rough handling. These incidents highlight deficiencies in the facility's compliance with its policies and federal requirements.
The facility failed to implement enhanced barrier precautions (EBP) as recommended. Observations revealed no EBP signs or PPE near resident rooms. Interviews with staff, including the Administrator, CNA, ADON, and IDON, confirmed the lack of EBP implementation and training.
A resident reported feeling cold in their room, which was confirmed by observations of low temperatures in the facility. The Maintenance Director acknowledged complaints and adjusted the thermostat, but the facility lacked a policy for managing temperatures, contributing to the deficiency.
The facility failed to provide the required RN coverage for 8 consecutive hours in a 24-hour period on 11 out of 15 days reviewed. The absence of a DON and the resignation of two RNs contributed to this deficiency, as confirmed by staff interviews and timecard reviews.
Incomplete and inaccurate posted nurse staffing information
Penalty
Summary
The facility failed to ensure that posted nurse staffing information was complete, accurate, and current, and failed to maintain the daily nurse staffing data for a minimum of 18 months. During observations on 09/03/2025, surveyors saw staffing schedules for CNAs and nurses posted in glass cases near the main front door entrance, near the common area front door, and outside the Administrator's office. A review of the posted nursing and CNA schedules showed that they did not contain the facility name, the date, the facility census, or the total number and actual areas worked per shift for licensed and unlicensed staff responsible for resident care. During interviews, the Administrator stated on 09/04/2025 that she was not aware she needed to keep up with staffing assignments and said she did not keep up with the regulated staffing assignments, did not post the staffing, and did not keep up with where each nurse or CNA was working each day. On 09/09/2025, the DON stated the staffing sheets should contain the staff's name, the hall they are assigned to, and whether they were working the day or night shift, and said it was important for the staffing sheets to contain all required components so family members could know who was taking care of their family member.
Failure to Provide Quarterly Statements for Resident Funds
Penalty
Summary
The facility failed to provide a financial record or quarterly statement to the resident or the resident's representative for residents' funds accounts. During record review and interviews, the Business Office Manager stated the facility did not have quarterly statements available for residents with personal funds kept by the facility. She provided a Personal Funds Receipts document that listed residents' names, cash withdrawals, and transaction amounts, but it did not include receipts. She also stated she was not aware that quarterly statements for resident funds were supposed to be sent to the resident or resident representative. The Business Office Manager explained that when a resident requested money, she completed a slip, verified it with the resident or representative, and then the resident or representative received the money. She stated residents wrote checks made out to cash, the facility took the checks to the closest bank, and the cash was returned to petty cash at the facility. The Administrator stated residents requested petty cash from the BOM and reported she was recently made aware that checks were written out to cash, taken to the local bank, and cashed by employees. She stated she did not consider that practice to be a proper accounting principle and said resident funds should never be mixed with employees' funds.
Care plans were not updated to reflect medications and repeated elopement events
Penalty
Summary
The facility failed to ensure care plans were person-centered for two residents. One resident had diagnoses including recurrent major depressive disorder, hypokalemia, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, hypertension, hyperlipidemia, dysuria, and constipation. The resident’s quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment. The care plan, revised 08/27/2025, addressed hypertension, left-sided hemiplegia, and taking, but did not include medication interventions for antihypertensives, anxiolytics, statins, diuretics, supplemental medications, laxatives, or antipsychotic medications. The care plan also included insulin care planning even though active orders showed the resident was not receiving insulin. Another resident was admitted with diagnoses including anoxic brain damage, anxiety disorder, depression, CHF, and hypertension. The care plan dated 03/10/2025 identified a behavioral symptom of potential for elopement and exit-seeking tendencies, and documented attempted elopements or elopements on 10/21/2024, 11/15/2024, 02/24/2025, and 03/23/2025. Interventions dated 02/24/2025 included monitoring and assessing emotional well-being, but no other updates, new interventions, or documentation of the other elopement events were included in the care plan. Interviews with the ADON and DON confirmed that care plans should be updated quarterly, annually, and with each change in condition, including each elopement attempt.
Failure to Timely Report Alleged Abuse and Elopement Events
Penalty
Summary
The facility failed to report alleged violations and the results of the investigations involving supervision and abuse to the proper state agency within the required time frame for two residents reviewed for accidents, supervision, and resident abuse. One resident had diagnoses including anoxic brain damage, anxiety disorder, depression, congestive heart failure, and hypertension, and had a BIMS score of 8 indicating moderate cognitive impairment. That resident’s care plan identified exit-seeking tendencies with potential for elopement, and the elopement risk assessment identified the resident as at risk for elopement. Record review showed the resident was found outside near the laundry and maintenance building, and later was found walking down the road in front of the facility after exiting through a hall door. Facility documentation showed the administrator, ADON, and DON were notified of the events, and one progress note stated 15-minute rounding was started after the later elopement. The facility event summary report listed one elopement event, but no event was listed for several other elopements documented in the progress notes. During interviews, the administrator stated she did not have a reportable for the earlier events, while the corporate nurse stated she was aware of some elopements and that reportables were filled out for those incidents, but she was not aware of the earlier events. The ADON stated the elopements should have been reported, and the DON stated a reportable should have been made due to the potential dangers to the resident and other residents. Facility policy required incidents to be investigated and reported, with the supervisor completing an incident report and submitting it to the DON within 24 hours, and the DON ensuring the administrator received a copy for each occurrence.
Failure to document discharge and provide required notices
Penalty
Summary
The facility failed to document Resident #35’s transfer/discharge in the resident’s medical record, failed to provide the resident and resident representative a written notice of transfer/discharge, and failed to send a written copy of the notice to a representative of the State Long-Term Care Ombudsman. Resident #35 was admitted on 11/08/2024 with diagnoses including anoxic brain damage, anxiety disorder, depression, congestive heart failure, and hypertension, and the face sheet indicated the resident was not responsible for self. The census summary showed the resident was discharged on 03/23/2025 at 11:56 AM, but the fields for discharged to, primary discharge diagnosis, discharge reason, and condition on discharge were not completed. Resident #35 had a care plan identifying exit-seeking tendencies with potential for elopement, with interventions to observe the resident, monitor emotional well-being, and notify supervisory staff if the resident verbalized a desire to go. A progress note dated 03/23/2025 stated the resident had an incident at the facility that ended with the resident being transported in police custody to the local emergency room for evaluation and assessment. A police incident report stated the resident was in police custody, transported by police to the emergency room for a medical evaluation, medically cleared, and then transported by police to a different hospital and placed on the lockdown unit. A hospital record dated 03/23/2025 showed the resident arrived at the emergency room via law enforcement with a chief complaint of needing a psychiatric evaluation, and the assessment noted anoxic brain injury with aggressive behavior. The record stated the facility called and said the Corporate Nurse would not accept the patient back until a psych eval was completed, and a physician accepted the resident at a behavioral hospital later that day. The resident’s transition of care/discharge summary contained no data, the EHR had no discharge summary, and there was no discharge order in the physician orders. Interviews with the Regional Ombudsman, psychiatric hospital Social Clinic Director, DON, and Administrator confirmed the facility was not sending Ombudsman notifications, that the resident was not given a 30-day notice from the facility, and that discharge documentation should have been present in the chart.
Unsafe Supervision and Elopement Events
Penalty
Summary
The facility failed to ensure a safe environment free of accident hazards and failed to provide adequate supervision to prevent accidents for a resident with a history of brain damage from oxygen deprivation, anxiety, depression, CHF, and HTN. The resident had a BIMS score of 8, indicating moderate cognitive impairment, and was documented as ambulatory with care plan interventions for exit-seeking behavior, elopement risk, and staff redirection. The record also showed the resident was assessed as at risk for elopement. Despite these identified risks, the resident was found outside near the laundry/maintenance building without staff knowing how the resident got out, later exited through the 300-hall door and was found walking down the road in front of the facility, and on another occasion crawled through the smoke wall. The resident also exited through the dining room door and was witnessed by staff leaving the facility, during which the resident punched and kicked staff and was taken by police to an emergency room for evaluation. An observation showed the dining room door was an exit-delay door, and the Medical Director stated the resident had found ways out of the facility, including finding outdoor codes or another way outside.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, which could potentially affect all 36 residents receiving meals from the kitchen. Observations revealed that food items such as bowls of crushed pineapple, shredded lettuce, chopped tomatoes, and ice cream were not properly covered, leaving them exposed to air and contaminants. Additionally, the facility did not have thermometers in all refrigerator/freezer units, making it difficult to monitor and maintain appropriate temperatures for food safety. The facility's policies on food receiving, storage, and sanitization were not adhered to, as evidenced by the lack of proper labeling, dating, and covering of food items. The kitchen environment was found to be unsanitary, with broken and chipped meal trays, sticky residues on kitchen equipment, and trash receptacles without lids. The range and deep fryer were covered in sticky residues and food particles, and the floor beneath them was discolored with debris. The facility's policy on maintaining a clean and sanitary food service area was not followed, as seen in the condition of the kitchen equipment and the lack of proper waste management. Interviews with the Dietary Manager (DM) and the Administrator highlighted the importance of proper food storage, dating, and temperature monitoring to prevent foodborne illnesses and ensure resident safety. However, the facility's practices did not align with these standards, as evidenced by the numerous deficiencies observed during the survey. The DM acknowledged the importance of these practices but admitted that the facility did not purchase plastic bags for food storage, contributing to the improper storage of food items.
Deficient Arbitration Agreement Components
Penalty
Summary
The facility failed to ensure that the arbitration agreement included all necessary components as required by regulations. Specifically, the agreement did not contain a statement about the resident or representative's right to rescind the decision to select arbitration within the first 30 days after admission. Additionally, there was no declaration affirming that signing an arbitration agreement is not a condition of admission, nor was there a statement confirming the resident's right to communicate with state or federal surveyors, the state Ombudsman, or health department officials. This deficiency was identified during a review of the facility's admission packet, particularly in Section XI, Dispute Resolution. The deficiency affected four residents who had signed arbitration agreements since the facility's change of ownership. During an interview, the Administrator acknowledged the absence of the required information in the arbitration agreement and reported having informed the owner about the necessary changes. The Administrator was unable to locate the missing information in the admission packet when asked by the surveyors, confirming the oversight in the documentation provided to residents upon admission.
Failure to Provide Adequate Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure proper personal hygiene for residents who required assistance, specifically in removing facial hair and trimming fingernails. Three residents were observed with facial hair that had not been removed despite their requests and care plans indicating the need for assistance with personal hygiene. Resident #3, who has a history of cerebral infarction and hemiplegia, was observed with chin hair and reported not receiving scheduled showers or assistance with hair removal. Similarly, Resident #28, who also has hemiplegia, was observed with chin hair and reported not receiving a scheduled bath, which is when hair removal typically occurs. Resident #17 was observed with both chin hair and long fingernails, despite having received a shower that day. This resident, who requires substantial assistance with personal hygiene, expressed a desire for hair removal and nail trimming, which had not been provided. Interviews with CNAs confirmed that residents should have facial hair removed and nails trimmed as part of their hygiene care, acknowledging that these tasks were not completed as requested by the residents. The Director of Nursing (DON) confirmed that facial hair should be removed and nails trimmed if requested by residents, as part of maintaining their hygiene and preventing potential harm from scratching. The facility's policy on Activities of Daily Living (ADLs) supports providing necessary care for residents unable to perform these tasks independently, yet the observations and interviews indicate a failure to adhere to this policy, resulting in unmet hygiene needs for the residents involved.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide activities for all 34 residents during the weekend, as observed by the surveyor and confirmed through interviews with residents and staff. The surveyor noted the absence of weekend activities upon entry and throughout the survey period. During a Resident Council Meeting, residents unanimously reported that no activities were held on weekends, except for occasional church services provided by a former employee. The Activity Director (AD) acknowledged that activities were listed on the calendar but required minimal setup and staff assistance, such as movies, coloring, or puzzles. However, the AD was unaware of any specific staff assigned to conduct these activities, and the activity logs for June 2024 were incomplete. Interviews with the facility's Administrator and staff, including a CNA and an LPN, revealed a lack of clarity and responsibility regarding weekend activities. The Administrator confirmed that activities should be conducted on weekends for residents' well-being and acknowledged the negative effects of not providing them. However, there was no designated person in charge of weekend activities, and staff members interviewed could not recall any activities taking place or who was responsible for them. The facility's policy on activity programs emphasized the importance of activities for residents' physical, mental, and psychosocial well-being, stating that activities should be scheduled seven days a week and documented in residents' medical records.
Narcotic Storage Deficiency
Penalty
Summary
The facility failed to ensure that narcotic medications were stored in a permanently affixed compartment, which could lead to the potential misappropriation of resident property. During an inspection, a surveyor, accompanied by the Assistant Director of Nursing (ADON), observed that the narcotic box in the main medication room's refrigerator had no visible locking mechanism and was easily removable. The ADON confirmed that the narcotic box should be permanently affixed to prevent unauthorized removal. The refrigerator itself was not locked, which the ADON acknowledged should be the case to prevent easy access to the narcotic box. Upon further inspection, the ADON retrieved a key from a nurse to unlock the narcotic box, revealing 10 boxes containing vials of Lorazepam for seven current residents and one vial labeled for the emergency kit. The facility's policy on medication labeling and storage, revised in February 2023, requires controlled substances to be separately locked in permanently affixed compartments. This policy was not adhered to, as evidenced by the unsecured narcotic box in the refrigerator.
Failure to Follow Planned Menu and Ensure Nutritional Variety
Penalty
Summary
The facility failed to adhere to a written menu that was designed to meet the nutritional needs of its residents, affecting all 36 residents who receive meals from the kitchen. The Dietary Manager (DM) admitted to not always having the necessary ingredients due to adjusting to a new food delivery schedule, leading to deviations from the planned menu. For instance, on one occasion, the lunch menu was supposed to include brown sugar meatloaf and mashed potatoes, but instead, soft shell tacos and refried beans were served. The DM claimed that the Registered Dietitian approved these changes as long as they were documented, but there was no evidence of such documentation. The Resident Council expressed concerns about the lack of variety in meals, noting repeated servings of beans and mashed potatoes and limited options for meal alternatives. The DM acknowledged the necessity of chopping pork due to its toughness, which was not part of the planned menu. The Administrator recognized the importance of following a planned menu to reduce repetition and ensure residents' nutritional needs are met. However, the facility's failure to follow the planned menu resulted in a lack of variety and potential nutritional inadequacies for the residents.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain appropriate food temperatures, which is crucial for promoting consumption and preventing foodborne illness. Observations revealed that cold food items were not held at the required temperature of 41 degrees Fahrenheit or below. Specifically, during a lunch meal observation, items such as shredded lettuce, sour cream, chopped tomatoes, chopped onion, shredded cheese, and salsa were recorded at temperatures above the safe threshold. Despite the Dietary Manager's decision to discard these items, residents had already consumed meals containing the improperly held cold food items. Further observations indicated that hot food items were also not maintained at appropriate temperatures. On a separate occasion, temperatures of chopped pork roast, mixed vegetables, and baked potato were recorded below the safe serving temperature. The Dietary Manager acknowledged the issue, noting that the steam table's middle sections were not as hot as the end sections, and expressed intentions to address this with the maintenance department. Both the Dietary Manager and the Administrator recognized the importance of maintaining food temperatures to prevent foodborne illness and ensure residents' enjoyment and consumption of meals.
Failure to Notify Resident's Representative and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident's representative or Power of Attorney (POA) regarding the resident's transfer to the hospital, as well as failing to notify the ombudsman of such transfers. The deficiency was identified during a survey when a resident confirmed a recent hospital visit due to bleeding after a catheterization. The facility's records showed the resident was discharged to the hospital and later returned, but there was no documentation of transfer or bed hold notices being sent to the responsible party. Interviews with facility staff, including the Business Office Manager (BOM), Assistant Director of Nursing (ADON), and the Administrator, revealed a lack of awareness and execution of the policy requiring notification of the resident's transfer to the hospital. The BOM and Social Services staff also confirmed that they did not notify the ombudsman about the resident's hospital transfer, contrary to the facility's policy. The facility's policy, revised in March 2021, mandates written notification to the resident and representative, including the ombudsman, in cases of transfer or discharge due to urgent medical needs.
Failure to Notify Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to notify the resident's representative or power of attorney in writing about the bed hold policy when the resident was transferred to the hospital. This deficiency was identified during a surveyor's review of the records and interviews with the staff. The resident, identified as Resident #28, was admitted to the hospital due to bleeding in the urine after a catheterization and returned to the facility a few days later. However, there was no documentation of a transfer notice or bed hold notice being sent to the resident's representative as required by the facility's policy. Interviews with the Business Office Manager, Assistant Director of Nursing, and the Administrator revealed a lack of awareness and execution of the policy regarding the notification of bed hold policies. The Business Office Manager and Assistant Director of Nursing were not aware of the requirement to send such notices, while the Administrator acknowledged that the notices should have been sent and documented. The facility's policy, revised in March 2022, clearly states that residents and their representatives should be informed in writing about the bed hold policies both in advance of any transfer and at the time of transfer, or within 24 hours in case of an emergency.
Lack of Restorative Program for Resident Post-Therapy
Penalty
Summary
The facility failed to ensure a restorative program was in place to prevent further decline in range of motion (ROM) for a resident who had completed occupational and physical therapy. The resident, who had a flaccid right arm due to a stroke, was observed using their left arm to move the right arm. The resident reported that they no longer received range of motion exercises because their insurance had run out, and there was no restorative aide available to continue the exercises. The resident's care plan indicated a fair rehabilitation potential, but therapy had been discontinued over a month prior to the survey. Interviews with facility staff, including the occupational therapist and the administrator, confirmed that the facility did not have a restorative program or a designated restorative aide. The facility's policies on restorative nursing services and resident mobility and range of motion, which were last revised in July 2017, stated that residents should receive restorative care to promote safety and independence and to prevent avoidable reductions in ROM. Despite these policies, the facility did not implement a restorative program for the resident, leading to a deficiency in care.
Failure to Report Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation of property for three residents. Resident #3, who has severe cognitive impairment, reported that a Certified Nursing Assistant (CNA) was rough while changing them. Despite notifying another CNA and discussing the incident with the Social Service Director, Administrator, and Director of Nursing, the facility did not investigate or report the allegation promptly. Resident #3 expressed feeling unsafe when the CNA was working. Resident #5, who is cognitively intact, filed a grievance about missing cigarettes. The grievance log indicated that the resolution was to lock the cigarettes behind the nursing station, but no investigation was conducted to determine if the cigarettes were indeed taken. The Social Service Director confirmed that there was no investigation, and the resident stated that the facility did not address the issue of the missing cigarettes. Resident #6, who has severe cognitive impairment, was involved in an incident where a CNA was reported to have been rough, grabbing and shaking the resident. Although the CNA was terminated, the incident was not investigated or reported as abuse. The Assistant Director of Nursing and Interim Director of Nursing confirmed that these incidents should have been investigated and reported, but they were not. The current Administrator acknowledged that these allegations were not handled appropriately and should have been reported.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to investigate allegations of abuse and misappropriation of property for three residents. Resident #3, who has severe cognitive impairment, reported being mistreated by a CNA, feeling unsafe, and experiencing rough handling. Despite the resident's report to the Social Service Director, Administrator, and Director of Nursing, the facility did not conduct a thorough investigation, and the CNA was not terminated until two weeks after the incident. Resident #5, who is cognitively intact, reported missing cigarettes, suspecting theft. The facility's response was to lock the cigarettes behind the nursing station, but no investigation was conducted to determine if theft occurred. The Interim DON confirmed that missing cigarettes should be investigated as theft, but the Administrator believed it was not necessary to report if the amount was less than $50. Resident #6, with severe cognitive impairment, was reportedly handled roughly by a CNA, who was terminated for sleeping on the job rather than for the alleged rough handling. The family of Resident #6 did not wish to pursue abuse charges, but the Interim DON and Administrator acknowledged that the incident should have been investigated and reported. These failures to investigate and report allegations of abuse and misappropriation of property demonstrate a deficiency in the facility's compliance with its own policies and federal requirements.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as recommended, which was identified through observations and interviews. A review of the facility's Nursing Services Policy and Procedure Manual for Long-term Care Infection Control, dated 03/01/2022, revealed no information regarding EBP. During multiple observations on 05/28/2024 and 05/29/2024, it was noted that there were no EBP signs on resident rooms, nor was personal protective equipment (PPE) available in close proximity to resident rooms. Interviews with the Administrator, a Certified Nursing Assistant (CNA), the Assistant Director of Nursing (ADON), and the Interim Director of Nursing (IDON) confirmed that the facility had not implemented EBP. The CNA also confirmed that no education or training on EBP had been provided, and they were unaware of which residents required EBP.
Failure to Maintain Comfortable Temperatures
Penalty
Summary
The facility failed to maintain proper temperatures to ensure a safe, comfortable, and homelike environment for a resident. The resident, who was admitted with diagnoses including ESBL resistance, chronic viral hepatitis C, malignant neoplasm of the bronchus or lung, and diabetes mellitus with diabetic neuropathy, reported feeling cold and was observed wearing warm clothing. The resident's room was located on the 100 hall, where the thermostat was set at 68 degrees, and the temperature was recorded at 66 degrees. The Maintenance Director acknowledged complaints from residents about the cold temperatures and adjusted the thermostat to 72 degrees. Observations revealed that the thermostat settings varied across different areas of the facility, with temperatures ranging from 64 to 73 degrees. The Maintenance Director confirmed that 66 degrees was a cool temperature and made adjustments to increase the warmth. Despite these efforts, the facility did not have a policy in place for managing physical environment and facility temperatures, as confirmed by the Administrator. This lack of policy contributed to the deficiency in maintaining a comfortable environment for the residents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours in a 24-hour period for 11 out of 15 days reviewed. The facility's policy requires an RN to provide services for at least eight consecutive hours every 24 hours, seven days a week. However, a review of daily timecards from May 14, 2024, through May 28, 2024, revealed that the facility did not meet this requirement on 11 days. Additionally, the Director of Nursing (DON) had not worked since May 16, 2024, and the facility had only one instance of an RN working for 5 hours on May 18, 2024. Interviews with facility staff, including the Social Service Director, Certified Nursing Assistants, and Licensed Practical Nurses, confirmed the absence of a DON and the lack of RN coverage. The Administrator acknowledged that the facility had been without a DON for approximately one week and confirmed that no RNs were available due to the recent resignation of two RNs. This lack of RN coverage and the absence of a DON contributed to the facility's failure to comply with the required staffing standards.
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Illustrative
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.
Illustrative
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Nursing homes near Piggott
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Campbell Healthcare & Senior Living | 9.7 mi | ★★★★★ | 15 | 0 |
| Rector Nursing And Rehab | 10.1 mi | ★★★★★ | 0 | 0 |
| Heritage Nursing Center - Skilled Nursing By Ameri | 12.1 mi | ★★★★★ | 7 | 0 |
| Nhc Healthcare, Kennett | 13 mi | ★★★★★ | 0 | 0 |
| Gideon Care Center | 16.1 mi | ★★★★★ | 7 | 0 |
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