Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pocahontas Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of falls and cognitive impairment experienced an unwitnessed fall and subsequently complained of pain and exhibited abnormal vital signs. Nursing staff did not initiate required neuro checks or notify the physician of the incident or the resident's change in condition, despite facility policy. The resident's condition deteriorated, leading to hospital transfer and diagnosis of subdural hematomas, which resulted in death.
The facility failed to secure a portable oxygen cylinder, which was found standing in front of the nursing station with residents and staff present. Interviews with an LPN and the DON confirmed that the tank should be secured to prevent accidents. The facility's policy indicated that oxygen cylinders should be stored in a designated ventilated area and secured to prevent them from falling over.
A resident with severe cognitive impairment was shaved by a CNA in the dining room, observed by other residents, violating dignity policies. The DON confirmed that such personal care should occur in private, as per facility guidelines.
A facility failed to ensure proper infection control practices by not using appropriate PPE in a contact isolation room. A resident with ESBL resistance required contact isolation, but a CNA was observed wearing only a mask and gloves, omitting the required gown. This was confirmed by both the CNA and an LPN, indicating a breach in the facility's infection control protocols.
The facility failed to prevent cross-contamination during lunch service. A dietary aide improperly handled food contact surfaces by touching the inside of plates and bowls and using bare hands to retrieve aluminum foil from a steam table pan. Interviews confirmed staff were instructed to avoid such practices to prevent cross-contamination.
A facility failed to enhance a resident's quality of life by not addressing a language barrier and not considering food preferences. The care plan lacked interventions for communication, and staff were unaware of the resident's native language or preferences. The resident's family expressed dissatisfaction, and staff interviews confirmed the care plan's inadequacy. The Dietary Manager noted the absence of an updated preference list.
The facility failed to maintain a safe and homelike environment in a secured unit, with issues such as exposed drywall, warped baseboards, and possible mold growth due to a leaking toilet. Maintenance staff acknowledged the problems but relied on verbal communication for repairs, while the DON stressed the importance of reporting hazards.
A facility failed to ensure a resident with cognitive and respiratory conditions used a required smoking apron while smoking. The resident, assessed as cognitively intact, was observed smoking without the apron, and the accompanying CNA was unaware of the requirement. The DON confirmed the apron is to prevent burns, as per facility policy.
The facility did not properly secure refrigerated narcotics, as a small medication box containing lorazepam was found unsecured inside the medication refrigerator. An LPN noted the ease of removing the box due to its size, and the facility's policy mandates that controlled drugs be stored in permanently affixed compartments.
The facility failed to provide meals in the correct form for residents on mechanical soft and puree diets. Residents on mechanical soft diets were served diced ham, which is inappropriate and led to them spitting out the food. Puree diet meals were also improperly prepared, with items being too thick or watery. The Dietary Manager and Aide acknowledged the inconsistencies, and the facility's dietary manual specifies the required consistencies for these diets.
A facility failed to ensure proper infection control during incontinent care for a resident with congestive heart failure and emphysema. The CNA did not change gloves or wash hands after care and before applying barrier cream, contrary to the procedure guide. Interviews confirmed the need for glove change to prevent contamination.
A facility failed to accurately complete the MDS assessment for a resident, incorrectly listing English as the preferred language. The resident primarily communicated through gestures, indicating a language barrier. A CNA was unsure of the resident's native language, and a family member expressed dissatisfaction with the facility's efforts to address the communication issue. The MDS Coordinator confirmed the error, noting that Marshallese should have been listed as the preferred language.
A resident with impaired cognitive function due to a language barrier did not have a comprehensive care plan addressing communication needs and preferences, affecting their well-being. Staff were unaware of the resident's native language and food preferences, leading to inadequate care. The MDS Coordinator and Administrator acknowledged the care plan's deficiencies, suggesting improvements like a picture board and language application.
Failure to Initiate Neuro Checks and Notify Physician After Unwitnessed Fall
Penalty
Summary
Nursing staff failed to respond appropriately to an unwitnessed fall involving a resident with a history of hypertensive encephalopathy, hypertensive emergency, and recent falls. The resident, who had moderate cognitive impairment and was assessed as high risk for falls, experienced an unwitnessed fall in the bathroom after attempting to get up without assistance or a walker. Although the resident complained of back pain and later of headaches, neurological checks were not initiated as required for unwitnessed falls, and the physician was not notified of the incident or the resident's change in condition. Documentation and interviews revealed that the resident's blood pressure was significantly elevated following the fall, and the resident became increasingly lethargic and unresponsive over the next several hours. Despite repeated complaints of headache and abnormal vital signs, staff did not perform neurological assessments or notify the physician until the resident's condition deteriorated further. The facility's policies required neuro checks and immediate notification of the physician and responsible party for unwitnessed falls and significant changes in condition, but these protocols were not followed by the staff involved. The failure to initiate neuro checks and notify the appropriate parties after the unwitnessed fall was confirmed through record review, staff interviews, and review of facility policies and training records. The resident was eventually transferred to the hospital after being found unresponsive, where imaging revealed new subdural hematomas. The resident subsequently died as a result of the injuries sustained from the fall.
Unsecured Portable Oxygen Cylinder Found in Facility
Penalty
Summary
The facility failed to ensure a portable oxygen cylinder was secured to prevent an accident or injury. During an observation, an unsecured portable oxygen cylinder was found standing in front of the nursing station with residents and staff present. Two nurses were sitting behind the nursing station documenting, while three staff members were standing on the opposite side, and two residents were in the adjacent day area. Interviews with an LPN and the Director of Nursing confirmed that a portable oxygen tank should be secured to prevent accidents or explosions. The facility's undated policy on accident hazards prevention and handling of oxygen and flammable gas indicated that oxygen cylinders should be stored in a designated ventilated area and secured to prevent them from falling over.
Resident Dignity Compromised During Shaving in Dining Room
Penalty
Summary
The facility failed to uphold the dignity of a resident by allowing a Certified Nursing Assistant (CNA) to shave a resident in the dining room, which was observed by other residents. The facility's policy on resident rights and responsibilities emphasizes the importance of protecting and promoting the dignity and privacy of residents. However, during an observation, CNA #1 was seen shaving Resident #6 in the dining room with other residents present. This action was confirmed by CNA #1, who stated that it was easier to perform shaving in the dining room while monitoring other residents. Resident #6, who was admitted with diagnoses including vascular dementia, unspecified psychosis, and Alzheimer's disease, had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 0. The resident's care plan required assistance with personal hygiene tasks such as shaving, which should have been performed in a private setting. The Director of Nursing (DON) confirmed that shaving should be conducted in resident rooms to maintain dignity, highlighting a failure to adhere to the facility's dignity and privacy policies.
Inadequate PPE Use in Contact Isolation Room
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, specifically in the use of personal protective equipment (PPE) in a contact isolation room. This deficiency was observed in the case of Resident #7, who was admitted with a diagnosis of extended spectrum beta lactamase (ESBL) resistance, a condition that requires contact isolation due to the risk of spreading multi-drug resistant organisms (MDRO). The facility's policy on transmission-based precautions mandates the use of gloves and gowns for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. During an observation, a Certified Nursing Assistant (CNA) was seen in Resident #7's room wearing only a mask and gloves while changing the resident's clothes, despite the requirement to wear a gown as well. This was confirmed by both the CNA and a Licensed Practical Nurse (LPN), who acknowledged that the resident was on contact isolation and that the proper PPE, including a mask, gown, and gloves, was necessary for providing personal care. The failure to adhere to these precautions was further confirmed by a consultant, highlighting a lapse in following the facility's infection control protocols.
Cross-Contamination During Lunch Service
Penalty
Summary
The facility failed to prevent cross-contamination during lunch service in the kitchen. On August 20, 2024, a surveyor observed a dietary aide handling food contact surfaces improperly. The aide placed their hand on top of a stack of plates while sliding it onto a tray, touched the inside of a divided plate intended for a puree diet, and inserted a finger inside a bowl where food would rest while serving gravy. Additionally, the aide used bare hands to retrieve a piece of aluminum foil that fell onto a steam table pan containing regular meatloaf. Interviews with the dietary manager and the aide confirmed that staff were instructed not to touch food contact areas to prevent cross-contamination. The facility's procedure, Serve Safe Manager, specifies that service staff should hold dishes by the bottom or edge and avoid touching food-contact areas of dishes or glassware.
Failure to Address Language Barrier and Resident Preferences
Penalty
Summary
The facility failed to provide an environment that promoted the maintenance or enhancement of a resident's quality of life, specifically denying self-determination and adequate communication for a resident with impaired cognitive function related to a language barrier. The care plan for the resident, dated 6/17/2024, lacked appropriate interventions to address the language barrier, and staff were not adequately informed about the resident's native language or food preferences. The resident's family member expressed dissatisfaction with the care provided, noting that the facility did not make sufficient efforts to eliminate the communication barrier and that the resident's food preferences were not adequately considered. Interviews with staff, including a CNA and the MDS Coordinator, revealed that the care plan did not guide staff in providing sufficient care to the resident, and there was a lack of communication tools such as a picture board or language app. The Dietary Manager confirmed that there was no updated preference list for the resident's likes and dislikes. The Administrator and Nurse Consultant acknowledged the deficiencies in the care plan and the need for immediate improvement to ensure the resident's needs and preferences were understood and met.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment in the 100-hall secured unit. Observations by the surveyor revealed several maintenance issues, including scratched walls with exposed drywall, warped and peeling baseboards, and a musty odor in the shared bathroom between two rooms. Additionally, a black substance was noted behind the toilet, suggesting possible mold growth. Maintenance staff acknowledged the issues, indicating that the toilet had been reported for leaking, but they only checked one side. They also noted that the right-hand corner of the bathroom had been wet frequently, leading to mold and water damage. The maintenance staff admitted that most repair needs are communicated verbally rather than through a formal log, which may contribute to delays in addressing environmental hazards. The Director of Nursing emphasized the importance of reporting such issues to ensure safety hazards are promptly addressed. The facility's policy on Accident Hazards Prevention states that the environment should be free from accident hazards, as much as possible, highlighting a discrepancy between policy and practice.
Failure to Provide Required Smoking Apron for Resident
Penalty
Summary
The facility failed to ensure that a smoking apron was utilized for a resident, identified as Resident #20, who was diagnosed with cognitive communication deficit, dementia, and chronic obstructive pulmonary disorder. The resident was assessed as cognitively intact with a score of 13 on the Brief Interview for Mental Status (BIMS) and required a smoking apron as per their care plan and smoking safety screen. However, during an observation, the resident was seen smoking without a smoking apron, accompanied by a CNA who was unaware of the requirement. The Director of Nursing confirmed that the smoking apron is intended to prevent burns while smoking. The facility's policy mandates a smoking assessment to determine necessary safety equipment, but this was not adhered to in this instance.
Improper Storage of Refrigerated Narcotics
Penalty
Summary
The facility failed to ensure that refrigerated narcotics were stored in a permanently affixed storage box, which could lead to the misappropriation of resident medications. During an observation of the medication storage area inside the medication refrigerator, a small, clear medication box with a red temporary cable tie lock was found. This box contained a controlled medication, lorazepam, and was not secured inside the refrigerator. A Licensed Practical Nurse acknowledged the importance of securing the box due to its size, which made it easy to remove. The facility's policy on pharmaceutical services requires that controlled drugs be stored in separately locked and permanently affixed compartments, which was not adhered to in this instance.
Improper Meal Preparation for Special Diets
Penalty
Summary
The facility failed to provide meals in the appropriate form for residents requiring mechanical soft and puree diets during two observed meal services. On the first day, residents on mechanical soft diets were served diced ham, which is not suitable for their dietary needs, leading to residents spitting out the food. Family members confirmed that this was a recurring issue. A CNA acknowledged that diced ham is inappropriate for mechanical soft diets and poses a choking risk. On the second day, the puree diet meals were improperly prepared, with the puree roll and meatloaf being too thick and sticky, and the cream of corn being too watery. A resident refused to eat the meal due to its consistency. The Dietary Manager admitted that diced ham should be processed to a ground form for mechanical soft diets and acknowledged the inconsistency in the puree diet's texture. The Dietary Aide also noted that the puree consistency changed from its original state. The facility's dietary manual specifies that mechanical soft diets should have foods that are chopped, ground, or shredded, and puree diets should have a consistency similar to moist mashed potatoes or pudding. The failure to adhere to these guidelines resulted in residents receiving meals that were not suitable for their dietary needs.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to implement proper infection control measures during incontinent care for a resident diagnosed with congestive heart failure and emphysema. The resident, who had a severely impaired mental status and an activities of daily living self-care deficit, was at risk for impaired skin integrity due to incontinence. The care plan for the resident included cleaning the perineal area with each incontinence episode. However, during an observation, a Certified Nursing Assistant (CNA) was seen performing incontinent care without changing gloves or washing hands after the care and before applying barrier cream. Interviews with the CNA, the Infection Preventionist, and the Director of Nursing confirmed that the CNA should have changed gloves before applying the barrier cream to prevent contamination and infection. The procedure guide titled "PERI-CARE PROCEDURE" indicated the need to remove gloves and put on clean gloves before applying a skin barrier, which was not followed in this instance.
Inaccurate MDS Language Assessment
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for a resident, leading to a deficiency in the assessment process. The Admission MDS for the resident incorrectly noted that English was the preferred language, and no interpreter was needed. However, during an interview attempt by the surveyor, the resident primarily responded with head nodding and smiling, indicating a language barrier. A Certified Nursing Assistant (CNA) confirmed uncertainty about the resident's native language and acknowledged communication challenges. Additionally, a family member expressed dissatisfaction with the care provided, citing the facility's lack of effort to address the communication barrier, as the resident only understands limited English. The MDS Coordinator later confirmed that the preferred language entry was incorrect and should have listed Marshallese as the resident's actual preferred language.
Deficient Care Plan for Resident with Language Barrier
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with impaired cognitive function related to a language barrier. The care plan did not adequately address the resident's communication needs or preferences, which affected the resident's physical, mental, and psychosocial well-being. During an interview, the surveyor noted that the resident responded inappropriately to questions due to limited English fluency, often nodding instead of verbally responding. The care plan only included minimal interventions, such as observing and reporting changes in cognitive function, without specific strategies to improve communication. Staff interviews revealed a lack of awareness regarding the resident's native language and food preferences. A CNA admitted to guessing the resident's needs by pointing to items and noted that the resident did not consume much from meal trays, preferring food brought by family. The family member expressed dissatisfaction with the care, highlighting the communication barrier and inadequate efforts to understand the resident's food preferences. The MDS Coordinator acknowledged the care plan's deficiencies and suggested using a picture board and language application to improve communication. The Administrator confirmed the care plan was minimal and lacked a comprehensive approach to address the resident's needs.
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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 Pocahontas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Randolph County Nursing Home | 0.2 mi | ★★★★★ | 0 | 0 |
| The Green House Cottages Of Walnut Ridge | 14.8 mi | ★★★★★ | 2 | 0 |
| Lawrence Hall Health & Rehabilitation | 15.1 mi | ★★★★★ | 0 | 0 |
| Corning Therapy And Living Center | 24.6 mi | ★★★★★ | 5 | 0 |
| Current River Rehabilitation & Health Care Center | 25.2 mi | ★★★★★ | 11 | 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 August 2026) and official state health department websites.