Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Quapaw Care And Rehabilitation Center Llc during CMS and state inspections, most recent first.
Meal portions were not prepared and served according to the written menu during a meal observation. Dietary staff used incorrect ladles and scoops for vegetable blend and pureed items, served mashed potatoes instead of the ordered pureed hashbrowns, and an employee stated he had not reviewed the menu and recipe. The menu required specific portions for residents on mechanical soft and pureed diets, and facility policy required standardized recipes and proper portion control using scoops, ladles, and scales.
Runny and Improperly Prepared Pureed Foods: Dietary staff repeatedly prepared pureed menu items using amounts of liquid that did not match facility recipes, including ham, vegetable blend, Philly steak, potato flakes, and bread. Observations showed the foods were runny, lumpy, or not formed, and the DM described the pureed vegetable blend served to residents as runny.
Food items were found improperly stored in multiple kitchen and storage areas, with several opened packages and containers left uncovered or unsealed and multiple items past their use-by or expiration dates. During meal service, a dietary staff member contaminated gloves and then handled clean blender equipment without washing hands, hot pureed foods were served below required temps without reheating, and the ice machine used for resident drinks and water pitchers had visible black residue.
Failure to follow a resident’s care plan for fragile skin: a resident with senile purpura and bruising to both arms was observed multiple times wearing a short-sleeved shirt without the ordered protective sleeves. The care plan called for sleeves over both arms, but an LPN confirmed they were not in place, and the DON stated they should have been applied earlier.
A resident with right-sided hemiplegia and a right-hand contracture was observed multiple times self-propelling a wheelchair without any device in place to maintain ROM or prevent further contracture. Records showed no active or passive ROM, no splint use, and a resolved hand-roll task with no replacement intervention added. Staff, including the RNA and DON, confirmed the resident was not receiving restorative services and that no current intervention was being implemented.
The facility failed to maintain cold food items at the required temperatures and did not keep one of the ice machines in a clean and sanitary condition. Cold food items were observed above the required 41 degrees Fahrenheit, and an ice machine in the therapy room had a wet brownish residue. The ice machine was used for residents' water pitchers and kitchen beverages.
The facility failed to prevent access to hazardous chemicals by allowing a resident to have odor eliminators at the bedside and leaving an unlocked housekeeping cart unattended. Additionally, the facility did not ensure the proper use of a mechanical lift, as CNAs used it with its legs in the closed position, contrary to the manufacturer's guidelines.
The facility failed to provide timely perineal care for a resident with cerebral palsy, leading to prolonged periods of incontinence and strong odors. Additionally, another resident's catheter bag and tubing were observed dragging on the floor, risking infection. The DON confirmed these practices were against protocol.
The facility failed to ensure meals were served at acceptable temperatures, affecting multiple residents who received meal trays in their rooms. One resident reported that the food was often not warm enough, with cold eggs and lukewarm coffee being common issues. An unheated food cart delivered to the 400-Hall had food items measured at unacceptable temperatures, further confirming the deficiency.
The facility failed to provide appropriate hand hygiene during perineal care for a resident with severe cognitive impairment and during medication administration by an LPN. Both staff members did not follow hand hygiene protocols, increasing the risk of infection spread among residents.
The facility failed to date and change the portable nasal cannula tubing for a resident every 7 days as required, potentially affecting two residents receiving oxygen therapy. The undated tubing was observed tucked into the resident's wheelchair, and staff confirmed the oversight and lack of a specific policy for oxygen storage.
The facility failed to ensure that a medication was stored securely, leading to potential misappropriation. An LPN left arthritis gel unattended on a cart while washing hands, and the DON confirmed that medications should not be left unattended. The facility lacked a policy on medication storage.
The facility failed to obtain informed consent for a resident prior to administering immunizations, which had the potential to affect all 87 residents. The consent form was not marked for or against vaccination, and the resident confirmed they did not consent. The facility's policy states that residents may refuse immunizations, but this was not followed.
Meal Portions Not Served Per Written Menu
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menus to meet residents’ nutritional needs for one of one meal observed. During an observation at the noon meal, Dietary staff used a three-ounce ladle, equal to 1/3 cup, to place five servings of vegetable blend into a blender instead of the #8 ladle, equal to 1/2 cup, specified on the lunch menu. The same staff member later placed an amount equal to ten servings of sliced ham into a blender, ground it, poured it into a pan, and placed it into a warmer for residents on mechanical soft diets. A Diet Order report showed 21 residents required mechanical soft diets. During the same meal observation, Dietary staff used a #10 scoop, equal to 1/3 cup, to serve pureed vegetables and pureed mashed potatoes instead of the #8 scoop, equal to 1/2 cup, required by the menu. Hashbrowns were not prepared for residents on pureed diets, and mashed potatoes were served instead. A staff member stated he had not looked at the menu and recipe and thought residents on pureed diets were not supposed to have hashbrowns. The noon menu indicated residents on mechanical soft diets were to receive three ounces of ground ham each, and residents on pureed diets were to receive a #8 scoop of pureed vegetable blend and pureed hashbrowns. Facility policy required use of standardized recipes based on census and cycle menus and serving portions according to the menu spreadsheet using scoops, ladles, and scales.
Runny and Improperly Prepared Pureed Foods
Penalty
Summary
The facility failed to ensure meals were served in a method that maintained appearance, nutritive value, taste, and acceptable consistency for pureed foods during one observed noon meal preparation. During observation, Dietary staff prepared pureed ham by placing seven thick slices of baked ham into a blender and adding two cups of broth, rather than the recipe amount of a half cup plus two tablespoons of stock or water. The pureed ham was then poured into a pan and placed on the steam table, and it was observed to be runny. The dietary staff member stated he used two cups of broth instead of the recipe amount. The same meal preparation issues were observed with other pureed items. A dietary staff member prepared vegetable blend by placing five servings into a blender and adding one and a half cups of water instead of the recipe amount of one tablespoon plus two teaspoons of food thickener with no liquid; the resulting mixture was observed to be runny. Another staff member prepared Philly steak by adding two and a half cups of broth to five servings in a blender, and the puree was observed to be runny and not formed. Potato flakes were also prepared with hot tap water and described by the staff member as looking watered down. In addition, six slices of white bread were blended with two cups of water instead of the recipe amount, and the mixture was observed to be lumpy and runny. The Dietary Manager stated the kitchen staff used the dinner roll recipe for pureed bread, and described the pureed vegetable blend served to residents as runny.
Improper Food Storage, Hand Hygiene, and Hot Food Temperature Control
Penalty
Summary
Food items were found improperly stored throughout the kitchen, refrigerator, freezer, dry storage areas, and food truck. Surveyors observed opened packages and containers that were not covered or sealed, including ham, powdered milk, cereal, brown sugar, tea, corndogs, egg rolls, hamburger patties, chicken fried steak, corn dogs, shrimp, sausage patties, French fries, and rice cereal. Several items were also past their expiration or use-by dates, including ham, strawberry topping, flour tortillas, honey thickened apple juice, and other dry goods. The observations showed food exposed to air, moisture, heat, and potential pests, and one dietary aide stated that an open bag of powdered milk could allow bugs to crawl in it if not sealed. During meal service, a dietary staff member wore contaminated gloves after turning off the water and then used those gloves to attach a clean blade to a blender for pureeing food, later stating he should have removed the gloves and washed his hands. At the 500-Hall dining room, hot pureed vegetables, potatoes, ham, Philly steak, and ground ham were measured below required serving temperatures and were not reheated before being served to residents. Surveyors also observed the ice machine in the 500-Hall therapy room with wet black residue on the panel and in the area where ice fell into the collector, and the dietary manager confirmed that the machine was being used for resident beverages and water pitchers while stating he did not know who cleaned it.
Failure to Follow Care Plan for Protective Arm Sleeves
Penalty
Summary
The facility did not ensure Resident #60 received treatment in accordance with the Comprehensive Resident Centered Care Plan for skin concerns. During three observations, the resident was seen with discoloration to both arms and was wearing a short-sleeved shirt without protective sleeve coverings. A weekly skin audit dated 07/17/2025 identified senile purpura, described as dark purple and brown bruising, on both arms. The quarterly MDS dated 06/11/2025 showed a BIMS score of 10, indicating moderately impaired cognition, and noted no skin issues. The care plan for Resident #60 identified a skin tear or potential for skin tears related to fragile skin and included an intervention, effective 01/03/2025, for the resident to wear protective sleeves over both arms. During interview, an LPN confirmed the resident had discoloration to both arms and no protective coverings in place. The resident stated, "I bruise easily if I bump something or someone grabs me." The DON stated the protective sleeves were not put on until 07/23/2025 and acknowledged they should have been in place earlier according to the care plan.
Failure to Maintain ROM Support for Resident With Right-Hand Contracture
Penalty
Summary
The facility did not ensure an intervention was in place to maintain or improve range of motion and mobility, or to prevent further contracture, for a resident with right-sided weakness and a right-hand contracture. During multiple observations, the resident was seen self-propelling a wheelchair in the hall, to the smoking area, and in the room, and each time the resident’s right hand contracture was observed without a device in place to maintain ROM. Record review showed the resident had a diagnosis of hemiplegia affecting the right dominant side. The annual MDS indicated moderately impaired cognition, no functional ROM limitation in either upper extremity, no active or passive ROM, and no splint use. The care plan identified an ADL self-care deficit related to right-sided weakness and right-hand contracture and directed staff to the restorative care plan. An OT plan of care from 09/01/2022 stated the resident had right upper extremity impairments, needed ROM therapy, and was at risk for further decline without therapy, with a goal of using a resting hand splint with maximum assistance. However, the task record showed the hand roll task had been resolved and no new task was added for another splint or roll. Staff interviews confirmed the resident had a right-hand contracture without a device in place, the RNA had never had the resident on restorative services, and the DON stated there was no intervention currently being implemented to prevent further contracture.
Cold Food Temperature and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure cold food items were maintained at the required temperatures on the pans of ice by the steam table while awaiting service. On 05/01/2024, it was observed that the temperatures of the cold food items, including regular potato salad, mechanical potato salad, and coleslaw, were above the required 41 degrees Fahrenheit. Dietary Employee #1 confirmed that the cold food items should have been kept at 41 degrees Fahrenheit and acknowledged that they should have been set on ice while in the refrigerator. Additionally, the facility failed to maintain one of the two ice machines in a clean and sanitary condition. On 05/05/2024, the ice machine panel in the therapy room on the 500-hall was found to have a wet brownish residue. The Dietary Supervisor confirmed that the residue was brownish dirt and stated that the ice machine was used by CNAs for residents' water pitchers and by the kitchen for beverages served at mealtimes. The ice machine had been in use since the kitchen's ice machine broke down, and it was cleaned once a month by the maintenance man.
Failure to Prevent Access to Hazardous Chemicals and Improper Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure that odor eliminators were not at the bedside for Resident #18, who was diagnosed with cerebral palsy, major depressive disorder, and anxiety. The resident, who was cognitively intact, had two 27-ounce bottles of scented odor eliminator labeled with warnings to keep out of reach of children and instructions for ingestion. These bottles were observed on top of a small refrigerator near the foot of the bed. The Licensed Practical Nurse (LPN) confirmed that residents should not have deodorizers in their rooms due to the risk of ingestion by residents with dementia who may wander into other rooms. The Director of Nursing (DON) also confirmed that it is inappropriate for residents to have odor eliminators in their rooms for the same reason. There was no policy on odor eliminators in the facility. Additionally, the facility failed to ensure the mechanical lift was used correctly. Certified Nursing Assistants (CNAs) used the lift with its legs in the closed position due to space constraints, which is against the manufacturer's guidelines that require the legs to be in the open position for stability to prevent falls. The DON confirmed that the legs should be in the open position to stabilize the lift's center of gravity. The manual guide for the mechanical lift also documented that the legs must be in the maximum opened/locked position before lifting a resident. Furthermore, the facility failed to ensure that the housekeeping cart was kept closed and locked. The surveyor observed an unattended housekeeping cart with the door open, keys in the door, and chemicals inside. Housekeeping staff admitted to leaving the cart unlocked and unattended, which could have allowed residents to access harmful chemicals. The DON confirmed that housekeeping carts should be locked to prevent residents, especially those with dementia, from ingesting chemicals. The facility did not have a policy on accidents and hazards related to housekeeping carts.
Failure to Provide Timely Perineal Care and Proper Catheter Management
Penalty
Summary
The facility failed to provide timely perineal care for a resident diagnosed with cerebral palsy, major depressive disorder, and anxiety, who required maximum assistance for toileting and bathing. Despite the care plan indicating the need for frequent peri care and the use of absorbent pads, the resident was observed to have a strong, foul odor in their room on multiple occasions. The resident reported being wet and not having their brief changed promptly. Certified Nursing Assistants (CNAs) were observed leaving the resident without changing the brief, and the Licensed Practical Nurse (LPN) confirmed that incontinent residents should be checked and changed every two hours, which was not done in this case. The Director of Nursing (DON) also confirmed that all staff are responsible for ensuring residents are clean and dry, but this protocol was not followed for this resident. Additionally, the facility failed to ensure proper catheter care for another resident. The resident's catheter bag and tubing were observed dragging on the floor while being transported in a wheelchair, which the CNA was unaware of until pointed out. The DON confirmed that the catheter bag and tubing should not drag on the floor as it could introduce infection or cause a leak. The facility's policy on perineal/catheter care did not contain pertinent information to prevent such occurrences.
Failure to Maintain Acceptable Food Temperatures
Penalty
Summary
The facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents. This deficiency was observed during one of two meals, affecting multiple residents who received meal trays in their rooms across various halls. Specifically, Resident #34, who had diagnoses of diabetes mellitus, chronic obstructive pulmonary disease, and depression, reported that the food was often not warm enough, with cold eggs and lukewarm coffee being common issues. The resident's care plan indicated a regular diet with specific instructions for breakfast, including enhanced cereal and prune juice, but the resident expressed dissatisfaction with the food quality and temperature during an interview with the surveyor. On another occasion, an unheated food cart containing nine breakfast trays was delivered to the 400-Hall. The temperature of the food items on the test trays was measured immediately after the last resident was served, revealing that the milk was at 46 degrees Fahrenheit, sausage at 103 degrees Fahrenheit, ground sausage with gravy at 105.9 degrees Fahrenheit, pureed sausage at 110 degrees Fahrenheit, scrambled eggs at 105.8 degrees Fahrenheit, and gravy at 108 degrees Fahrenheit. These temperatures were not acceptable to the residents and did not meet the standards for maintaining food palatability and safety, as evidenced by the residents' complaints and the surveyor's observations.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility failed to provide appropriate hand hygiene during perineal care for a resident with severe cognitive impairment and multiple diagnoses, including dementia and anemia. During an observation, a CNA was seen performing perineal care on the resident without changing gloves or performing hand hygiene before handling clean linens and dressing the resident. The CNA acknowledged the lapse in protocol when questioned by the surveyor. The Director of Nursing confirmed that the staff should perform hand hygiene after perineal care and before handling clean items, as per the facility's policies on perineal care and hand hygiene. Additionally, the facility failed to use proper hand hygiene during medication administration. An LPN was observed disposing of a plastic cup and medication, then proceeding to administer medications to another resident without performing hand hygiene in between. The LPN also handled a resident's inhaler and nasal spray, washed hands, and then touched the same medications again, leading to potential contamination. The LPN admitted to the surveyor that this was a lapse in protocol. The Director of Nursing confirmed that hand hygiene should be performed between residents during medication pass to prevent the spread of infections. The facility's policies on hand hygiene and perineal care were provided, which clearly state the importance of hand hygiene in preventing healthcare-associated infections. The failure to adhere to these policies was observed in both the CNA's and LPN's actions, which had the potential to affect all residents in the facility by increasing the risk of infection spread.
Failure to Date and Change Portable Nasal Cannula Tubing
Penalty
Summary
The facility failed to ensure that the portable nasal cannula tubing for a resident was dated to ensure it was changed every 7 days, as required to prevent respiratory infections. This deficiency was observed in Resident 52, who had a physician's order for oxygen therapy and a care plan indicating the need for oxygen at 2 liters per minute via nasal cannula. The surveyor observed that the portable nasal cannula tubing was not dated or properly stored, and the resident was unaware of the location of the storage bag provided for the tubing. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the tubing should be changed every 7 days, but the facility lacked a specific policy for oxygen or oxygen storage. The deficiency was noted during multiple observations over several days, where the surveyor found the undated nasal cannula tubing tucked into the side of the resident's wheelchair cushion. The LPN and DON acknowledged the oversight and confirmed the requirement for weekly changes of the tubing. The facility's failure to date and change the portable nasal cannula tubing as per the physician's order and care plan had the potential to affect two residents on the 300 hall receiving oxygen therapy.
Unsecured Medication Storage
Penalty
Summary
The facility failed to ensure that a medication was stored securely, which could potentially lead to misappropriation by other residents, staff, or visitors. On 05/01/2024 at 09:14 AM, an LPN applied arthritis gel to a resident's knee, then left the gel unattended on top of the cart while washing hands in the resident's bathroom. When questioned by the surveyor, the LPN acknowledged that the gel should not have been left unattended. On 05/02/2024 at 02:40 PM, the DON confirmed that medications should not be left unattended as it opens up the possibility for residents to take the medication. Additionally, the DON admitted that the facility did not have a policy on medication storage.
Failure to Obtain Informed Consent for Immunizations
Penalty
Summary
The facility failed to obtain informed consent for a resident prior to administering immunizations, which had the potential to affect all 87 residents in the facility. On 05/01/2024, the Surveyor requested to see the vaccination consents for a resident, and the Business Office Manager provided a consent form that was not marked for or against vaccination. The Infection Preventionist confirmed that the resident did not consent to the immunization. The Director of Nursing provided a policy stating that residents or their representatives may refuse offered immunizations, but the facility did not follow this policy in this instance.
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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.
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Nursing homes near Hot Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Blossoms At Hot Springs Rehab And Nursing Cent | 3 mi | ★★★★★ | 0 | 0 |
| The Springs Of Red Oak | 3.5 mi | ★★★★★ | 2 | 0 |
| The Pines Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Lake Hamilton Health And Rehab | 4.4 mi | ★★★★★ | 0 | 0 |
| The Springs Of Park Ave | 6.5 mi | ★★★★★ | 0 | 0 |
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