Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Russellville Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
MDS assessments were not completed timely or accurately for two residents. One resident’s admission MDS remained delinquent after admission, despite staff stating assessments were expected within the required 15-day window. Another resident was observed smoking, but the quarterly MDS and smoking safety evaluation did not accurately or timely reflect smoking status; the care plan also lacked smoking documentation even though a closet care plan identified the resident as a smoker.
Delayed Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments within the required 90-day timeframe for multiple residents. Record review showed 11 residents had overdue quarterly assessments, and interviews revealed the delinquency occurred after one MDS coordinator was on extended medical leave and no backup staff were provided, while leadership was unaware the assessments were past due.
A CNA provided perineal care to a resident with severe cognitive impairment and incontinence while wearing contaminated gloves, touched clean supplies without changing gloves, and confirmed this could spread germs. In a separate event, an LPN administered meds and water flushes through a resident’s PEG tube while wearing gloves but no gown, despite EBP signage and the resident’s care plan calling for gown and glove use during high-contact care. Staff interviews and facility policy confirmed that glove changes, hand hygiene, and gowning were expected during these tasks.
A resident was observed receiving O2 at 2 L/min via NC, but the chart did not contain an active oxygen order. The resident said they were on oxygen for COPD, though COPD was not listed in the diagnoses. Record review showed only a discontinued prior O2 order, and staff including an LPN, the ADON, the DON, and the Administrator confirmed they could not locate an oxygen order. The facility policy stated oxygen is administered only with a written physician order.
Expired eye drops were found in the bottom drawer of a med cart on the 300-Hall, with 10 closed vials past the manufacturer expiration date. MA-C confirmed the drops were expired and not being given to residents, while an LPN and the DON stated expired meds were supposed to be kept in a box in the locked med room. The Administrator said staff had received a verbal med in-service, but there was no documentation of the specific information presented.
Undocumented Dressing and Wound With Maggots Not Reported
The facility failed to ensure food safety and proper hand hygiene, affecting 80 residents. Observations showed expired food items were not discarded, and food storage lacked proper labeling and dating. Additionally, staff did not follow hand hygiene protocols, with contaminated hands used in food handling. The facility lacked a specific handwashing policy for the kitchen, despite the general policy emphasizing its importance.
The facility failed to maintain a clean and homelike environment, as observed by soiled linens on a resident's bed, structural damage in a shared bathroom, and fecal matter in a whirlpool tub. Staff interviews revealed unclear responsibilities for linen changes and cleaning duties.
The facility failed to use an accepted power source for medical equipment, creating a potential fire hazard. A resident's oxygen concentrator and pacemaker were plugged into a non-medical grade power strip. Additionally, a moving toilet in a resident's bathroom and a protruding pipe in another resident's room posed safety risks, with no immediate corrective actions taken.
A resident with a PEG tube was not provided appropriate care as an LPN administered enteral feeding without verifying tube placement, contrary to facility policy. The resident had conditions like gastroparesis and severe malnutrition, requiring careful management. The DON confirmed that tube placement should be checked before each feeding, which was not done.
A facility failed to ensure staff followed isolation precautions, including the use of PPE, during high contact care for a resident with a PEG tube. The resident's care plan required enhanced barrier precautions, but an LPN did not apply the necessary PPE, and the facility lacked a policy on these precautions. The DON confirmed that gowns, gloves, and masks should be used during such care.
A resident's family reported a missing tablet to the facility, expecting an investigation. However, the ADON was not informed, and the Administrator initially did not recall the incident. The facility's grievance policy requires prompt resolution, but no grievance report was completed, and no restitution was offered, indicating a failure to follow the procedure.
A facility failed to complete a comprehensive MDS assessment within 14 days after a resident was admitted to hospice care. The resident, with hypertensive heart disease and Alzheimer's, was admitted to hospice, but the MDS Coordinator overlooked the requirement for a significant change assessment. The coordinator acknowledged the oversight during an interview.
MDS Assessments Not Completed Timely or Accurately
Penalty
Summary
The facility failed to ensure Minimum Data Sets (MDS) were completed in a timely and accurate manner for two residents. For one resident, the facility admitted the resident on 02/05/2026 with diagnoses including alcohol use, unspecified intoxication, cardiac arrhythmias, and spinal stenosis, but the admission MDS was still in progress on 02/24/2026 with a start date of 02/09/2026. The MDS Coordinator confirmed the admission MDS was delinquent because of an extended medical leave that began in October 2025. The Administrator and Assistant Administrator stated that when one of the two MDS Coordinators was absent, the other was expected to complete assessments within the required 15-day timeframe. The DON and Assistant DON stated that delinquent assessments could delay communication of resident changes and proper care, and the MD stated assessments were expected to be completed in a timely manner. The RAI Manual provided to surveyors indicated admission MDS assessments were due within 15 days post-admission. For another resident, the facility did not accurately complete the quarterly MDS to reflect smoking status. The resident was observed smoking while wearing a protective apron, and staff provided cigarettes and a lighter. The resident had diagnoses including right-sided hemiplegia, heart disease with heart failure, wheezing, cerebral infarction, depression, hypertension, and COPD. The care plan reviewed did not document smoking status, although the resident had been assessed for smoking previously and a closet care plan listed the resident as a smoker. The quarterly MDS with an ARD of 01/01/2026 did not indicate the resident smoked, and the quarterly smoking safety evaluation was 19 days past the required completion date. MDS Coordinators stated the smoking and quarterly MDS assessments were not completed on time because one coordinator had been off work for an extended period, and they confirmed the assessments had fallen behind.
Delayed Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly MDS assessments were completed within the required 90-day timeframe for 11 of 15 residents reviewed. On 02/24/2026, record review identified that Residents #25, #36, #38, #50, #60, #62, #67, #69, #73, #76, and #83 each had a last quarterly MDS completed in October 2025, with the next quarterly assessment due in January 2026, but the assessments were past due at the time of review. The report states that the quarterly assessments were the responsibility of the MDS department and were required every 90 days. During interviews, MDS Coordinator #8 stated that many assessments were delinquent because the other MDS Coordinator was absent for six weeks and no backup was provided to assist with the workload. MDS Coordinator #9 confirmed that several assessments were delinquent due to an extended medical leave that began in October 2025 and stated that no staff filled the position during the absence. The Administrator and Assistant Administrator stated that if one MDS Coordinator was absent, the other was expected to complete all assessments within the required timeframe, and both acknowledged they were unaware the quarterly assessments were delinquent. The DON stated that delinquent quarterly assessments could prevent information from being relayed to the appropriate people and may cause delays in correct treatments, and the MD stated that failure to complete quarterly assessments accurately and on time could result in negative outcomes, improper care, and missed appointments.
Infection control failures during perineal care and PEG tube medication administration
Penalty
Summary
Hand hygiene and glove changes were not appropriately performed during perineal care for Resident #57, who had Huntington's disease, bipolar disorder, anxiety disorder, severe cognitive impairment, and was frequently incontinent of urine and always incontinent of bowel. During an observation, a CNA provided perineal care while wearing contaminated gloves, dropped a wet brief into a trash can, wiped the resident, placed wipes on the bedside table, and then picked up a clean brief and applied it to the resident without changing gloves. The CNA confirmed she did not change dirty gloves before touching the clean brief and acknowledged that doing so could spread germs. Interviews with staff and leadership showed that the expected practice during perineal care was to change gloves throughout the task and perform hand hygiene to avoid transferring bacteria. The DON stated staff were expected to have one clean and one dirty CNA during perineal care and to change gloves during the process. The Administrator also stated staff were expected to have a clean and dirty person and change gloves during perineal care to prevent cross contamination and perform hand hygiene after the task was completed. The facility policy for Perineal/Catheter Care required multiple pairs of gloves and directed staff to change gloves after removing the wet brief and wiping the resident. For Resident #11, who had diagnoses including stroke, heart failure, and respiratory failure and received nutrition through a PEG tube, an LPN administered medications and water flushes through the feeding tube while wearing gloves but no gown. The resident had an order for tube feeding and water flushes, and the care plan indicated the resident was on enhanced barrier precautions with staff to gown and glove during high-risk resident care activities. The LPN later stated she did not think a gown was required for feeding tube care, although the EBP sign outside the room listed gown and gloves for high-contact care activities and PPE was available at the door. RN and ADON interviews confirmed staff should gown and glove during high-contact resident care and that gowning and gloving was part of the enhanced barrier process.
Missing Oxygen Order for Resident Receiving O2
Penalty
Summary
The facility failed to ensure Resident #8 had an order for oxygen while the resident was receiving O2 at 2 L/min via nasal cannula. During observation, the resident was seen resting with mouth open while on oxygen, and a CPAP device was stored on the bedside table. The resident later stated they were on oxygen for COPD, although the medical diagnosis review did not list COPD and instead included anemia, heart disease, and wheezing. The quarterly MDS indicated the resident had moderate cognitive impairment and was on oxygen while at the facility. Record review showed an order summary with a discontinued order from 11/22/2023 for O2 at 2 L/min via nasal cannula PRN to keep O2 saturation above 90%, but there was no active oxygen order. The oxygen saturation summary from 11/30/2025 through 02/22/2026 showed no documentation of hypoxia and saturations above 90% both on and off oxygen therapy. During interviews, an LPN, the ADON, the DON, and the Administrator all confirmed they could not locate an oxygen order in the resident’s record and stated oxygen is a medication that requires an order. The DON also stated nursing should compare new orders to old orders when a resident returns from the hospital, and the facility policy stated oxygen is administered only upon the written order of a licensed physician.
Expired Eye Drops Stored in Medication Cart
Penalty
Summary
Expired medication was stored in a medication cart on the 300-Hall instead of being kept in the medication room as staff described for discontinued or outdated medications. During an observation, 10 vials of [Brand Name] eye drops were found in the bottom drawer of the cart with a manufacturer expiration date of August 2025. Medication Assistant (MA-C) #21 confirmed the vials were expired and stated they were not being administered to any residents. During interviews, an LPN stated expired medications were kept in a box in the medication room, and the DON stated nurses were supposed to dispose of expired medications in a box in the locked medication room. The Administrator stated the last medication in-service had been completed with all staff, but there was no medication pass in-service with just the nurses and no documentation of the specific information presented. Facility policy stated medications were to be stored in a safe, secure, and orderly manner, and discontinued or outdated medication should prompt contact with the dispensing pharmacy for return or destruction instructions.
Undocumented Dressing and Untreated Wound With Maggots
Penalty
Summary
The facility failed to ensure a resident’s wounds were identified, documented, accurately reported to the physician, and treated according to orders. Resident #20 had diagnoses including osteoarthritis, major depressive disorder, and anxiety, and was described in the MDS as cognitively intact. The care plan identified the resident as having a potential and actual risk for skin integrity problems related to weakness, fragile skin, decreased mobility, and a history of a healed open lesion to the right lower leg, with interventions to monitor and document skin injury and report failure to heal, maceration, and signs and symptoms of infection. A weekly skin assessment documented the resident’s skin as intact with no breakdown, but staff later found an undated, unsigned, and undocumented dressing on the lower right extremity. CNA #19 reported seeing flies at the foot of the bed, then finding drainage leaking from the resident’s lower right leg and calling an LPN because the bandage needed to be changed. When the dressing was removed, maggots fell out, the wound was described as fist-sized with raw pink and red tissue and holes, and the area had a strong odor. LPN #15 and LPN #17 confirmed that a fist-sized open lesion with maggots was found on the posterior right calf and that the dressing had not been ordered for that leg. The record and interviews showed the wound and maggots were not promptly or accurately reported to the physician. Staff stated they did not know who applied the initial dressing, how long it had been in place, or why it was there. The DON stated there were no progress notes documenting the discovery of maggots and that the facility could not establish a timeline. The PA later assessed the resident’s right calf wound, and the MD stated she had not been told nursing reported maggots in the wound and would have expected to be notified if myiasis was found. The report also noted that the facility’s wound dressing policy addressed cleansing wounds per order but did not address the procedure to follow with new skin findings.
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, affecting 80 residents who receive meals from this kitchen. Observations revealed that food items, such as a large plastic container of soup and containers of sliced tomatoes and onions, were not discarded before their use-by dates. Additionally, a tray with glasses of juice and tea in the refrigerator was not labeled with a date, and the refrigerator lacked an interior thermometer. These practices are contrary to the facility's food storage policy, which requires all food not stored in original containers to be labeled, dated, and stored in approved containers. Furthermore, the facility did not adhere to proper hand hygiene practices. Dietary Employee #1 was observed washing hands before handling kitchen items but then applied gloves to contaminated hands. This employee also placed contaminated fingers inside plates where food was served, a practice observed on three occasions. Dietary Employee #2 was seen placing contaminated hands inside insulated domes before covering lunch plates. The facility lacked a specific handwashing policy for the kitchen, although the general hand hygiene policy emphasized its importance in preventing infection spread. The Dietary Manager acknowledged the need for proper handwashing between tasks and handling dishes without contaminating food contact surfaces.
Deficiencies in Cleanliness and Maintenance
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by several observations made by the surveyor. One resident's bed was found unmade with visibly soiled linens, including large orange-colored spots on the fitted sheet and pillowcase, accompanied by a noticeable urine odor and multiple flies around the bed. Despite these conditions, the Certified Nursing Assistant (CNA) responsible for the resident's care indicated that linens were only changed on shower days or upon the resident's request, and could not explain why the visibly soiled linens had not been changed. Additionally, the surveyor observed structural issues in the personal bathroom shared by two residents, where cracks in the plaster between the wall and sink were noted, with a large piece of plaster missing. The Maintenance Supervisor was unaware of the issue. Furthermore, the whirlpool tub in the 100 Hall bathroom was found to have apparent fecal matter present on two separate occasions. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities, with a CNA attributing the cleaning of baths to housekeeping, while the housekeeper stated that baths are cleaned daily and should not have any dirt or bodily material present.
Facility Fails to Address Safety Hazards
Penalty
Summary
The facility failed to ensure the use of an accepted power source for medical equipment, creating a potential fire hazard. Observations revealed that an oxygen concentrator and pacemaker equipment for a resident were plugged into a non-medical grade power strip, which was not compliant with safety standards. The power strip was identified as lacking the necessary UL1363 or UL1363A certification for medical use. The facility administrator acknowledged the concern regarding the inappropriate use of the power strip for medical equipment. Additionally, the facility did not address a moving toilet issue in a resident's bathroom, which had been reported by the resident but remained unresolved. The toilet's instability made it difficult for the resident to use the bathroom safely. The maintenance supervisor was aware of the issue but had not taken corrective action. Furthermore, a protruding pipe in another resident's room posed a potential hazard, as it was left uncapped and could cause injury. The maintenance supervisor and a CNA acknowledged the pipe's presence and the risk it posed, but no immediate plans for correction were mentioned.
Failure to Verify PEG Tube Placement Before Feeding
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who was admitted with diagnoses including gastroparesis, severe protein-calorie malnutrition, and adult failure to thrive, was observed receiving supplemental enteral feeding without proper verification of PEG tube placement. The resident's care plan indicated a nutritional problem related to these conditions, and a physician's order specified enteral feeding twice daily with a water flush. During an observation, an LPN administered the feeding and water flush without checking the tube placement, stating that it had been checked the previous night and she did not want to disturb the resident. The Director of Nurses later confirmed that the facility's policy requires checking tube placement before each feeding, flush, or medication administration. The facility's policy on enteral feedings, revised in 2016, outlines the procedure for checking tube placement, which was not followed in this instance.
Failure to Follow Isolation Precautions for PEG Tube Feeding
Penalty
Summary
The facility failed to ensure staff adhered to isolation precautions, specifically the appropriate use of personal protective equipment (PPE), during high contact resident care. This deficiency was observed in the case of a resident who required supplemental feeding via a percutaneous endoscopic gastrostomy (PEG) tube. The resident had been admitted with diagnoses including gastroparesis, severe protein-calorie malnutrition, and adult failure to thrive. The resident's care plan, initiated in March 2024, required enhanced barrier precautions to reduce the transmission of resistant organisms, mandating the use of gowns and gloves during high contact care activities. On a specific occasion, an LPN was observed entering the resident's room to administer a tube feeding without applying the appropriate PPE as indicated by the Enhanced Barrier Precautions signage. The LPN admitted to not seeing the signage and planned to wash her hands in a different location than recommended. Additionally, it was noted that the facility did not have a policy on Enhanced Barrier Precautions, as confirmed by the Administrator. The Director of Nurses stated that gowns, gloves, and masks should be worn during high contact resident care, indicating a lack of adherence to the required precautions.
Failure to Follow Grievance Policy for Missing Tablet
Penalty
Summary
The facility failed to adhere to its grievance policy regarding a reported incident involving a resident's lost tablet. On August 19, 2024, a resident reported a lost tablet, which was purchased by the family, while in the facility. The family member at the bedside informed the administration, expecting an investigation to be initiated. However, the Assistant Director of Nursing (ADON) was not notified about the missing tablet, and the Administrator initially could not recall the incident. Later, the Administrator acknowledged remembering the report but did not interpret it as a grievance, and no grievance report was completed. The facility's grievance policy, dated November 22, 2016, mandates that residents have the right to voice grievances without discrimination or reprisal, and the facility must make prompt efforts to resolve grievances within five business days. Despite this policy, the family representative confirmed that no information was requested by the facility to locate or replace the tablet, nor was any restitution offered. This indicates a failure to follow the established grievance procedure, resulting in the unresolved issue of the missing tablet.
Failure to Complete Timely MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days after a significant change in condition was identified for a resident admitted to hospice care. The resident, who had diagnoses including hypertensive heart disease with heart failure and Alzheimer's disease, was admitted to hospice care on March 4, 2024. Despite this significant change, the MDS Coordinator did not complete the required significant change MDS assessment. During an interview, the MDS Coordinator acknowledged the oversight, stating that she uses the Resident Assessment Instrument (RAI) Manual to determine significant changes, such as a decline in two areas like weight loss or a change in hospice status, but overlooked the requirement in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Russellville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stella Manor Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
| Legacy Heights Nursing And Rehab, Llc | 2.2 mi | ★★★★★ | 0 | 0 |
| Dardanelle Nursing And Rehabilitation Center,inc | 6.1 mi | ★★★★★ | 4 | 0 |
| Atkins Nursing And Rehabilitation Center | 13 mi | ★★★★★ | 3 | 0 |
| Johnson County Health And Rehab, Llc | 19.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Russellville Nursing And Rehabilitation Center.
100% money-back within 48 hours.
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.