Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 St Elizabeth's Place during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, altered mental status, impaired mobility, and documented elopement risk repeatedly roamed the halls and was reported by CNAs to the assigned LPN, but no enhanced supervision was implemented. Late at night, the resident accessed an alarmed dining room exit door, held it open, and exited into an unsecured outdoor area, where the resident fell and then continued on foot to a nearby hotel. The door’s egress alarm sounded, but the LPN, despite prior training on alarm response, assumed it was related to trash removal, did not immediately investigate, later silenced the alarm, briefly looked through the door, and failed to go outside or verify resident safety. The resident’s absence was only discovered during later rounds, and a search was initiated after the resident had already been found at the hotel by emergency responders, demonstrating a failure to maintain a hazard-free environment and provide adequate supervision to prevent elopement.
Staff did not follow EBP and hand hygiene protocols while providing high-contact care to a resident with a wound requiring isolation precautions. Two CNAs failed to wear gowns and did not perform hand hygiene after removing gloves, despite being aware of the requirements and having received training. Facility policies specify the use of gowns and gloves for high-contact care and mandate hand hygiene after glove removal.
Failure to Respond to Exit Door Alarm Leads to Elopement of Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from avoidable accident hazards and to provide adequate supervision to prevent an elopement of a cognitively impaired resident. The resident was admitted with diagnoses including unspecified dementia, altered mental status, difficulty walking, lack of coordination, muscle wasting and atrophy, cachexia, hypoglycemia, and hypothermia. The admission MDS showed moderate cognitive impairment, upper body impairment on one side, and dependence on staff for ambulation on uneven surfaces, curbs, and steps, as well as partial to total assistance for transfers and mobility. Pre-admission screening documented dementia, cognitive impairment, use of a wheelchair and walker, oxygen therapy, and a need for one-person assist, with risk alerts for anticoagulation and falls. Nursing assessments identified the resident as at risk to wander, with an elopement risk score of 9 on admission and 7 on a subsequent assessment, and the care plan noted the resident was at risk for elopement and required assistance with wheelchair mobility. On the evening and night of the incident, multiple CNAs observed the resident repeatedly getting up, roaming, and going in and out of rooms, and reported these behaviors to oncoming nursing staff. One CNA working earlier in the day reported that the resident was “really roaming bad” and looking for a spouse, and another CNA on the 7:00 PM to 11:00 PM shift reported to the assigned LPN that the resident was wandering and coming out of the room multiple times, and that she had been instructed at shift change to keep an eye on the resident. Despite these reports, the resident was later last seen in the dining room in a wheelchair, and no continuous or enhanced supervision was documented at the time the resident accessed the dining room exit door. Video surveillance showed that at approximately 11:16 PM the resident held down the dining room exit door, triggering the egress alarm, and exited directly to an unsecured outdoor area. The resident then fell while attempting to step up onto a curb, crawled across grass and sidewalk toward a shed, and later used a broom and the shed to stand. During this time, the dining room door alarm sounded but was not promptly or appropriately addressed by staff. The LPN assigned to the resident’s hall stated she heard the door alarm and assumed it was someone taking out the trash, so she did not immediately check the alarm and continued passing medications. The LPN later followed the sound to the dining room, entered the code to turn off the alarm, and fully shut the door, stating she briefly looked through the door but did not exit the building to assess the outside area. Video footage showed the LPN entering the dining room with a cell phone in hand, turning off the alarm, and leaving the dining room while on the phone. The LPN acknowledged she had been trained on the egress-door alarm system and that training included the expectation to assess why the alarm was sounding and to go outside to see if any residents had exited. The Maintenance Director, DON, and Nurse Educator all confirmed that staff were instructed that a sounding egress alarm required staff to assess the situation, go outside, and verify that no resident had eloped, although this expectation was not in written egress policy. After the alarm was silenced and the door closed, the resident continued unobserved off facility premises. A hotel clerk reported that the resident walked into the hotel lobby, appeared confused, and requested help finding someone, prompting the clerk to call law enforcement. Police arrived and then requested EMS, who found the resident alert and oriented only to self, with cold, dry skin and severe confusion. EMS records indicated that as the ambulance was leaving the hotel parking lot, facility staff flagged them down and informed EMS that the individual was a resident who had been missing for a few hours. Hospital records documented that the resident was found in the hotel lobby near the facility and was oriented to person only, with a recorded temperature of 96.4°F and elevated blood pressure. Facility staff statements indicated that the resident’s absence was discovered only after a CNA on the 11:00 PM to 7:00 AM shift could not locate the resident during rounds, reported this to the LPN, and a facility-wide search was initiated, by which time the resident had already been located by emergency responders at the nearby hotel. Interviews with facility leadership and staff confirmed that the facility had policies on elopement and missing residents that required prompt reporting of suspected missing residents, initiation of building and premises searches, and notification of the Administrator, DON, resident representative, physician, and law enforcement. The Emergency Procedure – Missing Resident policy described resident elopement as a facility emergency requiring immediate implementation of a missing resident protocol and documentation of circumstances and notifications. However, the Exits or Means of Egress policy did not address door alarms or staff response to those alarms. The DON and Maintenance Director described expectations that staff respond to any door alarm by checking outside and conducting a head count, but this response did not occur when the dining room egress alarm sounded. The failure of the responsible LPN to appropriately respond to the active door alarm, combined with the lack of effective supervision of a cognitively impaired, exit-seeking resident, allowed the resident to leave the building through an alarmed exit door into an unsecured area and travel to a nearby hotel without the facility’s knowledge.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Staff failed to follow infection prevention and control protocols for a resident on enhanced barrier precautions (EBP) due to a wound on the left knee. During an early morning observation, two CNAs provided high-contact care, including transferring and changing the resident, without wearing gowns as required by the facility's EBP policy. Additionally, both CNAs did not perform hand hygiene after removing their gloves and before exiting the room, despite the facility's hand hygiene policy mandating this practice. Interviews with the involved CNAs confirmed their awareness that the resident was on EBP and that gowns and gloves were required for such care activities. Both CNAs acknowledged they did not adhere to the hand hygiene protocol after glove removal. Facility policies reviewed indicated that gowns and gloves are necessary for high-contact care under EBP, and hand hygiene is required immediately after glove removal. The Director of Nursing and Lead CNA confirmed that staff receive training on these protocols and are required to demonstrate competency.
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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 Jonesboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Jonesboro | 1.3 mi | ★★★★★ | 2 | 0 |
| Arkansas Continued Care Hospital Of Jonesboro | 2.1 mi | — | 0 | 0 |
| Ridgecrest Health And Rehabilitation | 4.3 mi | ★★★★★ | 3 | 0 |
| Craighead Nursing Center | 7.1 mi | — | 4 | 0 |
| Quail Run Health And Rehab | 12.1 mi | — | 0 | 0 |
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