Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Johns Place Of Arkansas, Llc during CMS and state inspections, most recent first.
Improper hand hygiene was observed during incontinence care for a resident with severe cognitive impairment who required extensive assistance and a mechanical lift. A CNA cleaned a resident with loose bowel movement, then continued care with the same gloves while pulling clean wipes, placing a clean brief, cleansing the groin area, and handling the lift equipment before discarding the gloves and performing hand hygiene after leaving the room. Interviews with CNAs and the DON confirmed expectations for glove changes and hand hygiene during dirty-to-clean care.
Facility Assessment Missing Required Components: The facility failed to include a governing body member in the completion of the facility assessment and did not document staff retention information. The Administrator stated he completed the assessment with input from the DON and Medical Director, but no governing body member was actively involved, QAA meetings had not been held since May 2025 to review the assessment, and the facility’s provided guidance did not identify the required team members or include a staff retention plan.
Failure to document Ombudsman notification for a resident's hospital transfers. A resident with GERD and hyperlipidemia was transferred to a hospital for SOB, and transfer/discharge forms were completed, but the record did not show that the state Ombudsman was notified. Progress notes lacked evidence of the required notification, and the facility could not produce proof that the emails were sent.
The facility failed to ensure proper food storage and hand hygiene practices, affecting 67 residents. Opened boxes of food in the freezer were not sealed, and dietary staff did not follow handwashing protocols, handling clean dishes after touching dirty objects. Additionally, hot food items were not maintained at the required temperature, with pureed bread served at 100°F instead of the required 135°F.
The facility failed to provide residents with access to their trust funds after business hours and on weekends, affecting 64 residents. Additionally, a deceased resident's trust funds were not reimbursed within 30 days of discharge. Discrepancies were also found in the trust account records, with individuals listed who were not current or past residents.
The facility failed to provide activities for residents on the secured unit, despite having an activities calendar. Observations showed residents unengaged with the television, and no activities were conducted. Staff interviews revealed confusion over responsibility for activities, with the Activity Director and aides both cited. The facility's policy emphasized varied activities for meaningful engagement, which was not implemented effectively.
The facility failed to secure medication carts and refrigerated controlled medications properly. A nurse left an unlocked medication cart unattended, and a surveyor found that the locked box for refrigerated controlled medications was not permanently affixed. The DON acknowledged the risk of unauthorized access to medications.
A resident was misdiagnosed with a psychological disorder, leading to inappropriate prescription of Quetiapine Fumarate. The diagnosis was entered by a previous APN to appease a family member, despite the resident not having a true diagnosis of schizoaffective disorder. The DON confirmed the misdiagnosis and noted the facility's policy did not address this issue.
A housekeeping cart containing harmful chemicals was left unlocked and unattended on a secured unit, allowing a resident to approach it without staff supervision. Housekeeping staff admitted to leaving the cart unlocked, and the supervisor confirmed it violated facility policy, especially given the risk to cognitively impaired residents.
A resident with a UTI was found without fluids within reach, despite requiring assistance with eating. Observations and interviews revealed that staff failed to ensure fluids were available at the bedside, contrary to facility policy on hydration.
A resident was prescribed Quetiapine Fumarate for a misdiagnosed schizoaffective disorder, as revealed by the DON. Despite a recommendation for dose reduction, the attending physician continued the medication due to periodic behaviors. The facility's policy did not address this deficiency.
The facility did not serve meals according to the planned menu, affecting residents' nutritional intake. Dietary staff used incorrect portion sizes for oatmeal, serving less than the required amount to residents on both regular and pureed diets. This was confirmed through staff interviews, impacting 22 residents on regular diets and 7 on pureed diets.
Improper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was consistently implemented during incontinence care for one resident who had severe cognitive impairment, required substantial to maximal assistance with toileting, personal hygiene, and transfers, and had a care plan calling for staff assistance with ADLs, a mechanical lift with staff assist x2, and cleaning of the perineal area with each incontinence episode. During an observation, two CNAs assisted the resident from a wheelchair to bed with a mechanical lift to provide incontinence care. Both wore gloves and gowns, and CNA #4 began cleansing the resident’s bottom after removing wet wipes from a package on the over-bed table. The resident’s brief was wet and contained loose, malodorous bowel movement. While cleansing fecal material, CNA #4 used the same gloves to continue pulling clean wipes directly from the package, then continued care without changing gloves or sanitizing hands after the bowel area was cleaned. She placed a clean brief under the resident and continued using the same gloves to cleanse the resident’s pubic area and groin, fastened the brief, and then used those same gloves to hook the lift pad to the mechanical lift and guide the resident in the wheelchair as the lift was lowered. CNA #4 discarded the soiled gloves only after the resident was in the wheelchair and then performed hand hygiene before leaving the room. Interviews with CNAs and the DON confirmed expectations for changing gloves and performing hand hygiene when moving from dirty to clean tasks and after glove removal; the DON stated the facility did not have a policy on hand hygiene.
Facility Assessment Missing Required Governing Body and Staff Retention Components
Penalty
Summary
The facility failed to ensure required components were included in the facility assessment dated 05/01/2025. A review of the assessment showed that no governing body member was listed as being involved in completing the assessment, and no staff retention information was documented in the assessment. During an interview on 11/19/2025 at 2:56 PM, the Administrator stated he completed the facility assessment and involved the DON for nursing questions and the Medical Director for input. He stated there was not a member of the governing body actively involved in forming the assessment, and that the Medical Director, DON, and he should be involved, but he was not 100 percent sure what the federal requirements were. He also stated the facility had not held any QAA meetings since May 2025 to review the facility assessment, and he did not know why the plan for staff retention was not included. A policy document provided by the Administrator did not identify which members were to be included in completion of the assessment and did not include a staff retention plan, while a sample process document indicated the assessment leader should review the regulation and invite team members including the Administrator, a representative of the governing body, the Medical Director, and the DON.
Failure to Document Ombudsman Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide evidence that notice of transfers or discharges was sent to the state Ombudsman for one resident who was transferred to a local hospital. Resident #74 was admitted on 01/01/2017 with diagnoses including gastro-esophageal reflux disease without esophagitis and hyperlipidemia. The record showed a Notice of Transfer/Discharge form was completed on 08/13/2025 and 09/16/2025, and Emergency Transfers from Facility documentation showed the resident was transferred to the hospital on [DATE] and 09/16/2025. A Notice of Transfer/Discharge/Leave of Absence with Bed Hold Policy form dated 09/16/2025 stated the resident was transferred to the local hospital for shortness of breath, but it did not indicate that the Ombudsman was notified. Progress notes from 08/16/2025 through 11/18/2025 did not show documentation that the transfer/discharge notices were sent to the Ombudsman for either hospital transfer. During interviews, the Administrator stated the Social Worker sent transfer logs and notices to the state Ombudsman, but the facility could not provide proof of the emails, and later stated the facility did not have a policy on Ombudsman notification. After survey exit, the facility was given an opportunity to provide the missing documentation, but the Administrator reported the Social Worker was unable to produce evidence that the Ombudsman had been contacted.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and handling practices in the kitchen, which had the potential to affect 67 residents. Observations in the walk-in freezer revealed that opened boxes of corn dogs and mixed vegetables were not covered or sealed, increasing the risk of cross-contamination. Additionally, dietary staff did not adhere to proper hand hygiene protocols. A dietary aide was observed handling clean dishes after touching dirty objects without washing her hands, and another dietary staff member turned off a faucet with bare hands after washing, then handled clean equipment without re-washing her hands. Furthermore, the facility did not maintain hot food items at the required temperature. The temperature of pureed bread with milk was recorded at 100 degrees Fahrenheit, which is below the required 135 degrees Fahrenheit, and it was not reheated before being served to residents. The facility's policy on personal hygiene, which mandates handwashing before handling food and clean dishes, was not followed by the dietary staff, contributing to the potential for foodborne illness among residents.
Failure to Provide Access to Trust Funds and Timely Reimbursement
Penalty
Summary
The facility failed to ensure that residents with trust accounts had access to their personal funds after business hours and on weekends. This deficiency was highlighted when a resident indicated that they could not access their money on weekends because the Business Office Manager (BOM) only went to the bank on Tuesdays and Fridays. The BOM confirmed that no petty cash was left with the charge nurse on weekends, and residents had to request money in advance for weekend use. This practice affected 64 residents with trust accounts managed by the facility. Additionally, the facility did not reimburse a resident's trust account funds within 30 days of discharge, as required. A resident who passed away had a remaining balance that was not returned within the stipulated time frame. Furthermore, there were discrepancies in the facility's trust account records, with several individuals listed as having balances despite not being current or past residents of the facility. The BOM and Administrator were unable to explain how these individuals appeared in the system, indicating a lack of proper management and oversight of resident trust accounts.
Failure to Provide Activities for Residents on Secured Unit
Penalty
Summary
The facility failed to provide activities to residents on the secured unit, despite having an activities calendar designed for residents with cognitive impairment. Observations by the surveyor on multiple occasions revealed residents sitting in the common area with the television on, but not engaged in watching it. Instead, residents were observed with their heads down, touching other residents, picking at their clothing, or being told to sit down. No ongoing activities were observed during these times, and the television was not considered an engaging activity for the residents. Interviews with staff revealed a lack of clarity regarding responsibility for conducting activities. CNA #9 indicated that the Activity Director was responsible for activities, while the Activity Director stated that aides on the hall were responsible for activities on the secured unit. The Director of Nursing contradicted this, stating that the Activity Director was responsible, as aides had enough to do. The facility's policy on activity programs emphasized the need for varied activities to meet individual needs and provide meaningful engagement, but this was not being implemented effectively in the secured unit.
Medication Security Deficiencies
Penalty
Summary
The facility failed to ensure that medication carts were locked and secure when left unattended and out of the line of sight of the nurse. On June 10, 2024, a surveyor observed a registered nurse leaving an unlocked medication cart unattended while entering a resident's room, with her back turned to the hallway where the cart was placed. The nurse confirmed that the cart was unlocked while unattended. The Director of Nursing acknowledged that an unattended medication cart not within view of the nurse should be locked, as residents and staff could access medications if the cart was left unlocked. Additionally, the facility did not ensure that controlled medications stored in the refrigerator were kept in a permanently affixed, locked compartment. On June 11, 2024, a surveyor noted that the locked medication box used for refrigerated controlled medications was not permanently affixed to the refrigerator shelf. A licensed practical nurse confirmed that the lock box could be removed from the refrigerator. The facility's policy on medication storage stated that medication rooms, carts, and supplies should be locked when not attended by authorized personnel.
Misdiagnosis and Inappropriate Medication Prescription
Penalty
Summary
The facility failed to ensure that a resident was not misdiagnosed with a psychological disorder, leading to inappropriate medication treatment. The resident, who had a diagnosis of dementia and schizoaffective disorder depressive type, was prescribed Quetiapine Fumarate, an atypical antipsychotic, for conditions including severe dementia with mood disturbance and schizoaffective disorder. However, the resident's Admission Minimum Data Set (MDS) did not document a diagnosis of schizophrenia, and the Director of Nursing (DON) later confirmed that the resident did not have a true diagnosis of schizoaffective disorder. The diagnosis was reportedly entered by a previous Advanced Practice Nurse (APN) to appease a family member who was upset about a medication dose reduction. During interviews, the DON acknowledged that the resident should not have been diagnosed with a psychological disorder solely for the purpose of prescribing medication. The DON was not employed at the facility when the misdiagnosis occurred. The facility's policy titled "Organizational Aspects" did not address this deficient practice, indicating a lack of proper procedural guidance to prevent such occurrences.
Unattended Housekeeping Cart with Chemicals Unlocked
Penalty
Summary
The facility failed to ensure that a housekeeping cart used to store harmful chemicals was locked when not in use, as required by facility policy. On June 10, 2024, at 10:02 AM, a surveyor observed an unattended and unlocked housekeeping cart on the secured unit. Later, at 11:16 AM, a resident was seen standing at the cart without any staff present. Housekeeping Staff #9 admitted to leaving the cart unlocked while she walked away to get something, acknowledging that residents could access the cart. On June 13, 2024, the Housekeeping Supervisor confirmed that the cart should always be locked when not in use, especially on the secured unit where cognitively impaired residents could mistakenly ingest the chemicals. A review of the facility's Accident Hazards Prevention policy emphasized the importance of maintaining a safe environment free from accident hazards.
Failure to Maintain Resident Hydration
Penalty
Summary
The facility failed to ensure that fluids were maintained within reach to promote good hydration for a resident diagnosed with a Urinary Tract Infection (UTI). The resident, who requires partial to moderate assistance with eating, was observed by a surveyor on two separate occasions without a water pitcher or any fluids in their room or mini refrigerator. During an interview, the resident confirmed that they were not provided with drinks regularly. Interviews with facility staff, including a Certified Nurse Aide (CNA) and a Licensed Practical Nurse (LPN), revealed that fluids should always be available at the resident's bedside. However, neither staff member could explain why the resident did not have a cup or fluids available. The facility's policy on Assisted Nutrition and Hydration emphasizes the importance of providing sufficient fluid intake to maintain proper hydration and health, yet this was not adhered to in the case of the resident in question.
Failure to Ensure Resident is Free from Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication. The resident, diagnosed with dementia and schizoaffective disorder, depressive type, was prescribed Quetiapine Fumarate, an atypical antipsychotic, to be taken twice daily. However, the Director of Nursing (DON) later revealed that the resident did not have a true diagnosis of schizoaffective disorder. The diagnosis was allegedly entered by a previous Advanced Practice Nurse (APN) to appease a family member, leading to the resident being misdiagnosed. Despite a Pharmacy Monthly Medication Review recommending a gradual dose reduction of Quetiapine Fumarate, the attending physician decided to continue the current medication regimen, citing the resident's periodic behaviors and fear of exacerbation. The DON confirmed that antipsychotic medication should not be prescribed without a psychological disorder, indicating a failure in adhering to proper medication management protocols. The facility's policy titled Organizational Aspects did not address this deficient practice.
Failure to Serve Meals According to Planned Menu
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, which was intended to meet the nutritional needs of the residents. During an observation, it was noted that the dietary staff used incorrect portion sizes when serving oatmeal to residents. Specifically, residents on regular diets were supposed to receive 3/4 cup of hot cereal, but were instead served with a 2-ounce spoon, providing less than the required amount. Similarly, residents on pureed diets were to receive a #8 scoop (1/2 cup) of hot cereal, but were also served with a 2-ounce spoon. This discrepancy was confirmed through interviews with the dietary staff, who acknowledged using the incorrect serving utensils. This practice had the potential to affect 22 residents on regular diets and 7 residents on pureed diets.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| The Green House Cottages Of Southern Hills | 15 mi | ★★★★★ | 0 | 0 |
| Chapel Woods Health And Rehabilitation | 25.7 mi | ★★★★★ | 2 | 0 |
| The Springs Of Camden | 30.9 mi | ★★★★★ | 0 | 0 |
| Pine Bluff Transitional Care | 31.2 mi | ★★★★★ | 6 | 0 |
| Ouachita Nursing And Rehabilitation Center | 31.4 mi | ★★★★★ | 3 | 0 |
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