Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 The Blossoms At Fort Smith Rehab & Nursing Center during CMS and state inspections, most recent first.
A resident with bipolar disorder, dementia with behavior disturbances, hypothyroidism, and allergic rhinitis was observed handling a prescription-labeled nasal spray and later had a cup of four unidentified meds left on an overbed table. The resident stated staff left the meds for later use, even though the care plan noted medication noncompliance and the MD order stated the resident may not self-administer meds. An LPN, ADON, and DON confirmed meds should not be left with the resident and must be administered per order.
Failure to consistently implement a physician order for a resident with severe cognitive impairment and a left-hand contracture. The resident was observed multiple times without the ordered handroll or splint, with the left hand tightly closed and held close to the body. Record review showed the order required the device every shift, but RNA task documentation was inconsistent, and staff interviews confirmed that NA entries meant the task was not completed because they did not have time.
Medication administration errors caused the facility’s error rate to exceed the allowed threshold, with 2 of 3 observed residents affected. An LPN gave a resident a plain multivitamin instead of the ordered multivitamin with minerals, and an RN improperly primed an insulin flex pen before giving insulin to another resident with diabetes. The DON confirmed that both events were medication errors because the medications were not administered according to the physician orders.
Insulin Pen Not Primed According to Manufacturer Instructions: An RN administered insulin to a resident with DM2 and severe cognitive impairment, but primed an Aspart FlexPen while holding it horizontally and did not observe insulin exiting the pen. The resident had orders for sliding-scale insulin plus a routine pre-meal dose, and the APN, DON, and Administrator all confirmed that meds must be given per MD order and facility policy. The manufacturer’s instructions required the pen to be held needle-up during priming until a drop of insulin is seen.
Failure to Follow EBP During Wound Care: An LPN provided wound care to a resident with a stage 3 pressure ulcer without washing hands or donning a gown before starting, leaned over the bed so the shirt touched the resident’s blanket, and touched a biohazard bag before reaching for clean supplies. The resident was on EBP for wounds, and the care plan and staff interviews confirmed that gown and glove use was required for wound care and that gloves should be changed when moving from dirty to clean tasks.
A resident with severe mental health conditions was admitted from a psychiatric facility without the required PASARR II evaluation, as the facility failed to notify the State Designated Authority and did not clarify staff responsibilities for obtaining the evaluation. Multiple staff members were unclear about the process, and necessary forms were not submitted, resulting in the evaluation only being requested after surveyor intervention.
After increasing its bed count to over 120, the facility did not hire a certified social worker as required. The current Social Services staff member lacked formal education or certification in social work, and both she and the Administrator acknowledged the need for a certified social worker based on the facility's size. There was also no policy in place for social worker staffing.
Staff did not promptly report or escalate allegations of verbal abuse involving two cognitively impaired residents, despite facility policy requiring immediate notification to the Administrator. The incidents included a CNA yelling at and using profanities toward residents, as well as rough handling of a wheelchair, with multiple staff witnessing or learning of the events but failing to ensure timely reporting and resident protection.
A resident with a history of falls and cognitive impairment collided with a laundry cart while walking to the bathroom, resulting in a head injury. The laundry technician was pushing the cart from behind, obstructing visibility. The facility's policy on resident safety was not followed, leading to the accident.
The facility failed to provide toilet paper and paper towels in the women's secured unit bathrooms, affecting residents' dignity and hygiene. A resident with severe cognitive impairment and a history of trauma was directly impacted, as staff admitted to neglecting necessary perineal care. The DON and Administrator were unaware of the issue, highlighting a lapse in oversight.
The facility failed to ensure safe wheelchair transport for a resident with multiple diagnoses, manage smoking materials properly, and maintain a clean environment in the women's secure unit shower room. A CNA let go of a resident's wheelchair, risking their safety, while another resident was found with a cigarette inside the facility, contrary to policy. The shower room had mold and clutter, and the facility lacked fitted sheets, compromising resident comfort.
A facility failed to obtain written authorization to manage a resident's personal funds, who was cognitively intact and their own POA. The resident was unaware of the management of their funds, how to access them, or the costs of services received. The Business Office Manager could not find the authorization, acknowledging the resident's decision-making capacity, leading to the deficiency.
A facility failed to provide perineal care during a brief change for a resident with severe cognitive impairment, citing a lack of paper products. Additionally, another resident received crushed iron tablets against physician orders due to a lack of liquid iron, risking potential complications. The DON was unaware of these issues, indicating a lapse in oversight and adherence to care plans.
The facility failed to ensure proper treatment and services for two residents with feeding tubes by not verifying tube placement before administering flushes and medications. An LPN was observed administering water through a PEG tube without prior placement check and used an unclean stethoscope. Interviews confirmed the importance of checking tube placement to prevent complications.
The facility failed to ensure an accident-free environment by not keeping doors locked on rooms containing chemicals and sharps. Observations revealed that doors to the hopper and shower rooms were not fully closed, exposing hazardous materials. Staff confirmed the importance of keeping these areas secure to prevent resident access. The facility's policy emphasized maintaining a hazard-free environment.
The facility failed to ensure call lights were within reach for residents, including a resident with hemiplegia, leading to potential unmet needs. Observations showed call lights were inaccessible, and staff confirmed the importance of keeping them within reach. However, the facility lacked a specific policy on call lights.
A resident with neuromuscular dysfunction of the bladder was not kept clean and dry as required, leading to soaked bedding and potential skin issues. Despite the care plan requiring checks every two hours, CNAs failed to adhere to this schedule, resulting in the resident being neglected overnight.
The facility failed to ensure proper food storage, handling, and sanitation practices, affecting 104 residents. Observations included expired milk, unsealed food items, and an ice scoop with corroded water. Staff did not consistently wash their hands before handling clean equipment or food, and cold food items were not maintained at safe temperatures. The ice machine also had wet black residue, indicating inadequate cleaning practices.
The facility failed to ensure the dignity and privacy of two residents who required total assistance. One resident was repeatedly observed uncovered and wearing only a brief with the door open, while another resident was exposed during perineal care due to an open door. Staff did not take immediate action to provide privacy, and the facility lacked a specific policy on perineal care.
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, affecting six residents on pureed diets. Observations revealed that pureed green beans, chili, sausage, and oatmeal were improperly prepared, posing a risk to residents. The deficiencies were confirmed by dietary staff.
The facility failed to ensure proper hand hygiene during perineal care for a resident with severe cognitive impairment and dependency on staff for all ADLs. CNAs did not perform hand hygiene before gloving or when changing gloves, and during meal and beverage service, multiple CNAs were observed providing meals and beverages without performing hand hygiene or using gloves. The facility's policy against carrying individual sanitizer bottles and the lack of sanitizer in resident rooms contributed to the issue.
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of flies in the kitchen during meal preparation. Despite pest control services targeting other pests, flies were not reported or addressed, posing a significant hygiene and health risk to 110 residents.
The facility failed to protect a resident from physical abuse by another resident with known behavioral issues. The incident, which involved one resident striking another on the head, was not reported as abuse by the DON due to the absence of visible injuries and the cognitive impairment of the aggressor.
A cognitively impaired resident with a history of dysphagia was left unsupervised during meals, despite care plan requirements for supervision. Observations and staff interviews confirmed that the resident was at risk for choking and should not have been left alone.
A resident with COPD was found with an albuterol inhaler on their bedside table, despite not being assessed to self-administer medications. The facility's policy requires medications to be stored with nurses unless residents are approved for self-administration and provided with a lockbox. The DON confirmed no residents were assessed for self-administration.
Resident Allowed to Handle Medications Despite Order Prohibiting Self-Administration
Penalty
Summary
The facility failed to ensure that Resident #7 was not allowed to self-administer medications when the resident was not clinically appropriate to do so. Resident #7 was admitted with diagnoses including bipolar disorder, dementia with behavior disturbances, hypothyroidism, and allergic rhinitis. Although the resident’s MDS showed a BIMS score of 15, the care plan documented that the resident was noncompliant with medications at times, refused medications, and would pick and choose which medications to take. The physician’s orders for September 2025 included that all medications may be given at one time and that Resident #7 may not self-administer medications. During observation, Resident #7 was seen reaching into a bedside drawer and handling a prescription-labeled box containing a nasal spray, and later was observed with a plastic medication cup on the overbed table containing four unidentified medications. The resident stated they took thyroid medication before breakfast and the remaining medications after eating, and that staff left them in the cup until then. An LPN confirmed medications should not be left in residents’ rooms and that any resident could get them. The ADON and DON both confirmed medications should be administered according to physician orders and that medications should not be left with the resident.
Failure to Consistently Implement Handroll Order
Penalty
Summary
The facility failed to ensure physician orders were consistently implemented for a resident with severe cognitive impairment and a left-hand contracture. The resident had an active order for a handroll or equivalent to be applied to the affected hand every shift, and the care plan included use of supportive devices for the contracture. The resident’s record also showed upper extremity limitation with functional range of motion and a contracture care task assigned to RNA staff for left handrolls. During observations, the resident was seen sitting in a chair after lunch with the left hand tightly closed, the thumb between the first and second finger, and the arm held close to the body, with no handroll or splint in place. On later observations in the dining room and day area, the resident was again seen without a handroll or splint, with the left hand held closed tightly and close to the chest. A handroll carrot and splint were present in the room on a shelf, but were not being used when the resident was observed. Staff interviews and task records showed inconsistent completion of the ordered care. CNA staff stated the resident could not open the left hand and did not know when the handroll or splint was applied. RNA task documentation for the resident showed many shifts marked as NA or refused, with only some shifts marked as applied. The DON confirmed the order meant the handroll should be worn all day every day, and RNA staff stated that NA meant they did not have time to complete the task. Staff also reported that RNA duties included other assignments such as shredding paper, stocking supplies, weighing residents, and delivering briefs, and the DON acknowledged awareness of a problem with RNA staff completing physician-ordered functional maintenance plans.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for 2 of 3 residents observed during the 8:00 AM medication pass, resulting in 2 medication errors in 36 opportunities and an overall error rate of 5.56%. The deficiency involved Resident #85 and Resident #30, and the report states the facility’s policy required medications to be administered as prescribed and to maintain a medication error rate of less than 5%. For Resident #85, an LPN gathered the resident’s medication cards and bottles, checked them against the EMR, withdrew one multivitamin tablet, and administered it. The physician order, however, was for a multivitamin with minerals, and the DON confirmed that a plain multivitamin is different from the ordered multivitamin with minerals. Resident #85 was admitted with diagnoses including weakened immune system, diabetes mellitus, obesity, and lipoprotein deficiency, and had a BIMS score of 15 indicating cognitive intactness. For Resident #30, an RN administered insulin aspart using a flex pen and was observed priming the pen while holding it horizontally toward the medication cart, with no insulin observed exiting the pen. The RN then administered the dose after dialing the sliding scale and routine mealtime insulin. The RN stated the purpose of priming was to relieve air bubbles and acknowledged that the pen should be primed with two units and that a drop of insulin should be seen. Resident #30 had type 2 diabetes, a BIMS score of 08 indicating severe cognitive impairment, and an HbA1c of 9.1. The APN and DON both stated that medications were expected to be administered according to physician orders and that incorrect administration would be considered a medication error.
Insulin Pen Not Primed According to Manufacturer Instructions
Penalty
Summary
The facility failed to ensure that an insulin pen was prepared and administered according to the manufacturer's instructions for one resident who was observed receiving insulin. During the 8:06 AM medication pass, RN #4 placed a needle on an Aspart FlexPen, dialed up 2 units, and while holding the pen horizontally depressed the plunger toward the medication cart, with no insulin observed exiting the pen. RN #4 then dialed up the resident’s sliding scale dose of 4 units plus the routine pre-meal dose of 10 units, for a total of 14 units, and administered the dose to the resident’s abdomen. After administration, RN #4 stated that priming was done to relieve air bubbles and confirmed that 2 units should be dialed up and ejected, but did not indicate that the pen should be held vertically or that a drop of insulin should be seen during priming. The resident had diagnoses including type 2 diabetes mellitus and a quarterly MDS showed a BIMS score of 08, indicating severe cognitive impairment. The resident’s orders included insulin aspart FlexPen by sliding scale before meals and at bedtime, as well as 10 units subcutaneously with meals before breakfast, with instructions to hold if CBG was less than 90 or the resident was not eating. A laboratory report dated 9/10/2025 showed an HbA1c of 9.1, which the APN described as elevated. The APN stated that medication administration staff are expected to administer physician-ordered medications correctly and follow facility policy, and explained that insulin pen priming should be done with the pen pointed up and held for a count of 5 or 6 seconds. The DON and Administrator both confirmed that medications must be administered according to physician orders and facility policy, and that failure to do so would be considered a medication error. The facility policy required medications to be administered as prescribed and according to the rights of medication administration, and the manufacturer’s instructions stated that the pen should be held with the needle pointing up during priming until a drop of insulin is observed.
Failure to Follow EBP During Wound Care
Penalty
Summary
The facility failed to follow proper infection control precautions during wound care for one resident who had a stage 3 pressure ulcer and was on Enhanced Barrier Precautions (EBP) because of wounds. During a concurrent observation, an LPN entered the resident’s room with wound care supplies on a sterile tray and placed a biohazard bag at the end of the bed. The LPN applied gloves, removed the resident’s shoes, and began wound care without washing hands or putting on a gown before starting the procedure. While providing care, the LPN leaned over the resident’s bed and the LPN’s shirt touched the resident’s blanket. The LPN removed gloves, sanitized hands, and reapplied gloves multiple times during the treatment. The LPN touched the inside of the biohazard bag with gloved hands and then reached over to obtain clean 4x4s from a cup with wound care solution in it. The LPN stated that the bag should not have been touched and that gloves should have been changed and hands sanitized after touching it. The resident’s record showed a quarterly MDS with a BIMS score of 9, indicating moderate cognitive impairment. The care plan required EBP and included use of gloves and gown prior to high-contact care. The ordered treatment for the stage 3 pressure ulcer to the right heel included cleansing, iodine to the peri-wound, an ointment to slough, calcium alginate, an abdominal pad, and wrap dressing changes on Monday, Wednesday, Friday, and as needed. Interviews with the DON, ADON, LPNs, CNA, and Administrator confirmed that EBP required gowns and gloves for wound care and that gloves should be changed when moving from dirty to clean tasks.
Failure to Coordinate PASARR II Evaluation for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate with the State Designated Authority regarding the Pre-Admission Screening and Resident Review (PASARR) process for a resident admitted with significant mental health diagnoses, including catatonic schizophrenia, anxiety, and alcohol abuse. Upon review, it was found that the resident was admitted from a psychiatric facility and exhibited severe cognitive impairment and daily wandering behaviors. Although the State Designated Authority had provided a letter approving nursing home placement and requested to be contacted upon admission for a PASARR II evaluation, the facility did not notify the authority or request the required evaluation at the time of admission. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for obtaining the PASARR II evaluation. The MDS nurse, Social Director, Business Office Manager, and Admissions staff each believed another department was responsible for securing the evaluation, and no related policies or procedures were in place. The forms required for the process were completed but not submitted, and the State Designated Authority was only contacted after the surveyor's inquiry, confirming that the resident was indeed a PASARR II case.
Failure to Employ Qualified Social Worker After Bed Count Increase
Penalty
Summary
The facility failed to employ a qualified, certified social worker after its bed count exceeded 120, as required by regulations. Interviews with the Administrator confirmed that the facility had 130 beds and had surpassed the 120-bed threshold since July 2024, but did not have a certified social worker on staff. The current Social Services staff member, who had been employed for two and a half years, lacked formal education or certification in social work and believed she could work under the Administrator's degree in social work. Both the Administrator and the Social Services staff member acknowledged the requirement for a certified social worker given the facility's size, and the Administrator further indicated that there was no policy in place for staffing a social worker.
Failure to Timely Report and Respond to Allegations of Verbal Abuse
Penalty
Summary
Staff failed to report allegations of verbal abuse involving two residents to the Administrator within two hours, as required by facility policy. The incidents involved a CNA who was observed yelling at and using profanities toward residents, as well as physically handling a resident's wheelchair in a rough manner. Multiple staff members, including LPNs, witnessed or were made aware of these actions but did not immediately report the allegations to the Administrator. Instead, the incidents were either reported several hours later or not at all until prompted by further inquiry. The residents involved had significant cognitive impairments and histories of trauma, with one being a hospice patient and the other requiring assistance for daily care and residing on a secure unit. During the night shift, the CNA was observed yelling at one resident in the shower, causing the resident to cry, and was also reported to have spoken harshly and handled another resident's wheelchair roughly, resulting in distress. Staff interviews confirmed that the CNA's actions were loud enough to be heard through closed doors and that the residents were visibly upset by the interactions. Despite facility policy and repeated abuse prevention training, staff did not follow the required protocol for immediate reporting. LPNs and other staff either delayed reporting or failed to escalate the incidents to the Administrator as mandated. The failure to promptly report and respond to the allegations resulted in a lack of immediate protection for the residents involved, as the alleged perpetrator was not removed from contact with residents until after the incidents had occurred.
Failure in Safe Laundry Transport Leads to Resident Injury
Penalty
Summary
The facility failed to ensure safe laundry transport techniques, resulting in an accident involving a resident. The resident, who had a history of falls and was at risk for abnormal bleeding due to antiplatelet therapy, collided with a laundry cart while walking to the bathroom. The resident had moderate cognitive impairment and was diagnosed with conditions such as generalized anxiety disorder, psychosis, schizophrenia, and lack of coordination. During the incident, the resident ran into the cart and fell backward, sustaining a head injury that required emergency room evaluation. The incident occurred when a laundry technician was pushing a tall laundry cart from behind, making it difficult to see residents in the path. The laundry technician and the Housekeeping & Laundry Supervisor both acknowledged that the proper technique should involve standing in front of the cart to ensure visibility of any residents. The facility's policy on resident rights emphasizes the right to a safe environment, which was not upheld in this instance, leading to the resident's injury.
Failure to Provide Toilet Paper and Towels in Women's Unit
Penalty
Summary
The facility failed to maintain the dignity of residents by not providing toilet paper and paper towels in the bathrooms of the women's secured unit. This deficiency was observed during a survey when it was noted that neither of the two bathrooms on the unit had these essential hygiene products available. The absence of these items was confirmed by a Certified Nursing Assistant (CNA) who stated that the decision was made to prevent toilets from clogging due to excessive use of paper products by residents. This lack of provision directly affected Resident #10, who has severe cognitive impairment and requires assistance with toileting and hygiene, as well as other residents on the unit. Resident #10, who has a history of trauma and requires trauma-informed care, was observed entering a bathroom without toilet paper or paper towels available. The CNA assisting Resident #10 admitted to forgetting to perform perineal care, which is crucial to prevent infections and maintain cleanliness. The Director of Nursing (DON) and the Administrator were both unaware of the situation until it was brought to their attention, indicating a lapse in oversight and communication within the facility. The deficiency potentially affected all 24 residents residing on the women's secured unit, compromising their right to a dignified existence and proper hygiene care.
Deficiencies in Resident Safety, Smoking Policy, and Facility Cleanliness
Penalty
Summary
The facility failed to ensure safe wheelchair transport techniques for a resident with multiple diagnoses, including Parkinson's disease, dementia, and PTSD. During an observation, a CNA was seen pushing the resident in a wheelchair and then letting go of the handles, causing the wheelchair to move forward without control. This action risked the resident's safety, as the wheelchair nearly collided with a door frame. The resident's care plan highlighted the need for trauma-informed care and monitoring for safety due to their conditions and medication use, which increase the risk of falls and confusion. The CNA admitted to being preoccupied and in a rush, which led to the lapse in safety protocol. The facility also failed to properly manage smoking materials, as a resident was observed with a cigarette in their mouth inside the facility, contrary to the smoking policy. The policy mandates that all smoking materials be kept in a secure location and that residents should not have access to them. The resident, who has moderate cognitive impairment, was not identified as a current tobacco user in their care plan, and staff were unaware of how the resident obtained the cigarette. The DON and Administrator acknowledged the issue but were uncertain about the procedure for storing cigarettes between smoke breaks. Additionally, the facility did not maintain a clean and sanitary environment in the women's secure unit shower room, which was found to have standing water, mold, rust, and clutter. Housekeeping staff were assigned to clean the area daily, but the issues were not reported or addressed. The maintenance department was also found to be lacking in communication and follow-up on repairs, as evidenced by broken tiles in a resident's room that had not been fixed. Furthermore, the facility was short on fitted sheets, leading to residents using flat sheets and blankets on their beds, which compromised their comfort and hygiene.
Failure to Obtain Authorization for Managing Resident's Personal Funds
Penalty
Summary
The facility failed to honor a resident's right to manage their own financial affairs, as evidenced by the lack of written authorization to manage personal funds for a resident who was cognitively intact and their own Power of Attorney. The resident, admitted with diagnoses including injury at the C7 level of the cervical spine, functional quadriplegia, depression, and panic disorder, was unaware of whether the facility was managing their money, how to access their funds, or the costs of services received, such as haircuts. The resident believed they were entitled to a monthly allowance but had not received any money or account information. Interviews revealed that the Business Office Manager was unable to locate an authorization for managing the resident's funds and acknowledged that the resident was their own decision-maker. The resident's lack of awareness regarding their financial management and the facility's failure to provide necessary information and authorization contributed to the deficiency. The issue was identified during a survey, highlighting the facility's failure to ensure the resident was informed and had control over their personal funds.
Failure in Perineal Care and Medication Administration
Penalty
Summary
The facility failed to provide adequate perineal care during a soiled brief change for a resident with severe cognitive impairment and a history of trauma. The resident required extensive assistance with toileting, including perineal care every two hours and as needed. During an observation, a CNA changed the resident's brief without performing perineal care, citing a lack of available paper products in the bathroom as the reason. The CNA acknowledged the oversight, and the Director of Nursing was unaware of the decision to remove paper products from the bathroom, which was intended to prevent clogs. Additionally, the facility did not follow physician orders for medication administration for another resident with severe cognitive impairment and a feeding tube. The resident was prescribed an iron tablet that should not be crushed, but due to a lack of liquid iron, the LPN had been crushing the tablets for administration. The DON confirmed that the iron tablets were enteric-coated and should not be crushed, as this could lead to potential complications. These deficiencies highlight a failure in adhering to care plans and physician orders, as well as a lack of communication and oversight regarding the availability of necessary supplies and the proper administration of medications.
Failure to Verify Tube Placement Before Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for two residents who were reviewed for tube feeding. Specifically, the facility did not appropriately check tube placement prior to administering flushes and/or medications for these residents. Resident #7, who has a diagnosis of metachromatic leukodystrophy, gastrostomy status, and dysphagia, was admitted to the facility in 2015 and requires a feeding tube for nutrition and fluids. Resident #9, diagnosed with Huntington Disease, gastrostomy status, and dysphagia, was admitted in 2014 and is in a vegetative state, requiring all nutrition and fluids through a feeding tube. The facility's policy mandates checking enteral tube placement prior to each feeding and administration of medication, which was not adhered to in these cases. Observations revealed that an LPN administered water through a PEG tube to Resident #9 without checking placement beforehand and used an unclean stethoscope to check for air movement in the stomach. The LPN also failed to aspirate gastric residual for placement verification and improperly handled a clogged PEG tube. Interviews with facility staff, including an RN and the Director of Nursing, confirmed the importance of checking PEG tube placement prior to medication administration or feedings to ensure the tube is correctly positioned in the stomach. The facility's failure to follow its policy and procedures for checking tube placement led to the identified deficiencies.
Failure to Secure Hazardous Areas
Penalty
Summary
The facility failed to maintain an accident and hazard-free environment by not ensuring that doors to rooms containing chemicals and sharps were locked. On the morning of September 18, 2024, it was observed that the hopper room door on the 300 Hall was not completely closed, allowing access to chemicals and overflowing sharps containers. The room also had a foul odor and a brown substance covering the inside of the hopper. Similarly, the shower room door on the Administration Hall was not fully closed, exposing chemicals such as rinse-free body wash, deodorant, anti-perspirant, shaving cream, body oil, and skin protectant, some of which had warnings about ingestion risks. Interviews with staff confirmed that these doors should always be closed and locked to prevent resident access to hazardous materials. A CNA acknowledged the potential for injury if residents accessed chemicals or sharps, while an LPN confirmed that sharps containers should not be overflowing and should be securely stored until picked up by a medical waste company. The facility's policy on Accidents and Hazards, provided by the Administrator, indicated a commitment to maintaining a hazard-free environment, and in-services had been conducted earlier in the year to reinforce the importance of keeping doors with locks shut completely.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that residents had reasonable accommodation of needs by not keeping call lights within reach for residents. Specifically, Resident #6, who had a diagnosis of hemiplegia and used a wheelchair, was observed on multiple occasions with the call light out of reach. On 9/17/2024, the call light was behind the chair the resident was sitting in, and on 9/18/2024, it was under the wheel of the bedside table, both times inaccessible to the resident. Additionally, another resident, Resident #15, was observed with the call light on the floor, out of reach. Interviews with CNAs and an LPN confirmed that staff were aware that call lights should be within reach before leaving a resident's room to ensure residents can call for assistance if needed. Despite this understanding, the facility did not have a specific policy related to call lights, and an in-service issued earlier in the year was not effectively implemented.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of neuromuscular dysfunction of the bladder was kept clean and dry, as required for their care. The resident, who had moderate cognitive impairment and occasional urinary incontinence, was observed with a soaked brief, pad, and sheet. The care plan for the resident indicated that they required extensive assistance with toileting and incontinence care every two hours and as needed. However, it was noted that the resident had not been checked on throughout the night, leading to the observed condition. Certified Nurse Aide (CNA) #5 reported changing the resident at the beginning of their shift, which started at 11:00 PM, and again at approximately 12:00 AM. Despite this, the resident was found in a state of neglect by 5:37 AM, indicating a lapse in the required two-hour checks. CNA #4, who was responsible for checking the resident during the morning, admitted it was her first time checking on the resident during her shift and was unsure if CNA #5 had checked on the resident during the night. This lack of adherence to the care plan resulted in the resident's skin being red on the lower abdomen and inner thighs, indicating potential skin breakdown due to prolonged exposure to moisture.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage, handling, and sanitation practices in the kitchen, which had the potential to affect 104 residents. Observations included expired milk in the refrigerator, an opened and unsealed box of French toast in the freezer, and an ice scoop with brown/black corroded water. Additionally, staff did not consistently wash their hands before handling clean equipment or food items, as evidenced by multiple instances where dietary staff touched dirty objects and then handled clean equipment or food without washing their hands. Furthermore, cold food items were not maintained at or below 41 degrees Fahrenheit, with temperatures recorded as high as 60 degrees Fahrenheit for certain items. The ice machine also had wet black residue on the inside top panel, indicating inadequate cleaning practices. The facility's policy on hand washing was not followed, as staff failed to wash their hands at the start of their shift, before donning disposable gloves, and after engaging in activities that contaminated their hands. Specific instances included a dietary cook handling a can of peach halves and a clean blender blade without washing her hands, and another dietary aide touching his beard cover and then handling a clean blade without washing his hands. Additionally, the temperature of pureed cornbread with milk was recorded at 112 degrees Fahrenheit and was not reheated before being served to residents. These deficiencies indicate a lack of adherence to professional standards for food storage, preparation, and sanitation, potentially compromising the safety and well-being of the residents.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents who required total assistance. Resident #7, diagnosed with Cerebral Palsy and Calorie Malnutrition, was observed lying in bed uncovered and wearing only a brief on multiple occasions. The resident's door was open to the hallway, and the privacy curtain was not pulled closed. Despite several staff members, including CNAs and a nurse consultant, observing the resident in this state, no immediate action was taken to cover the resident or close the privacy curtain. The Director of Nurses (DON) mentioned that the resident was care planned to not use covers and was scared to have the curtain pulled, but this preference was not documented in the resident's care plan. Resident #88, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed receiving perineal care with the door left open, exposing the resident to the hallway. CNA #10 entered the room without closing the door, leaving the resident without privacy. CNA #8 acknowledged the lack of privacy and subsequently closed the door. The DON confirmed that the facility did not have a specific policy on perineal care, and RN #12 stated that staff should provide privacy by closing shades, pulling curtains, and closing doors when providing care that exposes a resident.
Improper Preparation of Pureed Food Items
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is essential to minimize the risk of choking or other complications for residents requiring pureed diets. During observations, it was noted that the pureed green beans and chili prepared by Dietary Cook #14 were thin and not properly formed. Additionally, during a breakfast meal observation, the pureed sausage was found to be gritty, and the pureed oatmeal was thin and not properly formed. These deficiencies were confirmed by the Dietary Supervisor and Dietary Cook #16, who acknowledged the improper consistency of the pureed food items served to the residents. The failed practice had the potential to affect six residents who required pureed diets. The observations and interviews revealed that the dietary staff did not consistently achieve the required smooth, lump-free consistency for pureed foods, which is critical for the safety and well-being of residents on such diets. The dietary staff's inability to properly prepare pureed foods was evident in multiple instances, including lunch and breakfast meals, where the food items did not meet the necessary standards for texture and consistency.
Failure to Ensure Proper Hand Hygiene During Perineal Care and Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during perineal care for a resident with severe cognitive impairment and dependency on staff for all activities of daily living. During an observation, two CNAs entered the resident's room to perform a brief change and provide perineal care without performing hand hygiene before gloving or when changing gloves. The CNAs also did not perform hand hygiene or change gloves when moving from dirty to clean tasks. The CNAs expressed concerns about the lack of sanitizer in the rooms and the facility's policy against carrying individual sanitizer bottles in their pockets, which would require them to leave the resident unattended to access sanitizer in the hallway. During meal and beverage service, multiple CNAs were observed providing meals and beverages without performing hand hygiene or using gloves. One CNA spilled tea and sugar on the beverage cart and used a spoon to stir the drinks, placing the spoon back on the cart in the spilled fluids. The CNA did not clean the cart or perform hand hygiene during the beverage pass. Other CNAs were observed opening milk cartons with ungloved hands, touching the area where residents place their mouths to drink. Interviews with the CNAs revealed that they were aware of the need for hand hygiene but did not consistently practice it during meal and beverage service. The Director of Nursing and a Registered Nurse acknowledged the issues with hand hygiene and stated that in-services were started to address the problem. However, the facility's policy of not allowing small bottles of sanitizer due to cross-contamination concerns and the lack of sanitizer in resident rooms contributed to the failure to perform proper hand hygiene. The DON stated that staff would be taking in a medication cup of hand sanitizer to use in the room and must wrap it in a glove to dispose of it, so residents do not have access to it.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of flies in the kitchen during meal preparation. On 05/22/24, flies were observed on a food preparation counter, a spoon, a bread bag, a utility food cart, and the steam table bar. The Dietary Supervisor acknowledged the issue, attributing it to changing weather conditions and mentioned that some utensils had been washed the previous day. However, the presence of flies persisted, indicating an ongoing problem. Further review of pest control service reports from 03/15/24, 04/04/24, and 05/17/24 revealed that while other pests such as rodents, roaches, ants, beetles, crickets, spiders, and wasps were targeted and treated, flies were not reported or addressed. This oversight in the pest control program had the potential to affect 110 residents, as the presence of flies in food preparation areas poses a significant hygiene and health risk.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect Resident #83 from physical abuse by another resident, Resident #19, who had known behavioral issues. Resident #83, who was moderately cognitively impaired and used a wheelchair, was struck on the back of the head by Resident #19 in the dining room. This incident caused Resident #83 to lift out of their wheelchair. Despite the severity of the incident, the Director of Nursing (DON) did not consider it abuse because there were no visible injuries, and thus, it was not reported as such. Resident #19 had a history of aggressive behaviors, including hitting, kicking, and pushing others, as documented in their care plan. The resident had severe cognitive impairment and exhibited physical behavioral symptoms directed toward others. On the day of the incident, Resident #19 was noted to have a change in condition related to behavioral symptoms and was placed on one-on-one observation after the altercation. The DON and Administrator were questioned about the incident and their decision not to report it as abuse. The DON argued that the lack of visible injuries and the cognitive impairment of Resident #19 meant the incident did not qualify as abuse. The DON also mentioned that similar minor physical interactions between residents occur frequently and are not reported. This stance was maintained despite documentation indicating that Resident #19's actions had a significant physical impact on Resident #83.
Failure to Supervise Cognitively Impaired Resident During Meals
Penalty
Summary
The facility failed to ensure adequate supervision for a cognitively impaired resident at risk for choking during in-room meal service. Resident #91, who has severe cognitive impairment and a history of dysphagia, was observed eating alone in their room on multiple occasions. Despite having a care plan that required supervision during meals, staff did not remain with the resident, leaving them unsupervised while eating. This lack of supervision was observed on two separate occasions, where the resident was seen eating alone and engaging in potentially unsafe behaviors such as standing up and using utensils improperly. The resident's medical history includes early onset Alzheimer's Disease, dementia, and a need for assistance with personal care. The resident's care plan and speech therapy evaluation indicated the need for close supervision during meals due to swallowing difficulties. However, observations revealed that staff did not adhere to these requirements, as the resident was left alone during meal times. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the resident should not be left unsupervised due to the risk of choking. The Speech Language Pathologist (SLP) had evaluated the resident and recommended supervision during meals to ensure safe swallowing. Despite these recommendations, the resident was left alone, and staff were unaware of the need for supervision. This failure to provide adequate supervision during meals for a resident with known swallowing difficulties constitutes a significant deficiency in the facility's care practices.
Failure to Ensure Proper Medication Storage for Resident
Penalty
Summary
The facility failed to ensure prescribed medications remained with the nurse for a resident who was not assessed to self-administer medications. The facility's policy, dated 12/26/2022, stated that medications should not be stored in a resident's room unless the resident has been approved for self-administration and provided with a lockbox. Resident #31, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was observed with an albuterol inhaler on their bedside table on two separate occasions. The resident had a Brief Interview of Mental Status (BIMS) score of 12, indicating cognitive intactness, but was not assessed or care planned to self-administer medications. During an interview, RN #19 confirmed the presence of the albuterol inhaler on Resident #31's bedside table and acknowledged the importance of assessing residents for self-administration to prevent medication misuse. The Director of Nursing (DON) later confirmed that no residents in the facility, including Resident #31, were assessed to self-administer medications. The DON emphasized the importance of keeping medications with the nurses for the safety of the residents.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 33 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Smith
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Health Services | 1.4 mi | ★★★★★ | 6 | 0 |
| Covington Court Health And Rehabilitation Center | 2 mi | ★★★★★ | 5 | 0 |
| Fianna Hills Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Brooken Hill Health And Rehab, Llc | 3.2 mi | ★★★★★ | 10 | 0 |
| Chapel Ridge Health And Rehab | 3.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.