Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Springs Of Avalon during CMS and state inspections, most recent first.
The facility failed to provide smoking aprons for three residents on the secured unit who smoked, despite their care plans indicating the need for such safety measures. During a smoke break, these residents were observed without the required aprons. Interviews with staff revealed a lack of awareness and absence of a posted list or labeled aprons, contributing to the oversight. The DON confirmed the importance of smoking aprons for resident safety.
Expired medications were found in a medication cart, including Fish oil, Vitamin E, Bisacodyl laxative, Aspercreme, Preparation-H cream, and Spiriva Respimat inhalers. The facility's policy requires expired medications to be returned to the pharmacy or destroyed, but this was not followed. The DON and Administrator confirmed that expired medications could potentially cause harm to residents.
The facility did not adhere to the planned menu for resident meals, resulting in a deficiency. Residents on pureed diets received incorrect portions and items, such as hashbrowns without gravy and yellow cake instead of chocolate cake. Additionally, residents on regular diets were served fewer sausage patties than specified. These actions were contrary to the facility's policy requiring meals to be served as written.
The facility failed to provide pureed food items in a smooth, lump-free consistency for residents on pureed diets. During meal observations, pureed hashbrowns, sausage, and beets were served with visible pieces, and oatmeal was too thick. Staff interviews confirmed the inadequacy, and the dietary manager acknowledged the need for smoother consistency.
The facility failed to maintain proper food storage and hygiene standards. Observations included improperly sealed and expired food items, stained ceiling tiles, and cold food items not kept at safe temperatures. Dietary staff did not adhere to hand hygiene protocols, contributing to the deficiencies.
A resident with VRE was not properly identified with a contact isolation sign outside their room, leading to staff entering without appropriate PPE. The facility's policy required such signage to inform staff and visitors of necessary precautions, but observations and interviews revealed a lack of awareness and compliance among staff.
The facility failed to initiate a care plan for a resident identified as high risk for elopement. Despite the facility's policy requiring a care plan for residents at risk, the resident's care plan did not address the high risk for elopement. The DON confirmed that residents scoring high on the elopement risk assessment should be placed on the secure unit, but this was not reflected in the care plan.
A resident with cognitive decline and a history of elopement risk managed to leave the secure unit and the building, eventually being found approximately one mile away. The resident was unaccounted for approximately 30 to 45 minutes before being returned to the facility. Interviews with staff confirmed the sequence of events and the facility's failure to implement adequate measures to prevent the elopement.
Failure to Provide Smoking Aprons for Residents
Penalty
Summary
The facility failed to provide smoking aprons for three residents on the secured unit who smoked, despite the facility's policy requiring such safety measures. Resident #6, with moderate cognitive impairment, Resident #44, with severe cognitive impairment, and Resident #45, who was cognitively intact, were all identified as needing smoking aprons according to their care plans and smoking safety screens. However, during a smoke break observed by the surveyor, these residents were not wearing the required smoking aprons, which were intended to prevent burns and ensure safety while smoking. Interviews with staff members, including a CNA and an LPN, revealed a lack of awareness regarding the need for smoking aprons for these residents. The CNA and LPN both stated that there was no list posted or aprons labeled for use on the secure unit, which contributed to the oversight. The Director of Nursing confirmed that the facility's procedure was to label smoking aprons and maintain an updated list to inform staff of residents who required them, emphasizing the importance of these aprons for resident safety.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure that over-the-counter medications in medication cart #1 were not expired. During an inspection, it was observed that 16 medications were either expired or did not have an expiration date. These included Fish oil and Vitamin E without expiration dates, and Bisacodyl laxative, Aspercreme, Preparation-H cream, and Spiriva Respimat inhalers with past expiration dates. Interviews with the LPN and the Assistant Director of Nursing confirmed that expired medications were not appropriately discarded, which is against the facility's policy. The Director of Nursing and the Administrator acknowledged that expired medications should be removed from the medication carts and disposed of properly. The facility's policy requires that expired, discontinued, or deteriorated drugs be returned to the pharmacy or destroyed. However, the process was not followed, leading to the presence of expired medications on the cart. The DON and Administrator confirmed that expired medications could potentially cause harm to residents, as they may be less potent or cause side effects.
Failure to Follow Planned Menu for Resident Meals
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu, which resulted in a deficiency. On February 25th, during the supper meal, residents on pureed diets were supposed to receive 1/2 cup of hashbrowns and 2 ounces of country gravy, while those on regular diets were to receive 2 sausage patties. However, the dietary staff served 2 sausage patties to residents on large portion diets and only 1 sausage patty to those on regular diets. Additionally, residents on pureed diets received a smaller portion of hashbrowns than specified and were not served any gravy, as the dietary staff member forgot to include it. On February 26th, the noon meal menu indicated that residents on pureed diets were to receive pureed chocolate cake. Instead, yellow cake was pureed and served because there was not enough chocolate cake available. The facility's policy requires that food trays be inspected to ensure the correct meal is provided to each resident, and that menus should be served as written unless a substitution is made in response to preference. These actions and inactions by the dietary staff led to the deficiency in meeting the nutritional needs of the residents as per the planned menu.
Inadequate Preparation of Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets. During a supper meal observation, residents on pureed diets were served hashbrowns, sausage, and beets that were lumpy, thick, and contained visible pieces of food, contrary to the required smooth, pudding-like consistency. Interviews with staff, including LPNs, CNAs, and dietary personnel, confirmed that the pureed foods were not adequately prepared, with several staff members noting the presence of solid pieces and the need for a smoother consistency. Additionally, during a breakfast meal observation, the oatmeal served to residents was found to be too thick and dry, as confirmed by dietary staff and CNAs. The facility's menu guidelines indicated that pureed diets should be of pudding consistency, which was not adhered to during these meal services. The dietary manager acknowledged the issue, stating that more water should have been used to achieve the correct consistency.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and hygiene standards, as observed during a survey. In the dry storage area, an opened bag of fish breading was not sealed properly, leading to spillage onto other food items, and a partially sealed bag of penne noodles was exposed to air. Additionally, expired vinegar was found on the shelf, and the ceiling tiles in the storage area were stained and bowing. In the refrigerator, uncooked bacon was stored improperly, and cheese blocks lacked date labeling. Cold food items on the steam table were not maintained at safe temperatures, with pureed and regular beets being significantly above the recommended 41 degrees Fahrenheit. Dietary staff also failed to adhere to hand hygiene protocols. A dietary staff member dropped a temperature gauge on the floor, rinsed it without proper sanitization, and then used it to check food temperatures. Another dietary aide handled condiments and beverages without washing hands in between tasks, and yogurt was served at an unsafe temperature. The facility's hand hygiene policy, which requires handwashing before and after duty, was not followed, contributing to the deficiencies observed.
Failure to Display Contact Isolation Sign for Resident with VRE
Penalty
Summary
The facility failed to ensure that a resident on Transmission-Based Precaution had a contact isolation sign in a conspicuous location outside the resident's room. This deficiency was identified for a resident who was admitted with diagnoses including pressure ulcers and resistance to vancomycin (VRE). The facility's policy required that when a resident is placed on transmission-based precautions, appropriate notification should be placed on the room entrance door to inform staff and visitors of the need for and type of precaution. However, observations revealed that the sign on the resident's door only read 'see nurse before entering,' which did not specify the need for contact isolation precautions. During the survey, it was observed that a CNA entered the resident's room without wearing a gown, indicating a lack of awareness of the contact isolation requirement. Interviews with nursing staff, including an RN and an LPN, revealed uncertainty and lack of awareness regarding the resident's isolation status and the necessary precautions. The Director of Nursing confirmed that the resident should have had a sign indicating contact isolation to ensure that staff and visitors wore gowns and gloves before entering the room, as required by the facility's policy.
Failure to Initiate Care Plan for High Risk Elopement
Penalty
Summary
The facility failed to initiate a care plan for a resident identified as high risk for elopement. The facility's policy on Wandering and Elopements requires that residents at risk for elopement have a care plan that includes strategies and interventions to maintain their safety. Resident #3, admitted with a diagnosis of unspecified dementia and other mental health issues, was identified as high risk for elopement during the admission assessment. Despite this, the resident's care plan, initiated on the admission date, did not address the high risk for elopement. The Director of Nursing confirmed that residents scoring greater than 1 on the elopement risk assessment should be placed on the secure unit, but this was not reflected in Resident #3's care plan.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident with a history of cognitive decline and drug-seeking behavior. The resident, who had a BIMS score indicating moderate cognitive impairment, was identified as an elopement risk and had previously exhibited behaviors such as attempting to leave the unit and trying to escape through windows. Despite these known risks, the resident managed to leave the secure unit and the building, eventually being found approximately one mile away from the facility by an off-duty CNA. The resident was unaccounted for approximately 30 to 45 minutes before being returned to the facility. Interviews with staff, including the CNA, DON, and Administrator, confirmed the sequence of events and the resident's ability to exit the secure unit. The facility's policy on wandering and elopements was reviewed, which outlined procedures for identifying at-risk residents and actions to take if a resident goes missing. However, the facility failed to implement adequate measures to prevent the resident's elopement, leading to the deficiency noted in the report.
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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 West Memphis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Broadway | 0.6 mi | ★★★★★ | 1 | 0 |
| Willowbend Health And Rehabilitation, Llc | 4.4 mi | ★★★★★ | 0 | 0 |
| Regional One Health Subacute Care | 8.2 mi | — | 0 | 0 |
| Parkway Health And Rehabilitation Center | 9.5 mi | ★★★★★ | 1 | 0 |
| Harborview Post Acute | 9.6 mi | ★★★★★ | 7 | 0 |
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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 August 2026) and official state health department websites.