Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Springs Of Red Oak during CMS and state inspections, most recent first.
Unclean and wet food service pans were found stored in the kitchen serving residents on regular, mechanical soft, and pureed diets. During observation, a Dietary Manager found one quarter sheet pan with brown soft particles that transferred to a napkin and several other quarter sheet pans plus one full sheet pan that were wet inside. The DM said the kitchen was too small to air dry the pans, while the IP/DON and Administrator stated pans, serve ware, and dishware should not be stored wet or with food residue; the facility policy required items to be cleaned, sanitized, air dried, and properly stored.
Improper Infection Control During Medication Administration: A MAC administered oral meds to a resident with DM, dementia, and HTN after one pill fell to the floor. The MAC picked up the pill with bare hands, returned it to the cup, and gave the meds without hand hygiene. RNs, the DON/IP, and the Administrator stated that a dropped medication should be discarded and hand hygiene performed before continuing, and facility policy required hand hygiene before handling meds.
A resident with moderately impaired cognition was observed being transported in a shower chair without being fully covered, compromising their dignity. The CNA involved acknowledged the issue, and the DON confirmed that residents should be fully covered to maintain dignity and warmth, as per facility policy.
A facility failed to protect a resident's personal and medical information, as an unattended and unlocked tablet displayed sensitive details such as the resident's name, date of birth, code status, and physician's order. The resident had moderately impaired cognition. Interviews with the Nursing Consultant and DON confirmed that tablets should be locked when unattended to ensure confidentiality.
A facility failed to coordinate with the state authority for a resident's PASARR assessment, impacting care planning. The resident had severe cognitive impairment and mental health diagnoses, but the necessary level II evaluation report was not available, potentially affecting care. The DON was unaware of the resident's PASARR level II status, contrary to facility policy.
A facility failed to include tobacco use in a resident's care plan, despite the resident being a current smoker with diagnoses of heart failure and stroke. The resident was observed smoking with supervision and a smoking apron, but the care plan lacked details on smoking habits and necessary precautions. Interviews with staff confirmed the care plan should have addressed smoking for safety and monitoring purposes.
A facility failed to complete a discharge summary for a resident with moderately impaired cognition, omitting a recap of the stay, a final status summary, and medication reconciliation. The resident was discharged home with home health services, but the necessary documentation was not completed, as confirmed by the DON.
A resident with severely impaired cognition had a pressure ulcer on the left heel that required daily treatment according to physician's orders. However, the treatment was only documented as completed on two specific dates, and the DON confirmed the lack of daily documentation, indicating the treatment was not done as required. The facility's policy did not address this deficiency.
The facility did not update the nurse staffing information daily as required, with outdated information from January 6th remaining posted on subsequent days. The Administrator admitted that the Human Resources department was responsible for the oversight, but the update was neglected due to absence and forgetfulness. The Director of Nursing eventually corrected the posting, but the facility's staffing policy lacked pertinent guidance.
A facility failed to document gradual dose reductions (GDR) for a resident's anti-anxiety medication. The resident, with memory problems, was on a PRN anti-anxiety medication regimen. The facility's policy required PRN orders for psychotropic medications to be limited to 14 days unless a physician documented the risks and benefits of continuation. The DON confirmed the absence of necessary documentation from the MD, leading to the deficiency.
Unclean and Wet Food Service Pans Stored in Kitchen
Penalty
Summary
The facility failed to ensure food preparation and serving pieces were washed, dried, and stored in sanitary conditions in one kitchen serving 35 residents with regular diets, 11 with mechanical soft diets, and 2 with pureed diets. During an observation and concurrent interview on 05/16/2026 at 11:25 AM, the Dietary Manager retrieved pans stored on a shelf under the serving table and found five quarter sheet pans and six full sheet pans. One quarter sheet pan contained brown, soft particles that transferred to a white napkin when wiped, and the Dietary Manager stated the particles were probably breadcrumbs. Three other quarter sheet pans and one full sheet pan were observed to be wet inside. During interviews, the Dietary Manager stated the pans were wet and not entirely clean because the kitchen was small and there was no place to let them air dry. The Infection Preventionist, who was also the acting DON, stated that pans, serve ware, and dishware should not be stored wet or with food residue and that doing so could result in mold and bacteria growth. The Administrator also stated that pans should not be stored wet and/or unclean. A review of the facility's Quick Resource Tool: QRT Warewashing, issued 09/01/2021, showed that all dishware, service ware, and utensils are to be cleaned and sanitized after each use and that all dishware is to be air dried and properly stored.
Improper Infection Control During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control during medication administration for one resident. Resident #40 was admitted with diagnoses including diabetes mellitus, dementia, and hypertension, and a BIMS score of 13 indicated the resident was cognitively intact. The resident had an order for a medication for hypertension with a start date of 03/03/2026. During observation, Medication Assistant, Certified #1 popped oral medications from a blister pack directly into a medicine cup, and one antihypertensive pill bounced out of the cup and landed on the floor under the medication cart near the wall. The MAC picked up the pill with bare hands and placed it back into the cup with the other medication, then picked up the cup and gave it to the resident without performing hand hygiene. The MAC stated she would not usually pick up medications off the floor and administer them, but this pill was the last one in the blister pack. Interviews with RN #2, RN #3, the DON/IP, and the Administrator confirmed that a dropped medication should be disposed of and hand hygiene performed before continuing medication administration. Facility policies also stated that hand hygiene is required before preparing or handling medication and that staff are to follow infection control procedures during medication administration.
Failure to Maintain Resident Dignity During Transport
Penalty
Summary
The facility failed to maintain the dignity of a resident with moderately impaired cognition, as indicated by a Brief Interview of Mental Status (BIMS) score of 10. The resident required assistance with Activities of Daily Living (ADLs) due to a self-care performance deficit. During an observation, a Certified Nursing Assistant (CNA) was seen transporting the resident past the nurse's station in a shower chair without ensuring the resident was fully covered. This incident occurred in a common area, which was acknowledged by the CNA as a potential dignity issue. The Director of Nursing (DON) confirmed that staff should ensure residents are fully covered before being transported to maintain their dignity and keep them warm. The facility's policy on dignity states that residents should always be treated with dignity and respect, which was not adhered to in this instance.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to ensure the confidentiality of personal and medical information for a resident with moderately impaired cognition, as indicated by a Brief Interview of Mental Status (BIMS) score of 10. During a survey, an unattended and unlocked tablet was observed displaying the resident's personal and medical information, including their name, date of birth, code status, and physician's order. This incident occurred despite the facility's policy on safeguarding personal privacy and confidentiality. Interviews with the Nursing Consultant and the Director of Nursing confirmed that unattended tablets should be locked to protect resident information.
Failure to Coordinate PASARR Assessment for Resident
Penalty
Summary
The facility failed to coordinate with the state authority to determine the appropriateness of placement for a resident and did not incorporate the Pre-Admission Screening and Resident Review (PASARR) assessment into the resident's care planning. The resident in question had a severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of 06 and was diagnosed with anxiety, bipolar disorder, and schizophrenia. Despite these conditions, the facility did not have the necessary level II evaluation report readily available, which is crucial for understanding the specialized services or recommendations required for the resident. The deficiency was identified when the surveyor requested the level II evaluation report, and the facility was initially unable to locate it. The Director of Nursing (DON) and the Administrator Consultant acknowledged the absence of the report, which was only provided after the surveyor's request. The DON admitted to being unaware of the resident's PASARR level II status, which could have potentially affected the resident's care. The facility's policy requires all new admissions to be screened for mental disorders, intellectual disabilities, or related disorders as part of the PASARR process, but this was not adhered to in this case.
Failure to Address Tobacco Use in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was a current tobacco user, which was necessary to address the monitoring and precautions related to tobacco use. The resident, who had diagnoses of heart failure, stroke, and tobacco use, was observed smoking in the designated smoking area with a smoking apron and under staff supervision. However, the resident's care plan, initiated on 11/13/2024, did not include any information about the resident's smoking habits or the need for supervision and a smoking apron. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the resident's care plan should have included details about the resident's smoking to ensure safety and monitor for potential side effects. The facility's policy on care planning, provided by the Assistant Director of Nursing, indicated that care plans should be comprehensive and person-centered based on resident assessments. Despite this policy, the care plan for the resident in question did not address the necessary precautions for tobacco use, leading to a deficiency in meeting the resident's needs.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to develop a comprehensive discharge summary for Resident #111, who had a moderately impaired cognition with a BIMS score of 12. The resident was admitted with a plan of care indicating a wish to be discharged home with home health and durable medical equipment as needed. However, upon discharge, the facility did not complete a discharge summary that included a recap of the resident's stay, a final summary of the resident's status, and a reconciliation of all pre and post-discharge medications. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the discharge summary was not completed for the resident.
Failure to Provide Daily Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care to a resident according to the physician's order. Resident #39, who had severely impaired cognition as indicated by a BIMS score of 04, had a pressure ulcer on the left heel. The treatment plan required daily cleaning with wound cleanser, application of collagen and hydrogel, and covering with a dry dressing until the wound resolved. However, the Treatment Administration Record (TAR) showed that the treatment was only completed on two specific dates, 1/01/2025 and 1/05/2025, and not daily as required. The Director of Nursing confirmed that there was no documentation to show that the treatment was done daily, and stated that if it was not documented, it was not done. The facility's policy on pressure injuries did not provide relevant information related to this deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the nurse staffing information on a daily basis, which is a requirement to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. On January 7th, the surveyor observed that the staffing information posted was for January 6th. This outdated information remained posted on January 8th during two separate observations. During interviews on January 9th, the Administrator acknowledged that the Human Resources department was responsible for updating the staffing information, but it was not done because the responsible person was absent and forgot. The Director of Nursing later updated and posted the information. The facility's policy on staffing did not contain relevant information to address this deficiency.
Failure to Document GDR for Psychotropic Medication
Penalty
Summary
The facility failed to ensure gradual dose reductions (GDR) for psychotropic medications were attempted for a resident using anti-anxiety medication. The resident, identified as having memory problems, was on an anti-anxiety medication regimen for anxiety disorder. The facility's policy required that PRN orders for psychotropic medications be limited to 14 days unless a physician documented the specific risks versus benefits of continuing the medication and provided a rationale for not attempting a dose reduction. The Director of Nursing (DON) confirmed that there was no documentation from the Medical Doctor (MD) to justify the continuation of the anti-anxiety medication beyond the 14-day limit. The facility's policy indicated that physicians should identify situations where medications should be tapered or discontinued, especially when given in excessive doses or periods without adequate monitoring. The lack of documentation and adherence to the policy led to the deficiency identified by the surveyors.
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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 Hot Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pines Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Hot Springs Rehab And Nursing Cent | 1.7 mi | ★★★★★ | 0 | 0 |
| Quapaw Care And Rehabilitation Center Llc | 3.5 mi | ★★★★★ | 0 | 0 |
| The Springs Of Park Ave | 5.7 mi | ★★★★★ | 0 | 0 |
| Belvedere Nursing And Rehabilitation Center, Llc | 7 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.