Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Twin Rivers Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Food storage and dishwashing practices were not maintained as required. An opened pie crust in the pantry had no open or use-by date, and a box of sheet dough in the freezer was opened and left uncovered and unsealed. The low-temp dishwasher also repeatedly failed to reach the required 120 degrees F wash and rinse temperatures, with incomplete logs and staff unsure of the correct operating temperature.
Unqualified Dietary Manager: The facility failed to ensure a qualified dietary manager oversaw food and nutrition services for 67 residents. The DM stated she had been in the role since December 2025, had not started dietary certification classes, and had only worked as a cook previously. During observation, she used a bucket labeled laundry detergent with bleach on the dishwasher, could not confirm proper dish sanitizing, and was unaware of the dishwasher temperature requirements; she later confirmed she did not meet the job qualifications.
A resident with severe cognitive impairment and total dependence on staff for transfers sustained a spiral femur fracture after being improperly transferred with a mechanical lift by only one staff member, despite care plan requirements for two-person assistance. Staff interviews revealed that single-person operation of the lift occurred during short staffing, and there was confusion about proper lift procedures, including whether to lock the wheels, leading to inconsistent practices and ultimately resident harm.
The facility failed to maintain safe food temperatures, as observed when a staff member found pureed eggs at 125°F on a malfunctioning steam table. The Dietary Manager confirmed the required temperature should be 180°F, but the facility's in-service documentation stated hot foods should be 135°F or higher. No specific policy on safe food temperatures was provided.
A facility failed to ensure a psychotropic medication was used only for a diagnosed condition. A resident was prescribed an anti-depressant for depression, but their medical record lacked a depression diagnosis. Interviews with LPNs confirmed the need for a physician's order and diagnosis before medication administration. The facility also lacked a policy on unnecessary medications. The resident had moderate cognitive impairment.
A resident was found with an indwelling urinary catheter without a proper diagnosis, as confirmed by facility staff and documentation. The resident, who was cognitively intact, had no diagnosis requiring the catheter, yet it was placed without proper documentation or justification. Interviews with an LPN, RN, and the DON highlighted the necessity of a proper diagnosis to prevent risks. The facility lacked a catheter policy, contributing to the deficiency.
Food Storage and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to ensure foods stored in the pantry and walk-in freezer were properly handled and labeled. During the kitchen tour, an opened pie crust was observed in the pantry without an open date or use-by date, and the Dietary Manager verified it was not labeled with any date. The walk-in freezer also contained one box of sheet dough that was opened and not covered or sealed, and the Dietary Manager confirmed it was not covered or sealed. The Administrator later stated that opened food items should have an open date and a used-by date. The facility also failed to maintain the low-temperature dishwasher at the required temperatures. The dishwasher manual stated the wash and sanitizing rinse temperature should be at least 120 degrees F, and the facility policy required the dishwasher to be maintained and run according to the manufacturer's instructions. Review of temperature logs showed multiple instances in December 2025 and February 2026 when wash and rinse temperatures did not reach 120 degrees F, along with some missing documentation and no January 2026 log available. The Dietary Manager stated she was not sure what the dishwasher temperatures should be and thought they were over 100 degrees F. An outside vendor report documented the dishwasher wash temperature at 90 degrees F and noted that 120 degrees F was needed for best results.
Unqualified Dietary Manager
Penalty
Summary
The facility failed to ensure a qualified dietary professional served as dietary manager for 67 residents who received meals from the facility kitchen. The dietary manager job description required specific qualifications, including certification as a dietary manager or food service manager, similar national certification, an associate’s or higher degree in food service management or hospitality with relevant coursework, or experience with completed food safety and management training. During interview, the dietary manager stated she had been in the role since December 2025, had not started classes for dietary certifications, and had previously worked as a cook at the facility for the past year. During observation, the dietary manager attempted to attach a five-gallon bucket labeled Laundry Detergent with Bleach to the low temperature dishwasher and stated it was what the facility always used to sanitize dishes. The dishwasher was run three times with pH strips showing no color, indicating there were no chemicals in the water. The dietary manager stated she would rewash the same dishes using the same chemicals and was unsure what to do if the dishwasher was not properly disinfecting dishes, though she thought she could use the three-compartment sink. In follow-up interview, she stated she was not aware of the dishwasher temperatures, and later reviewed her signed job description and confirmed she did not meet the required qualifications. The Administrator stated he believed the dietary manager had completed her training, but was informed that she had not started the course and did not meet the dietary qualifications.
Improper Mechanical Lift Use Resulting in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and fully dependent on staff for all activities of daily living, sustained a right distal third spiral femur fracture due to improper use of a mechanical lift during transfer. The resident had multiple diagnoses, including brain damage, weakened bones, and contractures, and required two-person assistance with a mechanical lift for all transfers, as documented in the care plan and Kardex. Despite these requirements, staff interviews and record reviews revealed that the mechanical lift was sometimes operated by a single staff member, particularly during periods of short staffing, contrary to facility policy and the resident's care plan. Multiple staff members, including CNAs and LPNs, admitted or reported witnessing the mechanical lift being used by only one person, with the second staff member sometimes merely standing at the doorway or not present at all. The incident leading to the resident's injury was not directly witnessed, but interviews indicated that the resident was found with a swollen knee, and subsequent x-rays confirmed a displaced femur fracture. The family was informed of the injury after they noticed the swelling, and there was confusion and lack of clear communication from staff regarding the cause of the injury. The facility's policy required two staff for mechanical lift transfers, and staff were aware of this requirement, but it was not consistently followed. Further review revealed inconsistencies in staff training and understanding of manufacturer guidelines for the mechanical lift, particularly regarding whether the wheels should be locked during transfers. Staff in-services had provided conflicting information, and some staff continued to lock the wheels despite manufacturer instructions to leave them unlocked. The facility's accident prevention policy emphasized a culture of safety and adherence to protocols, but the failure to ensure proper supervision and adherence to transfer procedures resulted in harm to the resident.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe food temperatures prior to serving residents, as observed during a survey. On the morning of August 28, 2024, a staff member checked the temperature of pureed eggs on the steam table and found it to be 125 degrees Fahrenheit, which is below the required safe temperature. The staff member acknowledged that the steam table was malfunctioning, with two compartments not working. Later that day, both the staff member and the Dietary Manager confirmed that the food should be held at temperatures between 175 and 185 degrees Fahrenheit, with the Dietary Manager specifying 180 degrees as the standard. However, the facility's in-service documentation, dated May 7, 2024, indicated that hot foods should maintain a temperature of 135 degrees or higher. The facility did not provide a specific policy on safe food temperatures.
Failure to Ensure Medication Use for Diagnosed Condition
Penalty
Summary
The facility failed to ensure that a psychotropic medication was used only to treat a specific diagnosed condition for a resident. The resident was prescribed 15 mg of an anti-depressant to be taken at bedtime for depression. However, a review of the resident's electronic health record revealed no medical diagnosis for depression. Interviews with two LPNs confirmed that a physician's order and a diagnosis are required before administering medication. Additionally, the facility's administrator acknowledged the absence of a policy specific to unnecessary medications. The resident had a BIMS score indicating moderate cognitive impairment.
Inappropriate Use of Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications from an indwelling urinary catheter for a resident. The resident, who was cognitively intact with a BIMS score of 14, had no proper diagnosis for the use of an indwelling urinary catheter as indicated in their Diagnosis Record and Care Plan. Despite this, the resident was observed with an indwelling urinary catheter in place, which was attached to the side of the bed. The Medication Administration Record showed that the catheter was placed on a date prior to the order for its placement, indicating a lack of proper documentation and justification for its use. Interviews with facility staff, including an LPN, an RN, and the DON, confirmed that there should be a proper diagnosis before placing an indwelling urinary catheter to prevent unnecessary risks such as urinary tract infections or bladder damage. The facility did not have a catheter policy in place, as confirmed by the Administrator when asked by the surveyor. This lack of policy and proper diagnosis contributed 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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nightingale At Arkadelphia | 0.3 mi | ★★★★★ | 6 | 0 |
| Quapaw Care And Rehabilitation Center Llc | 22.4 mi | ★★★★★ | 0 | 0 |
| The Springs Of Red Oak | 22.8 mi | ★★★★★ | 2 | 0 |
| Lake Hamilton Health And Rehab | 23.1 mi | ★★★★★ | 0 | 0 |
| Encore Healthcare And Rehabi Of Malvern | 23.2 mi | ★★★★★ | 2 | 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.