Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Fayetteville Center For Nursing & Healing Llc during CMS and state inspections, most recent first.
A resident with significant neurologic and orthopedic diagnoses fell, but the facility failed to verify timely notification of the RP/family and physician as required by policy. Although an SBAR documented that notifications were made, the RP said no call was received, an LPN said she did not call the family before leaving, and another LPN reported the fall was not mentioned in report and was initially denied before being admitted. The DON could not verify that the physician or after-hours medical service was notified.
A resident's family reported missing eyeglasses and clothing to staff and later sent a formal email complaint, but the grievance was not promptly logged in the facility's tracking system. The resident was cognitively intact and had been admitted with eyeglasses documented in the admission inventory. The SSD stated the missing glasses were never entered as a grievance, and the ADON gave conflicting statements about receiving and handling the family's complaint.
Failure to Use Mechanical Lift During Resident Transfers: Staff did not follow care plans requiring a mechanical lift with two-person assistance for residents who needed help with transfers. An LPN and CNA improperly moved a resident from the floor to the bed by the legs and neck, dropping the resident so the head hit the floor, and later another CNA transferred a different resident from bed to wheelchair without the lift, causing a toe laceration. Both residents had significant mobility limitations and required lift transfers per their plans of care.
A resident with significant neurologic and orthopedic diagnoses was sent to the ER for evaluation and later cleared to return, but facility staff refused readmission based on a dashboard/payment decision made by the Clinical Marketing Director and relayed by the DON. Staff also would not let the family enter to retrieve the resident’s belongings. The record showed bed-hold policies, but there was no documentation that the family was told the resident would not be allowed back if sent out to the hospital.
A facility failed to follow care plan interventions for two residents who required mechanical lift transfers with 2 staff. One resident also did not have fall mats in place, and an LPN stated the resident was transferred without the lift and the care plan was not updated. Another resident was transferred by a CNA without the required lift, resulting in a laceration to the R leg and great toe; the CNA stated she knew the resident required a 2-person mechanical lift transfer.
A facility failed to follow care plans requiring a mechanical lift with 2 staff for transfers. One resident with significant mobility impairment was manually moved from the floor to the bed by an LPN and CNA, and the CNA let go during the transfer, causing the resident's head to hit the floor. Another resident with dementia and quadriplegia was transferred from bed to wheelchair without the mechanical lift, resulting in a right great toe laceration.
Missing Orders for Oxygen and CPAP: A resident with asthma, COPD, and OSA received oxygen and used CPAP at night, but the EMR had no physician order for oxygen, including frequency and flow rate, or for CPAP. Staff and family confirmed the resident routinely used both therapies, and the DON stated the orders were not part of the order summary and were not entered into the EMR.
Three residents were not assessed for self-administration of medications, and staff left medications unattended at the bedside, contrary to facility policy. Medications including powders, pills, and liquids were found in resident rooms, and staff interviews confirmed that medications were sometimes left due to workload or oversight, without verifying administration.
A resident with severe cognitive impairment and diagnoses of bipolar disorder and PTSD was admitted, but the care plan failed to include these mental health conditions as required. Both the DON and MDS Coordinator confirmed the omission and acknowledged that the care plan should have addressed all relevant diagnoses.
Two residents did not receive their prescribed medications as ordered, including IV and oral antibiotics, insulin, and anti-hypertensive drugs. In one case, a resident with recent sepsis and diabetes was admitted but did not receive multiple critical medications, despite their availability in the facility, and staff failed to document reasons for omissions. In another case, an LPN withheld two blood pressure medications without provider guidance or documented parameters, and could not explain the decision. Staff interviews confirmed that medications were available and that provider consultation was expected when in doubt.
Surveyors found expired folic acid and Benadryl capsules stored outside their original packaging on two medication carts. LPNs acknowledged responsibility for checking expiration dates and proper storage, but facility policy requiring medications to remain in original containers and be discarded if expired was not consistently followed.
Staff did not consistently perform hand hygiene or sanitize shared medical equipment during medication passes, as observed with two residents. In both cases, an LPN failed to use hand sanitizer before and after administering medications, and in one instance, a shared blood pressure cuff was not cleaned between uses. Facility policies required these infection control practices, and the DON confirmed these expectations.
Failure to Notify Physician and Family of Resident Fall
Penalty
Summary
The facility failed to notify the physician and the Responsible Party/family of a resident’s fall, despite its policy requiring prompt notification of the resident, the resident’s physician, and the resident’s representative when an accident occurs. The policy titled Notification of Changes, reviewed/revised January 2024, listed accidents as a circumstance requiring notification. The deficiency involved R7, who was admitted with diagnoses including bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage. The admission MDS dated 6/24/2025 showed BIMS was not assessed. Records showed an SBAR Communication Form dated 7/15/2025 and created on 7/16/2025 documented that R7 had a fall, with the family noted as notified at 6:50 a.m. and the primary care physician at 11:00 a.m. However, the resident’s family member, who was the RP, stated they did not receive a call from the facility about the fall. LPN III stated she did not call the family before leaving work regarding the fall and said she notified the medical service that takes calls after hours or on weekends. LPN JJJ stated LPN III did not mention the fall during report, and when the family asked about a fall, LPN III initially denied it before later admitting it occurred. LPN JJJ then assessed the resident, notified the NP, and received an order for x-rays. The DON stated she could not verify that the physician or medical service was notified of the fall on the morning it occurred.
Failure to Promptly Log and Address Grievance About Missing Personal Items
Penalty
Summary
The facility failed to make a prompt effort to file a grievance for one of nineteen sampled residents, R8, after the resident's family/responsible party reported both a written and verbal grievance about missing personal items. The facility policy titled Resident and Family Grievances stated that grievances may be voiced verbally or in writing and that the staff member receiving the grievance will record the nature and specifics on the designated grievance form or assist the resident or family member to complete the form. The policy titled Resident Personal Belongings stated that resident personal items are to be inventoried at admission and documented in the medical record. R8 was admitted with diagnoses including cerebrovascular disease, COPD, and obstructive sleep apnea, and his MDS showed a BIMS of 13, indicating he was cognitively intact. The admission packet documented that he was admitted with a pair of eyeglasses. A family email identified the missing glasses and lack of accountability, and the family member later stated that the missing shorts and eyeglasses were reported to the ADON and a CNA, with the shorts returned but the glasses not located. The Social Service Director stated no one reported or logged the missing eyeglasses in the grievance tracking system, and the ADON initially stated she had no communication with the family about the lost items before later confirming receipt of the email.
Failure to Use Mechanical Lift During Resident Transfers
Penalty
Summary
The facility failed to protect residents from neglect by not using the designated mechanical lift for transfers for two residents who required lift assistance. For R7, the care plan initiated on 6/20/2025 directed staff to use a mechanical lift with two staff assistants for transfers. R7’s admission record showed diagnoses including bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage, and the MDS indicated he was dependent on staff for transfers. A family member reported that after R7 fell from the bed, staff attempted to move him from the floor to the bed by his legs and neck, dropped him so his head hit the floor, and then transferred him again. Video reviewed by surveyors showed a person in a blue shirt and a person in a white lab jacket lifting R7 by the legs and neck from the floor, dropping him so his head hit the floor first, and then lifting him again to the bed while he moaned and cried. Documentation and interviews showed the event was not handled according to the resident’s plan of care. The nurse’s note documented that R7 was found almost on the floor, was assisted to the floor, assessed, and transferred back to bed with one assist, but it did not document family notification. The DON stated the family was notified, while the LPN later stated she did not notify the family during the interview and said the family was called later that day. The LPN and CNA involved were identified through video review and later interviews; the LPN stated she could not find a sling and therefore used a two-person transfer, and the CNA stated she placed her hands under the resident’s shoulders/arm pits to transfer him. The facility record showed both employees continued working after the incident for additional shifts before their employment ended for gross misconduct. A second resident, R16, also had a care plan requiring a mechanical lift with two staff for transfers. R16’s admission record listed dementia, quadriplegia, and type 2 diabetes mellitus with diabetic neuropathy, and the MDS showed a BIMS score of 8 with moderate impairment. Surveyors observed swelling in the right knee and a laceration on the right great toe with red drainage, and the resident complained of right knee pain. The facility reportable incident stated that an employee transferred R16 from bed to wheelchair without using the mechanical lift, causing a small laceration to the right great toe. The CNA later stated she knew R16 required a two-person mechanical lift transfer, but transferred the resident alone because the resident was crying, complained of hurting, and refused to get up. The CNA stated she did not report the resident’s pain or the transfer to the charge nurse or UM.
Improper refusal to readmit resident after hospital transfer
Penalty
Summary
The facility failed to permit one resident to return after being sent to the hospital emergency room and also denied the resident’s family entry into the building to obtain the resident’s personal belongings. The resident had diagnoses including bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage. The resident’s admission MDS showed that BIMS was not assessed, and the care plan participation record documented participation by interdisciplinary staff and one family member by telephone, but it was unclear whether the resident attended the care plan meeting. The record review showed the facility had policies stating that written bed-hold information should be provided to the resident and/or representative within 24 hours of hospitalization, and that the resident and representative should receive a copy of the bed-hold policy within 24 hours. The admission packet included an undated bed-hold policy and the resident’s identification and insurance information. The facility’s midnight census reports showed multiple empty beds, including open beds for male admission on both nights reviewed. There was no documentation that the family was informed the resident would not be allowed to return if sent to the hospital. The resident was sent to the emergency room for suprapubic pain and later treated for a urinary tract infection without hematuria. Hospital documentation showed the resident was cleared for discharge back to the facility, but EMS reported that facility staff stated the resident was banned and not allowed back. A DON texted an LPN not to take the resident back and not to allow the transport to bring him in. Facility interviews showed the DON relied on a digital dashboard to determine whether a resident could be admitted, and the Clinical Marketing Director stated she made the decision not to allow the resident to return because payment had not been secured. The Ombudsman stated the facility did not allow the resident or family to comply with or appeal the discharge. The family later stated they were shocked when the resident was not allowed to return and were also told they could not enter to retrieve his belongings.
Failure to Follow Transfer Care Plans and Update Care After Incident
Penalty
Summary
The facility failed to implement care plan interventions for mechanical lift transfers with two staff assistants for two residents, and also failed to implement fall mats and update one resident’s care plan after an incident and accident. The facility policy titled Comprehensive Care Plans required a comprehensive, person-centered care plan with measurable objectives and timeframes, and stated that qualified staff responsible for carrying out interventions would be notified of their roles and responsibilities. The Charge Nurse Job Description stated that the charge nurse initiates, reviews, and updates care plans as required. For one resident, the admission MDS showed dependence on staff for transfers, and the care plan initiated on 6/20/2025 included a mechanical lift with two staff for assisted transfers and fall mats due to fall risk. An LPN stated that on 7/15/2025 the resident did not have fall mats in place and was transferred from the floor to the bed with assistance from a CNA without using a mechanical lift; the LPN also stated the care plan was not updated and that updating care plans was not part of her job description. For the second resident, the admission MDS showed moderately impaired BIMS and partial/moderate assistance with transfers, and the care plan initiated on 7/25/2025 included a mechanical lift with two staff for transfers. A facility reportable incident dated 9/8/2025 stated that a CNA transferred the resident from bed to wheelchair, causing a laceration to the right leg and a small laceration to the great right toe; the CNA stated she knew the resident required a transfer with two people using the mechanical lift but transferred the resident anyway.
Unsafe resident transfers without required mechanical lift
Penalty
Summary
The facility failed to provide appropriate interventions during mechanical lift transfers for two residents whose care plans required a mechanical lift with two staff assistance. The facility policy titled Safe Resident Handling/Transfer stated that resident lifting and transferring must be performed according to the resident's individual plan of care and that mechanical lifts are a safer alternative and should be used. For one resident, the admission record showed diagnoses including bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage, and the MDS indicated dependence on staff for transfers. The care plan identified an ADL self-care performance deficit and directed use of a mechanical lift with two staff assistants for transfers. Video reviewed by the DON showed the resident on the floor in his room on his right side, moaning, with the bed initially in a high position. An LPN lowered the bed, left the room, then returned with a CNA. During the transfer from the floor to the bed, the CNA used manual handling rather than a mechanical lift and let go of the resident, causing his head to hit the floor first followed by his legs. The NP later stated she had assessed the resident and issued orders based on information from nursing staff, and said the orders would have been different had she known the resident had been dropped and hit his head. The LPN later stated the resident had been assisted to the floor and that the mechanical lift sling was not located. For the second resident, the admission record showed diagnoses including dementia, quadriplegia, and type 2 diabetes mellitus with diabetic neuropathy. The MDS showed moderately impaired cognition and partial/moderate assistance with transfers, and the care plan also required a mechanical lift with two staff assistance for transfers. A facility reportable incident stated that a CNA transferred the resident from bed to wheelchair without using the mechanical lift, causing a small laceration to the resident's great right toe. The resident's family stated the resident reported knee pain and that they were told the CNA had transferred the resident without the mechanical lift and that the right leg/foot was injured.
Missing Orders for Oxygen and CPAP
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for R8. R8 was admitted with diagnoses including asthma, COPD, and obstructive sleep apnea, and the admission MDS indicated he was cognitively intact. The care plan noted CPAP related to COPD and included interventions to implement CPAP as ordered by the physician. The admission summary stated that the resident's daughter brought in the CPAP machine from home, that the CPAP was set up at the bedside, and that oxygen was in place and functioning properly per the ordered liter. The physician admission H&P documented COPD with a baseline 2 liters nasal cannula requirement, OSA on CPAP, maintain oxygen saturation 88-92 percent, supplement oxygen as needed, and CPAP at night. Review of the physician order summary report showed no order for oxygen or for CPAP at night. The EMR oxygen concentration log showed the resident received oxygen on multiple days, and staff interviews confirmed that R8 used oxygen and slept with CPAP at night. The family member stated R8 was dependent on oxygen and used CPAP every night before admission. The DON stated the nurse was responsible for reviewing hospital discharge orders and entering them into the EMR, but she was not aware that R8's CPAP and oxygen were not part of the order summary. She later stated there was no order for oxygen or CPAP and that nurses would be educated to ensure hospital orders were accurately transcribed.
Failure to Assess and Monitor Self-Administration of Medications
Penalty
Summary
The facility failed to assess three residents for their ability to self-administer medications, as required by policy, and allowed medications to be left unattended at the bedside. Facility policy states that staff must remain with residents until medication administration is complete and that medications should not be left at the bedside. However, observations revealed that medications, including Nystatin powder, pills, and a red liquid medication, were found on the bedside tables or dressers of three residents. In each case, staff either left the medication for later use or failed to verify that the resident had taken the medication before leaving the room. One resident with a history of cerebral infarction, diabetes, heart failure, and paraplegia was found with Nystatin powder at the bedside, which the resident stated was left by the nurse for CNAs to apply. Another resident with end-stage renal disease and moderate cognitive impairment was observed with two pills in a clear container at the bedside, and the resident was unsure of the purpose of one of the pills. A third resident with end-stage renal disease, diabetes, and other conditions had a medication cup with red liquid and an antidiarrheal medication at the bedside, with the resident stating he had refused the medication and that the nurse had left it for him. Interviews with staff confirmed that medications were sometimes left at the bedside due to being busy or called away, and that staff did not always verify medication administration. The facility's DON and Administrator acknowledged that medications should not be left at the bedside and that self-administration assessments were required but not documented for these residents. The practice of leaving medications unattended was confirmed by multiple staff and observed during the survey.
Failure to Include Mental Health Diagnoses in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident, as required by its own policy and federal regulations. The policy states that a comprehensive care plan must be developed within seven days after the completion of the comprehensive MDS assessment, and that all Care Assessment Areas (CAAs) triggered by the MDS should be considered. Record review showed that the resident was admitted with diagnoses including bipolar disorder, PTSD, and hyperlipidemia. The resident's MDS assessment indicated severe cognitive impairment but did not document any behaviors. However, the care plan created for the resident did not include the mental health diagnoses of bipolar disorder or PTSD. Interviews with the DON and the MDS Coordinator confirmed that the care plan was incomplete and should have included the resident's mental health diagnoses. Both staff members acknowledged that it is a collaborative responsibility to ensure all relevant diagnoses are reflected in the care plan. The omission of these diagnoses from the care plan was verified through record review and staff interviews.
Failure to Administer Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received their prescribed medications as ordered by their physicians. One resident, who had recently been hospitalized for serious conditions including sepsis, hematuria, and bacteremia, was admitted to the facility with orders for multiple intravenous and oral antibiotics, as well as diabetic medications and insulin. Despite these orders, the resident did not receive several critical medications, including IV antibiotics, oral antibiotics, insulin injections, and oral diabetic medications, during their stay. The medication administration record (MAR) showed missing documentation for these medications, and there was no explanation for the omissions in the progress notes. The resident's blood sugar was only checked once, and the facility's automated medication system had the required antibiotics available, yet they were not administered or documented as given. Interviews with facility staff, including the DON and ADON, confirmed that the medications in question were available in the facility's emergency medication system. The DON was unable to explain why the medications were not administered or documented, and stated that staff were required to document reasons for any missed doses. The nurse practitioner confirmed that she was not notified about the unavailability or potential allergy concerns regarding the antibiotics, which was not standard practice. The resident was eventually transferred back to the hospital due to a change in condition, including fever and lethargy, and did not return to the facility. A second resident with a history of heart failure, hypertension, and atrial fibrillation did not receive all prescribed anti-hypertensive medications during a medication pass. The LPN administered one blood pressure medication but withheld two others without provider-specified parameters for holding the medications. The LPN was unable to explain the rationale for withholding the medications and did not consult the provider as expected. The nurse practitioner confirmed that, in the absence of specific hold parameters, the medications should have been administered, and the DON reiterated that staff were expected to follow provider orders or seek guidance if uncertain.
Expired and Improperly Stored Medications Found on Medication Carts
Penalty
Summary
Surveyors identified that the facility failed to ensure medications were not available for use past their expiration date and were not stored in their original containers on two of seven medication carts. On one medication cart, a bottle of folic acid with an expiration date of 1/2025 was found, and the LPN present acknowledged that both day and night shift nurses were responsible for checking expiration dates. On another cart, a medication cup containing pink capsules was found, and the LPN identified the medication as Benadryl by its appearance, admitting that storing medications outside their original packaging was not acceptable practice. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that facility policy required medications to be stored in their original containers, labeled with the date of opening, and discarded if expired. Both leaders stated that medications should not be kept in open cups or identified by appearance. The observations and staff interviews demonstrated that the facility's medication storage policy was not consistently followed, resulting in expired and improperly stored medications being accessible for use.
Failure to Perform Hand Hygiene and Sanitize Shared Equipment During Medication Pass
Penalty
Summary
Staff failed to consistently perform hand hygiene and sanitize shared medical equipment during medication passes, as observed during two of four medication administration events. In one instance, an LPN prepared and administered medication to a resident without performing hand hygiene before or after the process, despite facility policy requiring the use of alcohol-based hand rub or soap and water before and after direct resident contact and medication handling. The LPN acknowledged the omission when questioned and subsequently obtained hand sanitizer from the nurses' unit. In another instance, a different LPN also did not perform hand hygiene before or after administering medications to a resident and used a shared blood pressure cuff without sanitizing it before or after use. The LPN admitted to not sanitizing her hands and was unsure about the cleaning protocol for the blood pressure cuff. Review of facility policies confirmed the expectation for staff to perform hand hygiene before and after resident contact and medication administration, as well as to clean and disinfect multi-resident use equipment after each use. The Director of Nursing confirmed these expectations in an interview, stating that staff are required to follow these protocols. The observed failures to adhere to these policies during medication passes constituted deficiencies in the facility's infection prevention and control program.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Fayetteville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southland Health And Rehabilitation | 7.2 mi | ★★★★★ | 0 | 0 |
| Christian City Rehabilitation Center | 7.5 mi | ★★★★★ | 2 | 0 |
| Riverdale Center For Nursing And Healing | 9.7 mi | ★★★★★ | 8 | 0 |
| Fairburn Heights Of Journey Llc | 10.1 mi | ★★★★★ | 9 | 0 |
| Arrowhead Post Acute Llc | 10.5 mi | ★★★★★ | 0 | 0 |
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