Below 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 Jonesboro Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
Failure to provide SNF ABN with Medicare non-coverage notices. The facility did not issue the required CMS-approved SNF ABN with NOMNCs for three residents whose skilled nursing therapy/services were ending. Records showed each resident had significant diagnoses such as stroke-related hemiplegia, CKD, dementia, diabetes, dysphagia, and malnutrition, and staff including the MDSC, BOM, SWD, DRC, and Regional Director confirmed the SNF ABNs were not being sent.
A facility failed to ensure tuna salad sandwiches were served at the proper temperature. During kitchen observation, an alternate menu item of tuna salad sandwiches was ready to be served while stacked on a counter and measured 55 degrees F, above the 41 degrees F threshold stated by the DM and RD. The DM later prepared deli turkey sandwiches, checked temperatures, and used turkey held on ice that was within the proper range before serving residents in the dining room.
A resident with severe cognitive impairment and dependence for dressing was observed in bed wearing only a brief and sheet, and later in a hospital gown instead of daily clothing. A CNA confirmed the resident had clothing available and should be dressed in his own clothes for dignity, and the DON confirmed residents should be dressed in their own clothing.
A resident with Parkinson's disease experienced decline in multiple ADL areas, including toileting, upper body dressing, lower body dressing, and personal hygiene. The annual MDS showed setup or clean-up assistance in these areas, while the quarterly MDS showed partial/moderate assistance. The MDSC confirmed the decline and stated that an SCSA MDS should have been completed instead of a quarterly MDS.
The facility failed to transmit MDS assessments within the required timeframe for two residents. One resident’s admission MDS, completed after an admission for diabetes, ESRD, and dementia, was sent late to iQIES, and another resident’s discharge MDS, completed after discharge with hypertensive heart disease, was never transmitted. The MDSC confirmed both transmission failures.
Inaccurate and Missing MDS Assessments: The facility failed to complete accurate MDS assessments for several residents by omitting required services and missing discharge assessments. One resident’s annual and modified annual MDS did not consistently capture extremity impairments despite prior assessments and observations showing significant limitations. Another resident’s 5-day MDS failed to show continuous oxygen use even though the admission record, physician order, observations, and staff interviews confirmed oxygen therapy. Two discharged residents also had no discharge MDS completed, and the MDSC confirmed the omissions.
A resident admitted with bipolar disorder did not have a completed PASARR Level II assessment, and the facility record showed the Level II application remained pending. The resident’s PASARR evaluation did not identify bipolar disorder, while the care plan noted antipsychotic medication use related to the diagnosis. The SWD confirmed the facility had not followed up with the PASARR agency, and the DON stated she was unaware the agency had not been contacted.
The facility failed to maintain good hygiene for three residents who needed help with bathing. One resident with chronic respiratory conditions and moderate ADL needs reported she had only gotten two showers since admission, while records showed many scheduled bath/shower opportunities with few completed. Another resident with parkinsonism and dementia had repeated missed bathing opportunities and was observed with stale urine odor, wet urine-smelling clothes, and dry skin. A third resident who was dependent on staff for bathing had only four baths documented, and staff observed oily hair and confirmed he needed a bath.
Failure to provide ongoing activity programs based on resident preferences for two residents. One resident with CHF and dementia and another resident with encephalopathy and dementia were both severely cognitively impaired and dependent on staff for most ADLs. Their MDSs identified preferences such as music, religious services, group activities, animals, and favorite activities, but observations showed them lying in bed or sitting alone with no music or TV and little evidence of meaningful activity involvement. The AD stated she was new and planned to begin a one-to-one program, while the DRC acknowledged the activity program was limited.
A resident with severe cognitive impairment, total ADL dependence, and contractures developed a fungal rash in the axilla, but the skin care plan documentation was incomplete and staff did not consistently identify or communicate the skin concern. Records showed antifungal orders and a history of moisture and redness under the axillary folds, while the NP stated she was not aware of the issue until it was brought to her attention and the DON was also unaware of redness under the opposite arm.
Failure to provide restorative ROM and splint services for two residents. One resident with dementia, contractures, and ADL dependence was repeatedly observed without the ordered splint and with wedges positioned beside the body rather than under the arms; staff were unaware of the splint and the OT/DOR reported the restorative program had stopped and staff education was not documented. A second resident with muscle contracture and aphasia had no evidence of restorative services or splint use in the chart, and facility interviews confirmed there was no active restorative program, no restorative nurse, and no care plan or Kardex direction for splinting.
Respiratory supplies were not dated or stored properly for a resident receiving oxygen for chronic respiratory conditions. Staff observed the oxygen tubing undated and a storage bag absent, and at one point the concentrator was off with tubing lying on the bed. An LPN confirmed the oxygen was set below the ordered flow rate and that the bag and dating were used to prevent contamination; the DON also confirmed the ordered flow rate, tubing dating, and storage bag were required.
Incomplete fall assessment and missing hospice documentation: A resident with generalized weakness and psychotropic drug use had an unwitnessed fall, was found on the floor beside the bed, and was sent to the hospital, but the later fall assessment incorrectly stated there had been no fall in the prior 90 days. The record also lacked complete hospice documentation for two residents, including missing hospice binder materials and no additional hospice records in the EMR, despite hospice services being in place.
A facility failed to provide a written bed hold policy notice to a resident upon hospital transfer, as required. The resident, with multiple medical conditions, was transferred without the necessary documentation, potentially affecting their re-admission. Interviews with staff revealed confusion and lack of responsibility regarding the provision of the notice, with the Director of Admissions stating it was included in the admission package but not sent during transfers. The Administrator confirmed the absence of a policy for sending out bed hold notices upon transfer.
A facility failed to implement a care plan for a resident receiving oxygen therapy, as the oxygen level was set at 3 LPM instead of the ordered 2 LPM. Observations and interviews with the resident and staff confirmed the discrepancy, despite the facility's policy requiring adherence to physician orders.
A facility failed to transcribe physician orders for catheter care for a resident with an indwelling catheter, risking potential complications. Additionally, the facility did not follow physician orders for oxygen therapy for another resident, as the oxygen was set higher than prescribed. Interviews with staff confirmed these discrepancies, highlighting a lack of adherence to physician orders and proper documentation.
Failure to Provide SNF ABN With Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms as required for three sampled residents when Medicare-covered skilled nursing therapy services were ending. Review of the facility policy titled, Advance Beneficiary Notices, indicated that the facility was to use the CMS-approved SNF ABN form for Part A services and that the notice was to be issued by the Business Office Manager or designee with delivery requirements including timely notice before the end of covered services. However, review of the records for three residents showed that each received a Notice of Medicare Non-Coverage (NOMNC) without an accompanying SNF ABN. Resident R160 was admitted with diagnoses including hemiplegia and hemiparesis following stroke, chronic kidney disease stage 3, and protein calorie malnutrition, and the NOMNC stated skilled nursing therapy services would end on 12/23/25 with no SNF ABN included. Resident R76 was admitted with diagnoses including hemiplegia and hemiparesis following stroke, chronic kidney disease stage 5, vascular dementia, type 2 diabetes with diabetic chronic kidney disease, dysphagia, depression, and pain, and the NOMNC stated skilled nursing services would end on 01/25/26 with no SNF ABN included. Resident R103 was admitted with diagnoses including chronic kidney disease stage 3, type 2 diabetes mellitus with diabetic arthropathy, dementia with behavioral disturbance, and Alzheimer's disease, and the NOMNC stated skilled nursing services would end on 12/07/25 with no SNF ABN included. During interviews, the MDS Coordinator, Business Office Manager, Social Work Director, Director of Regulatory Compliance, and Regional Director of Operations confirmed that SNF ABN notices were not being sent out with the NOMNCs.
Cold Sandwiches Served Above Safe Temperature
Penalty
Summary
The facility failed to ensure tuna salad sandwiches were served at the proper temperature. During a kitchen observation and interview, a small steam table pan containing eight tuna salad sandwiches, stacked in pairs, was observed on the counter at the left end of the steam table. At 12:09 PM, the Dietary Manager stated the tuna salad sandwiches were the alternate menu item and were ready to be served to residents in the dining room. When the Dietary Manager took the temperature of the sandwiches, they measured 55 degrees Fahrenheit, and the Dietary Manager and Registered Dietician stated the sandwiches should be 41 degrees Fahrenheit to be served. The Dietary Manager then stated she put the tuna sandwiches in the freezer to cool. Later during the same observation, the Dietary Manager was making deli meat turkey sandwiches and took the temperature of the turkey at 50 degrees Fahrenheit. There was more turkey sitting on ice next to where the sandwiches were being prepared, and the Dietary Manager took that temperature and found it was within the proper range before proceeding to make turkey sandwiches for residents in the dining room. The Director of Regulatory Compliance stated food served to residents should be served at the correct temperature. The facility policy titled Food Preparation and Service stated nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices and that all cold food on the tray line should be held at 41 degrees Fahrenheit or colder.
Failure to Dress Resident in Daily Clothing
Penalty
Summary
The facility failed to ensure that one resident was dressed in daily clothing to maintain dignity. The resident was admitted with a diagnosis of contracture of the left knee and, on the most recent MDS, had a BIMS score of 6 out of 15 indicating severe cognitive impairment. The assessment also showed the resident required partial to moderate assistance with upper body dressing and was dependent for lower body dressing, and the care plan identified an ADL self-care performance deficit requiring extensive to total assistance by one staff member for dressing. During observations, the resident was seen lying in bed wearing only a brief with a sheet across himself, then on later observations wearing a hospital gown. During interview, a CNA confirmed the resident was in a hospital gown and stated he should be in his own clothing because it is a dignity issue, and also confirmed clothing was available in the resident's armoire. The DON confirmed residents should be dressed in their own clothing because it is more homelike and comfortable, and confirmed this resident should be dressed in his own clothing.
Failure to Complete Required SCSA After Functional Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe when a resident experienced multiple areas of functional decline. The facility policy titled, MDS3.0 Completion, stated that an SCSA is required within 14 days of identifying a qualifying status change that affects more than one area and requires Interdisciplinary Team review and revision of the care plan. Resident 57 was admitted with multiple diagnoses including Parkinson's disease. Review of the resident's annual MDS showed setup or clean-up assistance for toileting, upper body dressing, lower body dressing, and personal hygiene. Review of the quarterly MDS showed decline in all four of those areas, with each changed from setup or clean-up assistance to partial/moderate assistance. During interview and record review, the MDS Coordinator confirmed that the resident had four areas of decline on the quarterly MDS compared to the annual MDS and stated that an SCSA MDS should have been completed instead of a quarterly MDS.
Late and Missing MDS Transmissions
Penalty
Summary
The facility failed to transmit MDS assessments within the federally required timeframe for two residents reviewed for resident assessments. The facility policy titled, MDS3.0 Completion, stated that all assessments shall be transmitted to the designated CMS system (iQIES) within 14 days of completion, but record review and staff interviews showed that this did not occur for Resident 4 and Resident 144. Resident 144 was admitted with diagnoses including type 2 diabetes, end stage renal disease, and dementia. Review of the admission MDS showed an ARD of 06/12/25, completion on 06/18/25, and transmission on 07/03/25, which the MDS Coordinator confirmed was late because it should have been submitted by 07/02/25. Resident 4 was admitted with diagnoses including hypertensive heart disease and was discharged on 08/28/25. Review of the discharge returned anticipated MDS showed an ARD of 08/28/25 and completion on 09/02/25, but it was never transmitted to iQIES; the MDS Coordinator confirmed it should have been transmitted within 14 days of completion.
Inaccurate and Missing MDS Assessments
Penalty
Summary
The facility failed to ensure accurate assessments were completed for four residents by not capturing services they were receiving or by not completing required discharge assessments. Review of the facility policy titled MDS 3.0 Completion stated residents are to be assessed using a comprehensive assessment process, and discharge assessments are to be completed using the discharge date as the ARD within 14 days of discharge. The report identified deficiencies involving R33, R117, R67, and R96. For R33, the annual MDS with an ARD of 12/07/25 did not reflect impairments on either side of the upper and lower extremities and indicated the resident was dependent on staff for bed mobility. A modified annual MDS with the same ARD later showed impairments of both upper extremities and one lower extremity, but this remained inaccurate compared with prior quarterly MDS assessments that documented impairments of both upper and lower extremities. During observations, R33 was seen lying in bed with foam wedges on both sides and both arms resting on the chest with bent wrists and curled fingers. The MDSC stated the 12/07/25 MDS was inaccurate and that accuracy was important so residents received the care they needed. For R117, the Medicare 5-day MDS with an ARD of 01/18/26 did not indicate the resident was on oxygen, even though the admission record and physician order showed oxygen at 3 liters via NC for shortness of breath. Staff observed an oxygen concentrator in the room running at 1.5 LPM and later at 2 LPM, and the resident stated she had been on oxygen for a long time and had difficulty breathing without it. The MDSC and DON both confirmed the resident used oxygen continuously and that the MDS should have reflected this. For R67 and R96, both residents were discharged from the facility, but discharge MDS assessments were not completed. The MDSC reviewed each record and confirmed that discharge MDSs were missing and should have been completed with the discharge dates as the ARDs.
Failure to Complete PASARR Level II Assessment for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure a PASARR Level II assessment was completed for a resident admitted with a diagnosis of bipolar disorder. Record review showed the resident was admitted with bipolar disorder, and the facility’s PASARR evaluation dated 02/08/25 showed the Level II application status was pending. The resident’s care plan also reflected use of antipsychotic medications related to the bipolar diagnosis. The facility policy titled, Resident Assessment-Coordination with PASARR Program, states that residents with a mental disorder or intellectual disability who require PASARR review are to be screened and referred for Level II evaluation, and that the Social Services Director is responsible for tracking PASARR status and referring residents to the appropriate authority. The resident’s PASARR evaluation dated 01/25/25 did not indicate bipolar disorder. An Initial Performance Improvement Plan dated 01/23/26 documented that social services identified six potential residents for whom Level II applications had not been submitted. During interviews, the Social Work Director confirmed the facility should have followed up on the pending PASARR before then and stated that although a PIP was started and a list of residents was provided to the Business Office Manager, no one had contacted the PASARR agency to make corrections. The DON also stated she was unaware the PASARR agency had not been contacted since the PIP was initiated.
Failure to Maintain Resident Hygiene Through Inadequate Bathing Assistance
Penalty
Summary
The facility failed to ensure good hygiene was maintained for three residents who required assistance with bathing. The deficiency was identified through record review, interviews, and observation, and involved Residents 1, 7, and 156, all of whom had care plans and MDS assessments showing they needed assistance with bathing or were dependent on staff for bathing. The facility policy stated that residents’ abilities in ADLs should not deteriorate unless unavoidable and that bathing services would be provided based on resident needs and choices. Resident 1 was admitted with chronic pleural effusion and chronic respiratory failure, had a BIMS score of 12, and required moderate assistance with bathing. Her care plan called for extensive assistance with bathing, and her POC showed scheduled baths three times weekly. The skin and bath report showed 42 opportunities for a bath or shower, with only 12 completed and one refusal. She was offered a bath or shower 13 times since 11/01/25, and during interview she stated she had only gotten two showers since admission. Resident 7 was admitted with vascular parkinsonism and dementia, had a BIMS score of 8, and required moderate assistance with bathing. His care plan also called for extensive assistance with bathing, and his POC showed scheduled baths three times weekly. The skin and bath report showed 42 opportunities, with only eight baths/showers completed and 10 offers documented. During observation, he smelled of stale urine, his clothes had a wet urine smell, and his face had whiskers and gray patches of dry skin; he stated he washed up in the sink and that was enough. Resident 156 was admitted with stroke and muscle weakness, was dependent for showering/bathing, and his care plan stated he was totally dependent on staff for bathing. Shower sheets showed only four baths, and during interview and observation his hair appeared oily; staff confirmed he needed a bath and that he should have been bathed two to three times per week and more if necessary to maintain proper hygiene.
Failure to Provide Ongoing Activity Programs Based on Resident Preferences
Penalty
Summary
The facility failed to ensure two residents, R33 and R12, received an ongoing activities program that supported their choices of activities. R33 was admitted with chronic systolic congestive heart failure and dementia. Her annual MDS showed she was unable to complete the BIMS and was severely cognitively impaired, with bilateral upper extremity impairment and one-sided lower extremity impairment. Her MDS also indicated it was very important for her to participate in religious services or practices and somewhat important to listen to music she likes. Her care plan stated she had little or no group activity involvement and was on a one-to-one program, with interventions to invite and encourage her to attend group activities, post the monthly calendar, praise efforts, and provide supplies for sociable activities. Continuous observations of R33 on multiple days showed her lying in bed with the lights off and no music or television in the room. On one observation she was sitting in her wheelchair along the wall next to the nurses' station. R12 was admitted with encephalopathy and dementia. His annual MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, and he was dependent on staff for most ADLs. His MDS indicated it was very important for him to listen to music he likes, do things with groups of people, be around animals, and participate in his favorite activities. His care plan stated he was dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits, with interventions to have staff converse with him, introduce him to residents with similar backgrounds, invite him to scheduled activities, and provide materials for individual activities. The care plan for R12 did not mention one-to-one as an intervention. Continuous observations showed him lying in bed with his covers pulled up over his face, with no music or television in the room and the lights off. At other times he was observed sitting inside the doorway of his room or in his wheelchair next to the nurse's cart across from his room. During interview, the Activity Director stated she was new to the position, planned to start a one-to-one program on the last day of the survey, and did not know what she would provide because she needed to get a feel for what the residents liked doing. She stated both residents would be placed on one-to-one visits three times a week and mentioned possible activities such as puzzles, aromatherapy, nail care, massage, talking, and reading the Bible. The Director of Regulatory Compliance stated the activity logs did not show much and acknowledged there was a limited activity program since the new company had taken over.
Failure to Monitor and Treat Axillary Rash
Penalty
Summary
The facility failed to ensure one resident with severe cognitive impairment and total dependence for ADLs received proper care and monitoring for a rash under the left axilla. The resident had diagnoses including chronic systolic congestive heart failure and dementia, and the care plan identified risk for chronic fungal rash under the left arm related to moisture, with the left arm contracted and a history of purple-reddish discoloration from a previous rash. The care plan included applying PRN antifungal cream, monitoring for spread or signs of infection, and placing wedges under each arm as tolerated. Record review showed the resident had a rash on the left axilla on the Skin and Bath Reports, and a skin check dated 02/05/26 noted no prior discoloration or rash. The skin care plan documentation had blank sections for review of medical conditions, medications, risk factors, positioning, contractures, mobility, and changes to the plan of care, indicating those areas were not reviewed. Clinical physician orders showed antifungal treatment had been ordered at different times, including Diflucan and topical antifungal powder, with miconazole powder ordered for the left arm and an antifungal powder under the left arm discontinued the day before the rash was noted. During interviews and observations, staff described the area as a long-standing yeast rash and noted moisture and redness under the axillary folds. The NP stated she had not been treating the resident for the skin issue and was not aware of concerns until the day before the interview, stating she would have expected to be notified and to see a skin assessment. The DON also stated she was not aware of red areas under the right arm. The OT stated the resident had contractures and that wedges under both arms would help airflow and relieve pressure, and the policy required review of risk factors, weekly reassessment, and ongoing review of interventions for effectiveness.
Failure to Provide Restorative ROM and Splint Services
Penalty
Summary
The facility failed to ensure restorative services were provided to maintain or improve range of motion and mobility for two residents reviewed for ROM concerns. One resident had diagnoses including chronic systolic heart failure and dementia, was severely cognitively impaired, dependent on staff for all ADLs, and had bilateral upper extremity impairments and lower extremity impairment. The resident’s record showed a history of contractures and therapy involvement, including recommendations for a left-hand splint and positioning wedge for the left shoulder, but the care plan did not mention the right hand contracture until during the survey, and there were no active physician orders for the splint or shoulder wedge in the chart reviewed. During observations, the resident was repeatedly seen lying in bed with foam wedges placed beside the body rather than under the arms, and splints were not observed on either hand. The resident’s arms were positioned across the chest with elbows bent and both hands curled into the palms. Staff interviews showed the CNA was not aware of any hand splint, and the OT and DOR stated the resident had contractures, had previously been recommended for a splint and restorative therapy, and that the restorative program had been discontinued after the restorative nurse resigned and the new company took over. The OT also stated she had not measured ROM during prior or current treatment and that staff education about splint placement had not been documented. The second resident had diagnoses including muscle contracture and aphasia, was cognitively intact, and the MDS indicated no ROM or splint devices were received during the prior seven days. The record contained no evidence of restorative services or splint devices, and the care plan did not mention splints. The resident stated there were no splints and that the last one had been used by therapy, and the resident was observed with a contracted left hand. Therapy discharge documentation showed a restorative splint and brace program had been established and staff trained to don and doff the splint to prevent further joint problems, but facility interviews confirmed the restorative program was no longer in place, there was no restorative nurse, no restorative list or tracker available, and the care plan and Kardex did not identify splint use for the resident.
Respiratory Supplies Not Dated or Stored Properly
Penalty
Summary
The facility failed to ensure respiratory supplies were dated and stored in a sanitary manner for one resident who was admitted with acute and chronic respiratory failure with hypoxia, asthma, and obstructive sleep apnea and had an order for oxygen at 3 liters via nasal cannula for shortness of breath. During observations, the resident’s oxygen concentrator was present in the room and running, but the oxygen tubing was not dated, and a storage bag was not present. At one observation, the resident was out of the room and the oxygen concentrator was turned off, with the tubing laying on the bed and no storage bag present. During interview, the resident stated she had been on oxygen for a long time and confirmed she had difficulty breathing without it. An LPN confirmed the resident was on oxygen, that the concentrator was set at 2 LPM instead of the ordered 3 LPM, and that the storage bag was used to avoid contamination and bacteria when the resident left the room and used portable oxygen. The DON also confirmed the resident should have been receiving oxygen at 3 LPM, that the tubing should be dated, and that a storage bag should be present to avoid contamination. The facility policy stated oxygen tubing and masks/cannulas should be changed weekly and as needed if soiled or contaminated, and delivery devices should be kept covered in a plastic bag when not in use.
Incomplete fall assessment and missing hospice documentation
Penalty
Summary
The facility failed to complete a comprehensive fall assessment and implement individualized fall interventions after a resident with generalized weakness and psychotropic drug use had an unwitnessed fall. The resident was found on the floor beside the bed, lying on his back, after staff heard yelling from the room. He reported that he was trying to go to the bathroom by himself, complained of back pain rated 7/10, and was transferred to the hospital by stretcher. The resident later stated at the hospital that he fell because he did not receive assistance despite multiple attempts to use his call light. The resident’s record showed a discharge return not anticipated MDS with a BIMS score of 15, indicating he was cognitively intact, and the care plan identified him as at risk for falls and related injuries due to generalized weakness, psychotropic drug use, and an actual fall on 12/14/25. However, the fall assessment completed on 01/13/26 stated the resident had not had a fall in the last 90 days, which was inaccurate because the facility had already documented the fall. The DON and Regional Director of Operations both confirmed during interview that the assessment was inaccurate because the resident had fallen in the facility a month earlier. The facility also failed to maintain complete and accurate hospice-related records for two residents. One resident with Alzheimer’s disease, dementia, and hypertension was admitted with hospice services, but the hospice binder and documents were not available in the facility at the time of review; the binder was later brought to the conference room. Another resident with severe cognitive impairment, dementia, hemiplegia, and hemiparesis following cerebral infarction was marked as receiving hospice services, but the record contained only one hospice certification/order document and no additional hospice documentation in the EMR. Staff stated there was no hospice documentation in the EMR and that the Unit Managers were responsible for obtaining hospice documentation.
Failure to Provide Bed Hold Policy Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy notice to a resident, identified as R16, at the time of transfer to the hospital or within 24 hours, as required. R16, who had multiple medical conditions including end-stage renal disease, type 2 diabetes, and Alzheimer's disease, was transferred to the hospital on 2/4/2025. A review of R16's electronic medical record revealed no documentation of a bed hold policy notice being provided at the time of transfer. This oversight had the potential to contribute to the denial of re-admission and loss of the resident's home following hospitalization. Interviews with facility staff, including an LPN, the Director of Admissions, and the Business Office Manager, revealed a lack of clarity and responsibility regarding the provision of the bed hold policy notice. The Director of Admissions stated that the bed hold policy was included in the admission package and signed by the resident or their representative, but it was not sent with residents during hospital transfers. The Administrator confirmed that the facility did not have a policy for sending out bed hold notices upon transfer, relying instead on the initial admission documentation. This lack of a clear process and policy led to the deficiency identified by the surveyors.
Failure to Implement Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to implement a care plan for oxygen therapy for a resident receiving oxygen therapy. The deficiency was identified through observations, resident and staff interviews, and record reviews. The facility's policy on Comprehensive Person-Centered Care Plans requires each resident to have a care plan that identifies problems, needs, strengths, preferences, and goals. However, the care plan for the resident in question did not align with the physician's order for oxygen therapy. The resident had a physician's order for oxygen to be set at 2 liters per minute (LPM) via nasal cannula. However, observations on multiple occasions revealed that the resident's oxygen level was set at 3 LPM, contrary to the physician's order. Interviews with the resident and staff, including Licensed Practical Nurses and the Director of Nursing, confirmed the discrepancy between the ordered and actual oxygen settings. The Director of Nursing expected staff to adhere to physician orders and ensure oxygen levels were set correctly during rounds.
Failure to Transcribe Orders and Adhere to Oxygen Therapy Instructions
Penalty
Summary
The facility failed to transcribe and obtain physician orders for catheter care for a resident with an indwelling catheter, identified as R93. The resident was admitted with diagnoses including obstructive and reflux uropathy and bladder-neck obstruction. Despite the presence of a foley catheter, there were no physician orders documented for its care. Interviews with the unit manager and admission nurse revealed that the orders were not written or transcribed from the hospital discharge notes, which could lead to staff being unaware of the catheter's presence and necessary care, potentially resulting in infection or other complications. Additionally, the facility did not adhere to physician orders for oxygen therapy for another resident, identified as R53. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus and peripheral vascular disease, and had a physician order for oxygen at 2 liters per minute via nasal cannula. However, observations revealed that the oxygen was consistently set at 3 liters per minute, contrary to the physician's order. Interviews with LPNs confirmed the discrepancy, and the Director of Nursing expressed the expectation that staff should follow physician orders. These deficiencies highlight a lack of adherence to physician orders and proper documentation, which are critical for ensuring appropriate care and preventing potential complications for residents. The absence of physician orders for catheter care and the incorrect oxygen settings demonstrate a failure in the facility's processes for managing and executing care plans as prescribed.
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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 Jonesboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake City Center For Nursing And Healing Llc | 4.4 mi | ★★★★★ | 15 | 0 |
| Pruitthealth - Laurel Park, Llc | 4.9 mi | ★★★★★ | 1 | 0 |
| Arrowhead Post Acute Llc | 5.3 mi | ★★★★★ | 0 | 0 |
| Riverdale Center For Nursing And Healing | 6.1 mi | ★★★★★ | 8 | 0 |
| Westbury Center Of Mcdonough For Nursing & Healing | 10.9 mi | ★★★★★ | 3 | 2 |
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