Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverside Health Services during CMS and state inspections, most recent first.
Failure to Report Alleged Abuse: A resident with severely impaired cognition had concerns raised about possible inappropriate sexual contact with a spouse. The DON said the administrator was notified by a CNA and the facility began an investigation, but the allegation was not reported to the health department because leadership did not consider it abuse, despite the administrator stating abuse allegations must be reported within two hours.
The facility did not update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed licensed nursing staff. The written assessment specified one RN for one day shift per week and projected a need for 10 LPNs across 24 hours, with detailed LPN coverage by shift, and stated it should be reviewed and updated as needed to guide staffing decisions. At the time of survey, the DON reported 36 residents in the facility, acknowledged that resident acuity was higher than when the assessment was completed, and stated that the actual pattern was two LPNs on the floor for the day shift and two LPNs for the night shift, with the DON, ADON, and MDS coordinator available only during weekday business hours. The DON identified a total of seven licensed staff available and stated that more staff were needed to work directly with residents, confirming that the facility assessment no longer reflected current resident needs or staffing resources.
A resident with a pressure ulcer received wound care during which an LPN and CNAs failed to follow basic infection control practices. The overbed table was not sanitized before wound supplies were placed, gloves were not changed after contact with feces, and the resident was repositioned onto a clean bed pad while still soiled. The LPN used the same contaminated gloves to handle personal items, suction equipment, wound care supplies, and to cleanse the resident’s skin and pressure ulcer, including applying collagen paste and calcium alginate with gloved fingers. Hand hygiene was not performed between glove changes, and the resident’s open wound came into contact with a cloth bed pad or pillow after cleansing and medication application but before the final dressing was applied.
A resident with severe cognitive impairment, multiple comorbidities, and identified risk for pressure ulcers developed a new in-house acquired stage 2 pressure ulcer to the buttock. Nursing documentation indicated that family, physician, and wound nurse were notified and wound care was initiated per an unsigned order, but the ADON later acknowledged not notifying the physician and could not identify who gave the wound care order. The attending physician reported not managing wounds or writing the documented order, and the wound care NP stated they first assessed the wound nearly two weeks after its onset and had no prior notification. The wound care schedule initially did not list the resident for wound rounds, and the DON could not explain the omission, demonstrating a failure to promptly notify the physician and secure valid treatment orders for a significant change in condition.
A resident with severe cognitive impairment, dependence for repositioning, and documented skin integrity issues developed an in-house acquired stage 2 pressure ulcer to the buttock and later an unstageable pressure ulcer to the ankle despite identified risk and preventive care plan interventions. The care plan called for use of positional devices, a therapeutic air mattress, skin monitoring each shift, and an every-hour turning schedule, but EHR task documentation showed the resident was not repositioned every hour as ordered. The wound care company did not initially see the resident on one of its scheduled visits after the first ulcer was identified, and when later assessed, the buttock wound was classified as unstageable and larger than first documented. A CNA reported hourly repositioning as the primary preventive measure but could not recall other interventions, while the physician stated they did not manage wounds and did not write the wound care order attributed to them, indicating reliance on the wound care company for pressure ulcer management.
The facility failed to ensure CMAs had current advanced gastrostomy certifications while administering medications via PEG tubes. A resident’s MARs over several months showed that three CMAs with expired or undocumented gastrostomy credentials repeatedly gave medications through a PEG tube. One CMA reported believing they were allowed to pass PEG tube meds and perform feedings, while the DON later stated that two CMAs supposedly had certifications that were not reflected in the nurse aide registry, and no documentation was produced to verify those credentials.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility failed to ensure dependent residents were repositioned every two hours, leading to the development and worsening of pressure ulcers. A resident, initially without pressure ulcers, developed severe wounds due to inadequate repositioning and documentation. Staff interviews revealed a lack of documentation and monitoring, contributing to the deficiency.
A facility failed to document physician visits for a resident with chronic respiratory failure, despite the physician and DON confirming the visits occurred. The facility's policy requires documentation of all services and changes in condition, but the resident's medical records lacked physician progress notes.
The facility did not ensure RN coverage for eight consecutive hours, seven days a week, during October 2024 and January 2025. The CASPER report highlighted the absence of RN coverage on multiple days, and payroll documents confirmed this deficiency. The business office manager and DON acknowledged the lack of RN coverage on the specified dates.
A facility failed to update the PASARR Level II assessment for a resident with a new diagnosis of a serious mental health condition. The resident had pseudobulbar affect and a mood affective disorder, but the PASARR Level I assessment did not reflect a serious mental illness. The DON acknowledged the oversight and stated a referral should have been made.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency for 1 of 3 sampled residents reviewed for abuse. The resident had severely impaired cognition, with a Brief Interview for Mental Status score of 3 on the admission assessment. A physician progress note documented follow-up evaluation regarding prior concerns of potential inappropriate physical contact involving the resident and spouse, and noted allegations of possible sexual behavior, although no such activity had been witnessed by staff. The DON stated that on 04/28/26 the administrator was notified by a CNA of concerns related to potential sexual contact between the resident and their spouse, and that the facility began an investigation but did not report the concerns to the health department. The administrator stated that abuse allegations must be reported to the health department within two hours, but this incident was not reported because they did not think it was an allegation of abuse.
Failure to Update Facility Assessment to Reflect Increased Resident Acuity and Staffing Needs
Penalty
Summary
The facility failed to update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed nursing resources. The written facility assessment dated 10/15/25 stated that one RN was needed for one day shift per week, including weekends, and projected a total of 10 LPNs needed to provide care in a 24-hour period. The assessment further specified that seven LPNs were needed for the day shift, five for the evening shift, and four for the night shift. The assessment document itself stated that it was to be reviewed annually and updated as needed, and that it was to be used to evaluate the resident population and determine the resources necessary to care for residents competently during day-to-day operations and emergencies, and to drive staffing decisions. At the time of the survey, the DON identified that 36 residents resided in the facility and reported that the acuity level of the residents was higher than it had been in October 2025 when the facility assessment was completed. The DON stated that the projected need for ten LPNs in a 24-hour period was not correct and described the actual staffing pattern as two LPNs working on the floor from 7 a.m. to 7 p.m. and two LPNs working on the floor from 7 p.m. to 7 a.m., with the DON (RN), assistant DON (RN), and MDS coordinator (LPN) available to assist with resident needs during business hours, five days a week. The DON counted a total of seven licensed staff members available and acknowledged that more staff were needed to work directly with residents given the current higher acuity, demonstrating that the facility assessment had not been updated to reflect the current resident population and resource needs.
Improper Infection Control During Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care in a manner that prevented contamination and potential infection for one resident with a pressure ulcer. During an observed dressing change, an LPN entered the resident’s room, pushed personal items aside, and placed plastic trash bags and wound care supplies on the overbed table without sanitizing the surface. The LPN and CNAs provided incontinent care during which feces remained on the resident’s legs and buttocks, and at least one CNA did not change gloves after wiping feces and before placing a clean cloth bed pad under the resident. The resident was repositioned onto the new pad while still soiled with feces. Wearing the same gloves used during incontinent care, the LPN handled the resident’s personal items, oral suction yankauer, and suction machine, and prepared wound care supplies, including soaking gauze in a cleansing solution. The LPN then used the same contaminated gloves to obtain wet gauze from the cleansing solution and clean feces from the resident’s legs and buttocks before proceeding to remove the old dressing and packing from the pressure ulcer. Some packing fell onto the cloth bed pad, and the resident’s back and buttocks, including the open pressure ulcer area after cleansing and medication application but before placement of the absorbent dressing, came into contact with the cloth bed pad or pillow. The LPN applied a collagen paste to the wound bed by inserting gloved fingers into a cup of white paste and then applied calcium alginate with the same gloved fingers, without using an applicator. The LPN discarded the gloves but did not perform hand hygiene before donning a new pair of gloves stored on the overbed table. During a post-observation interview, the LPN acknowledged feeling nervous, recognized that their gloves and multiple items and surfaces may have been contaminated by contact with feces, and stated that the resident’s bed pad and wound bed were likely contaminated during the dressing change.
Failure to Notify Physician and Obtain Valid Orders for New Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the physician of a new pressure ulcer and to obtain a valid, signed treatment order for one resident. The facility’s Notification of Changes policy required prompt consultation with the resident’s physician and notification of the resident’s representative when there was a change requiring alteration of treatment. An admission assessment dated 12/02/25 documented that the resident was severely impaired for daily decision making, dependent for rolling, at risk for developing pressure ulcers, and did not have a pressure ulcer at that time. A weekly nursing evaluation on 11/27/25 showed normal skin findings. On 12/06/25, a nurse progress note documented that the resident developed a new, in-house acquired stage 2 pressure ulcer to the left gluteus, with exposed dermis and specific measurements. The note stated that the family, physician, and wound nurse were notified, and an unsigned physician order dated 12/07/25 directed application of Mesitran Soft Wound Gel and Medi-honey with dressing changes. The treatment administration record showed that wound care was provided as ordered. However, the ADON later stated that the wound care order obtained on 12/07/25 was not signed by a physician, did not recall who gave the order or how it was received, and acknowledged they did not notify the physician of the wound, believing the wound care company would sign the order and that writing orders was outside their scope of practice. Additional documentation showed that the wound care company’s nurse practitioner first assessed the buttock pressure ulcer on 12/19/25, classifying it as unstageable and measuring it at different dimensions, and noted the wounds had been present for five days without being able to determine if they were improving or worsening. The wound care clinical schedule dated 12/12/25 did not list the resident to be seen by the wound care company, and the DON could not explain why the resident was not on the list. The wound care nurse practitioner did not recall any prior notification about the resident’s pressure ulcer before 12/19/25. The attending physician stated they did not treat wounds, did not write wound care orders, and did not write the 12/07/25 order, indicating that wound management was handled by the wound care company. These findings show that the facility did not follow its own policy to promptly notify and consult the physician when the resident experienced a significant change in condition requiring altered treatment.
Failure to Prevent and Manage Pressure Ulcers for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development and worsening of pressure ulcers for one resident with known skin integrity risks. The resident’s baseline care plan noted existing skin integrity issues and ordered zinc cream to the bottom twice daily for prevention of skin breakdown. An admission assessment later documented that the resident was severely impaired in daily decision making, dependent for rolling from side to side, and at risk for pressure ulcer development, with no pressure ulcers present at that time. Despite these identified risks, a nursing progress note shortly thereafter documented a new, in‑house acquired stage 2 pressure ulcer to the left gluteus, with exposed dermis and specific wound measurements, and the family, physician, and wound nurse were notified. Subsequent documentation showed evolving and additional pressure ulcers and gaps in wound management. A care plan for impaired skin integrity included interventions such as use of positional devices, a therapeutic air mattress, monitoring skin integrity every shift, notifying the physician for treatment orders, and continuing an every‑hour turning schedule. However, the wound care company’s clinical schedule did not show the resident as being seen on one of the dates they were in the facility, even though the pressure ulcer had already been identified. When the wound care company nurse practitioner eventually assessed the buttock wound, it was classified as unstageable with larger dimensions than initially documented, and the practitioner could not determine if the wound was improving or worsening. A later nursing skin evaluation documented a new, in‑house acquired unstageable pressure ulcer to the left ankle. Physician orders were written for specific wound treatments and for the resident to be turned every hour from left to right only, but the electronic health record task tab for two subsequent months showed the resident was not repositioned every hour as ordered. A CNA stated that prevention for this resident consisted of repositioning every hour and that documentation of repositioning was in the task tab, but could not recall other interventions. The physician reported that they did not treat pressure ulcers or write wound care orders, stating that the wound care company managed wounds, and denied writing the wound care order dated 12/07/25. The wound care nurse practitioner stated they treated wounds weekly and assessed the resident’s pressure ulcer on 12/19/25, without recalling prior notification. The DON confirmed that the wound care company was present on multiple dates and that the resident’s pressure ulcer was identified before one of those visits, but the resident was not seen by the wound care company on that earlier visit, and also confirmed that documentation did not show the resident was turned and repositioned every hour as ordered.
Expired and Unverified CMA Gastrostomy Certifications During PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) held current advanced gastrostomy certifications before administering medications via gastrostomy (PEG) tubes. Record review showed that CMA #1’s advanced gastrostomy certification had expired, yet the October 2025 MAR for Resident #1 documented that CMA #1 administered medications through the resident’s PEG tube on multiple dates. The facility’s undated Medication Administration policy stated that medications are to be administered by licensed nurses or other staff legally authorized to do so in the state, in accordance with professional standards of practice. The DON identified that 24 residents in the facility received medications through PEG tubes. Further review revealed that CMA #2 and CMA #3 also lacked documented, current advanced gastrostomy certifications while administering PEG tube medications. CMA #2’s certification had expired, but October and November 2025 MARs for Resident #1 showed that CMA #2 administered medications through the PEG tube on several dates, and CMA #2 stated they were allowed to pass medications and perform feedings via PEG tube. CMA #3’s advanced gastrostomy certification was also not current, yet October, November, and December 2025 MARs for Resident #1 documented multiple instances of PEG tube medication administration by CMA #3. The DON initially stated that CMA #1 was the only CMA not certified to work the medication carts and later reported that CMA #2 and CMA #3 did have certifications, but they were not in the nurse aide registry and would be verified with the testing school. However, the facility did not provide documentation confirming current gastrostomy certification for CMA #2 and CMA #3 by the time of the survey.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Reposition Residents Leads to Pressure Ulcers
Penalty
Summary
The facility failed to implement a system to ensure that dependent residents were repositioned every two hours to prevent the development and worsening of pressure ulcers. During a tour of the facility, it was observed that none of the 32 dependent residents were positioned on their right side as per the repositioning schedule. The facility's policy required a consistent program for changing residents' positions, but this was not being followed, and there was no documentation of repositioning in the ADL book. Resident #2, who was at high risk for developing pressure ulcers, was not repositioned as required. Initially, Resident #2 did not have any pressure ulcers upon admission, but later developed a fluid-filled blister and an open area on the buttocks. Despite receiving wound care orders, the resident's condition worsened, with the pressure ulcer becoming unstageable and showing signs of infection, including a foul odor and drainage. The resident was eventually sent to the hospital with a diagnosis of a pressure ulcer and sepsis. Interviews with staff revealed a lack of documentation and monitoring of repositioning activities. CNAs stated they did not document when residents were turned, and there was no list of residents requiring repositioning. The DON acknowledged that the ADL book was not being used to document repositioning and that monitoring by charge nurses and the DON was not occurring as it should have been. This lack of a systematic approach contributed to the development and worsening of pressure ulcers in residents.
Incomplete Documentation of Physician Visits
Penalty
Summary
The facility failed to ensure complete and accurate documentation for one of the five sampled residents reviewed for medical records. The facility's policy on Charting and Documentation, revised in July 2017, mandates that all services provided to residents, progress toward care plan goals, and any changes in the resident's condition must be documented in the medical record. However, a review of the medical records for a resident admitted with chronic respiratory failure revealed the absence of physician progress notes. Despite the physician having seen the resident in person on two occasions, as confirmed by both the physician and the Director of Nursing (DON), these visits were not documented in the resident's medical records.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours, seven days a week, during two of the four months reviewed, specifically October 2024 and January 2025. The CASPER report for fiscal year Quarter 4 2024 indicated a lack of RN coverage on four or more days within the quarter. A review of payroll documents confirmed the absence of RN coverage on specific dates in October 2024 and January 2025. The business office manager confirmed that all available documentation had been submitted, but acknowledged that the Director of Nursing (DON) did not punch in and instead completed missed visit forms. The DON confirmed the lack of RN coverage on the specified dates.
Failure to Update PASARR Level II for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a new diagnosis of a serious mental health condition had an updated Pre-Admission Screening and Resident Review (PASARR) Level II assessment. This deficiency was identified for one resident who was reviewed for PASARR Level II. The resident had diagnoses including pseudobulbar affect and a mood affective disorder. A PASARR Level I assessment dated 10/26/18 indicated that the resident did not have a diagnosis of serious mental illness or other psychotic disorder. However, the annual assessment dated 11/09/24 showed that the resident was not considered by the state PASARR Level II process to have a serious mental illness and/or intellectual disability or a related condition. On 02/04/25, the Director of Nursing (DON) reviewed the resident's clinical record and acknowledged that the resident had a diagnosis of mood affective disorder and a psychotic disorder, and stated that a PASARR Level II referral should have been made to the Level of Care Evaluation Unit.
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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 Arkoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Blossoms At Fort Smith Rehab & Nursing Center | 1.4 mi | ★★★★★ | 9 | 0 |
| Covington Court Health And Rehabilitation Center | 2.5 mi | ★★★★★ | 5 | 0 |
| Chapel Ridge Health And Rehab | 3.1 mi | ★★★★★ | 0 | 0 |
| Fianna Hills Nursing And Rehabilitation Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Brooken Hill Health And Rehab, Llc | 4.6 mi | ★★★★★ | 10 | 0 |
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