Citations in Arkansas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Arkansas.
Statistics for Arkansas (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Arkansas
A resident with moderate cognitive impairment, behavioral symptoms, a history of falls, and an active PRN pain medication order returned from the hospital at night and repeatedly requested pain medication for head pain. A CNA reported the requests multiple times to the only LPN on duty, who had the keys to all med carts, but the LPN did not assess the resident on that hall or administer any pain medication, stating that another LPN (who was not present or on the staffing log) was supposed to pass meds there. Review of the eMAR and staffing records confirmed that no pain medication was given during this period despite the resident’s repeated requests and an active PRN order, constituting a failure to provide ordered and requested pain management.
The facility failed to report an alleged sexual abuse incident to the State Agency within the required two-hour timeframe. A severely cognitively impaired resident with dementia and Parkinson’s disease was found in another severely cognitively impaired resident’s room; later, blood was observed in the first resident’s brief with vaginal redness, and dried blood was noted on the second resident’s fingers. CNAs notified an LPN, who then notified the Director of Admissions and Marketing, and the issue was subsequently reported to the DON and the Administrator. The Administrator acknowledged knowing that allegations or suspicions of abuse must be reported to the State Agency within two hours but submitted the report close to four hours after discovery in order to gather additional information, resulting in noncompliance with reporting requirements.
The facility did not update care plans with specific fall interventions after several residents experienced falls, despite their complex medical conditions and histories of falls. Staff interviews confirmed that the process for care plan updates was not followed, and the responsibility for these updates was not fulfilled. The facility's care plan policy was requested but not provided.
A CNA transferred a resident without using the required mechanical stand-up lift or a second staff member, contrary to the care plan. After the resident fell and complained of pain, two CNAs moved the resident to a wheelchair before a nurse assessment. The resident, who had a history of falls and required two-person assist for transfers, sustained an acute femoral fracture requiring surgery. Staff interviews confirmed the care plan and post-fall protocols were not followed.
The facility did not have a Licensed Administrator overseeing daily operations for several months after the previous Administrator resigned. During this period, administrative duties were not properly fulfilled, with a Compliance Officer—who lacked the required Administrator's license—listed as interim Administrator on official reports, including those related to a resident injury. The facility had not interviewed any candidates for the position and was still seeking a replacement.
A resident with cognitive impairment and mobility deficits, care planned for two-person assistance with a mechanical stand-up lift for transfers, was transferred by a CNA without the required lift or second staff member. During the transfer, the resident fell and sustained a right femur fracture. Staff interviews confirmed the care plan was not followed, and the facility's policy requires adherence to care plan interventions.
A resident with severe cognitive impairment and a history of agitation was physically restrained by two CNAs using a sheet tied around the waist and secured to a chair, while an LPN was present. The restraint was not authorized by a physician or included in the care plan, and staff involved had previously received training on restraint policies prohibiting such actions without proper authorization.
A facility failed to ensure an LPN working through an agency held an active and unencumbered license, as required by state law and facility policy. The facility relied on the agency for credential verification and did not independently confirm the LPN's license status, resulting in the LPN working multiple shifts while the license was expired or encumbered, in violation of licensure restrictions.
Staff failed to follow manufacturer guidelines during a mechanical lift transfer for a resident with multiple medical conditions, resulting in the lift's wheels being locked while lowering the resident. Interviews and competency reviews revealed inconsistent staff understanding of proper procedures, despite training and care plans specifying that wheels should remain unlocked during lowering.
Multiple residents with cognitive and medical impairments developed persistent rashes over several months, which were later identified as scabies in several cases. Despite ongoing symptoms and spread across different rooms and floors, the facility did not implement isolation, PPE, or enhanced cleaning until after a confirmed scabies diagnosis. Staff and housekeeping reported inconsistent communication and lack of infection control measures prior to this, resulting in a significant outbreak.
Failure to Provide PRN Pain Medication After Resident’s Return From Hospital
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed and requested PRN pain medication to a resident following a return from the hospital. The resident had been admitted with diagnoses including bipolar disorder, current episode manic severe with psychotic features, and had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The resident’s MDS documented verbal behavioral symptoms directed toward others, dependence for toileting/personal hygiene, a history of multiple falls, and use of high‑risk medications including antianxiety agents, antidepressants, opioids, and anticonvulsants. The care plan, revised in late February, identified a behavior problem of agitation related to communication, including that the resident would throw themself on the floor if verbalized demands were not instantly met, and also identified a risk for pain with an intervention to anticipate the resident’s need for pain relief and respond immediately to any complaint of pain. The eMAR for January showed an active PRN pain medication order to give one tablet orally every four hours as needed for pain, with ongoing pain monitoring orders. On the night in question, the resident returned from the hospital around 10:30 PM. After being put to bed, the resident requested pain medication for head pain. CNA staff reported informing an LPN that the resident was requesting pain medication. The CNA later stated that around 12:30 AM, the resident continued calling out for help and reporting pain, and the CNA again went to the nurse. The CNA further reported that around 5:00 AM, the resident was still awake and asking for medication for head pain, and the CNA again approached the same LPN, who refused to administer pain medication, stating that another LPN, who was not present in the building, had agreed to pass medications on that hall. The CNA stated that the LPN did not go to the resident’s room at all during the shift and did not provide any pain medication despite multiple requests relayed by the CNA. Documentation and interviews showed that the LPN on duty had accepted the keys to all medication carts and was the only nurse listed on the staffing log for that night, with no timecard entries indicating that the other LPN was working or present. The LPN’s own witness statement indicated they signed for the resident’s return from the hospital and that a co‑worker handled all medications for the hall where the resident resided, and that they rarely appeared on that hall. However, the daily staffing log and timecard records showed no other LPN assigned or clocked in after an earlier date. The DON and another LPN stated that the nurse who accepts the keys to all medication carts and is the only nurse in the building is responsible for addressing any resident’s request for medication, including pain medication. Review of the MAR during the facility’s investigation confirmed that no pain medication was administered to the resident during the period when the resident repeatedly requested it after returning from the hospital. Additional interviews supported that the resident was distressed the following morning. Social Services reported finding the resident lying on a mat on the floor the morning after the incident, with the resident voicing being mad, though not specifying the reason. The Administrator stated that there was no written communication from the LPN about what was occurring in the resident’s room and that the LPN did not always communicate back with administration. Facility policies on administering medications required that medications be administered in a safe and timely manner as prescribed, and the Abuse Prevention Program policy required the administration to protect residents from abuse and neglect. The Office of Long‑Term Care Incident and Accident report categorized the event as abuse and neglect, noting that the resident was sent to the hospital after a fall and, upon return, requested pain medication twice with no medication provided, and that the alleged perpetrator was a facility employee.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an alleged or suspected incident of sexual abuse to the State Agency within the required two-hour timeframe. Resident #1, who had Parkinson’s disease with dyskinesia, dementia, generalized anxiety disorder, and major depressive disorder, was severely cognitively impaired per the annual MDS and care plan, which noted impaired cognitive function and the need for cueing, reorientation, supervision, and observation for signs of distress. Resident #2, who also had severe cognitive impairment and diagnoses including dementia, anxiety disorder, irritability and anger, and unspecified psychosis, had a care plan revised after the incident to reflect a history of physical and sexual aggression toward females related to anger, dementia, history of harm to others, and poor impulse control. On the day of the incident, an OLTC Incident and Accident Report documented that at 12:05 PM the facility recorded the discovery of Resident #1 standing in Resident #2’s room, with both residents fully clothed. After Resident #1 was taken back to their room and perineal care was performed, blood was noted in Resident #1’s brief, and redness was observed in the vaginal area upon assessment by the charge nurse and nurse manager. Assessment of Resident #2 revealed a scant amount of dried blood on the first and second digits of the left hand. CNA #1 reported finding Resident #1 in Resident #2’s room between 10:30 AM and 10:40 AM, and CNA #2 reported noticing blood in Resident #1’s brief at approximately 11:00 AM, at which time LPN #5 was notified. LPN #5 stated that around 11:00 AM she was informed by CNA #2 about the blood in Resident #1’s brief and that she observed a small amount of blood herself, then contacted the Director of Admissions and Marketing around 11:30 AM. The Director of Admissions and Marketing reported being notified at 11:30 AM and assessing Resident #1, then reporting the situation to the DON and the Administrator at around 12:00 PM. The DON stated she was informed by the Administrator around noon that there had been an incident between the two residents. The Administrator confirmed she was notified around 12:00 PM and acknowledged that, although facility policy and regulatory requirements mandated reporting allegations or suspicions of abuse to the State Agency within two hours, the report to OLTC was submitted at approximately 3:50 PM, close to four hours after discovery, because she wanted to gather more information and facts before reporting. This delay constituted the failure to ensure timely reporting of alleged or suspected sexual abuse as required by policy and regulation.
Failure to Update Care Plans with Fall Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that fall interventions were incorporated into person-centered care plans following falls for five out of seven residents reviewed. Each of these residents experienced a fall during a specified period, but their care plans were not updated to reflect new or revised interventions addressing the specific incidents. The absence of these interventions was confirmed through record reviews, care plan audits, and interviews with facility staff, including the RN Supervisor, Restorative CNA, DON, and Administrator. The residents involved had significant medical histories and varying degrees of cognitive and physical impairment. For example, one resident had severe cognitive impairment and multiple fractures, another had muscle wasting and hemiplegia following a stroke, and others had diagnoses such as congestive heart failure, encephalopathy, and gait abnormalities. Despite these complex needs and documented falls, their care plans did not include interventions specific to the falls that occurred during the review period. Interviews with facility staff revealed a lack of clarity and follow-through regarding the process for updating care plans after a fall. The RN Supervisor, who also served as the MDS Coordinator, acknowledged that fall interventions were not added to the care plans for the incidents in question. The DON and Administrator both confirmed that the responsibility for updating care plans with fall interventions rested with the MDS Coordinator, and that this had not been done for the affected residents. The facility's policy and procedure for care plans was requested but not provided during the survey.
Failure to Follow Transfer Protocols and Post-Fall Assessment Leads to Resident Injury
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to demonstrate competency in the care of a resident by not following the resident's care plan and by moving the resident prior to a nurse assessment following a fall. Specifically, one CNA attempted to transfer a resident from bed to wheelchair without using the required mechanical stand-up lift and without a second staff member to assist, as mandated by the resident's care plan. During this improper transfer, the resident's legs gave out, resulting in the resident falling to their knees on the floor. After the fall, the CNA requested assistance from another CNA, and together they moved the resident from the floor to a wheelchair before the resident was assessed by a nurse, despite the resident complaining of pain. Both CNAs admitted in interviews that moving the resident prior to a nurse's assessment was not appropriate. The resident was later found to have sustained an acute right femoral fracture, which required surgical intervention. The resident involved had a history of scoliosis, unsteadiness on feet, dementia, and was care planned for transfers with a mechanical stand-up lift and two-person assist due to dependency in activities of daily living and a recent history of falls and fractures. Staff interviews and record reviews confirmed that the care plan was not followed, and the required protocols for post-fall assessment were not adhered to, resulting in significant harm to the resident.
Removal Plan
- All licensed nursing staff and certified nursing assistants will be in-serviced by the Director of Nursing (DON)/designee on the proper steps taken after a resident has sustained a fall, to prevent serious harm, serious injury, serious impairment, or death.
- All Certified Nursing Assistants (CNAs) and licensed nurses will be educated and in-serviced by the DON/designee on proper resident transfers to prevent serious harm, serious injury, serious impairment or death.
- All CNAs and licensed nurses will be educated and in-serviced by the DON/designee on locating and reviewing the care plan prior to resident care and implementing the care plan during resident care to prevent serious harm, serious injury, serious impairment, or death.
- All licensed nurses and CNAs will be educated to check the Kardex /plan of care, located in the kiosk, on a resident and implement it, also the proper steps to take after a resident sustain a fall, and to be educated on the proper transfer technique to prevent serious harm, serious injury, or death.
- The DON/designee will visually monitor residents being transferred, visually monitor licensed nurses and certified nurse assistants on locating, reviewing the plan of care, and implementing the plan of care, also proper steps taken when a resident sustains a fall, by CNA, and licensed staff, to prevent serious harm, serious injury, or death 5 times a week for 8 weeks or until compliance is verified by Office of Long-Term Care.
- The DON/designee will present all findings to the monthly QAPI (Quality Assurance & Performance Improvement) committee for further review and recommendations.
Failure to Employ Licensed Administrator for Facility Oversight
Penalty
Summary
The facility failed to ensure that a Licensed Administrator was hired to oversee the day-to-day operations in accordance with federal, state, and local regulations. Review of the Administrator job description and facility policy confirmed that the position requires a current, unencumbered Administrator's license and that the governing body is responsible for ensuring proper management and oversight. However, interviews and documentation revealed that the facility had been without a licensed Administrator since the previous Administrator resigned in July 2025. The Compliance Officer, who was listed as the interim Administrator on official reports, confirmed she did not hold an Administrator's license and was not acting in that capacity. Further review of incident reports indicated that administrative duties were not being properly fulfilled, as evidenced by the Compliance Officer's name being listed in the Administrator's section of an incident report involving a resident injury. Interviews with the Director of Nursing and Human Resources confirmed that no one had been filling the Administrator role and that no candidates had been interviewed for the position since the resignation. The facility was actively advertising for the position but had not yet hired a replacement.
Failure to Implement Care Plan for Safe Resident Transfer
Penalty
Summary
The facility failed to consistently implement a comprehensive care plan for a resident with multiple diagnoses, including scoliosis, unsteadiness on feet, dementia, and a history of fractures and falls. The resident was assessed as having moderate cognitive impairment and required staff assistance for activities of daily living, including transfers, for which the care plan specified the use of a mechanical stand-up lift with two staff members. Despite this, on the day of the incident, a CNA attempted to transfer the resident without the stand-up lift and without a second staff member, resulting in the resident falling to the floor. The incident occurred when the CNA, believing the resident could bear weight and pivot, assisted the resident from bed to wheelchair without following the care plan's specified interventions. During the transfer, the resident's shoe slipped, causing the resident's legs to give out and leading to a fall. The CNA admitted to not using the stand-up lift and was uncertain if she had reviewed the care plan prior to providing care that day. Other staff, including another CNA and an LPN, confirmed that the resident was care planned for two-person assistance with a stand-up lift and that this protocol was not followed during the incident. As a result of the improper transfer, the resident sustained an acute fracture of the right femur, confirmed by radiology and requiring orthopedic consultation. Interviews with facility staff, including the DON and compliance officer, revealed that staff are expected to review and follow care plans for all residents, particularly regarding transfer methods. The facility's policy requires that care plan interventions be implemented as written, but in this case, the specified transfer protocol was not followed, directly leading to the resident's injury.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by regulation. On the evening of the incident, two CNAs were observed tying a sheet around a resident's waist and securing it to the back of a chair, while an LPN was present in the room. The incident was witnessed by another CNA, who reported it to the lead CNA, and subsequently to facility administration. The resident involved had severe cognitive impairment, with a diagnosis of dementia and anxiety, and had a history of agitation and striking at staff, but there was no physician order or care plan in place for the use of physical restraints for this resident. Facility documentation, including incident reports and witness statements, confirmed that the staff involved had knowledge of the facility's restraint policies, which prohibit the use of physical restraints for staff convenience and require a physician's written order for any restraint use. Despite this, the staff proceeded to restrain the resident without proper authorization or documentation. The facility's investigation included review of personnel files, interviews with involved staff, and review of relevant policies, all of which indicated that the restraint was not care planned or medically authorized. The incident was reported to the appropriate authorities, and the facility's internal investigation found that the staff involved had violated facility policy regarding restraint use. The resident was assessed following the incident, with no negative outcomes documented. The deficiency was identified based on observations, interviews, and review of facility records, which demonstrated a failure to protect the resident's right to be free from physical restraints except as authorized for medical treatment.
Failure to Verify Active LPN License for Agency Nurse
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) working in the facility held an active and unencumbered license, as required by state law and facility policy. The LPN in question was employed through an agency and later applied to work directly for the facility. The Administrator reported that the facility relied on the agency to verify the nurse's credentials and did not independently verify the license status of agency nurses. There was no policy in place for hiring agency nurses, and the facility did not maintain employee records for them. Documentation revealed that the LPN worked multiple shifts through the agency while the license was expired or encumbered, and the facility only confirmed the expired status after the LPN had already worked these shifts. Further review of records indicated that the LPN's license had been placed on probation by the Arkansas State Board of Nursing, with explicit restrictions prohibiting employment through a staffing agency. Despite this, the LPN continued to work in the facility via the agency. Facility policies required verification of licensure for all new hires, but this process was not followed for agency staff. The deficiency was identified through interviews, document reviews, and policy examinations, which collectively demonstrated the facility's failure to ensure compliance with licensure requirements for nursing staff.
Failure to Follow Manufacturer Guidelines During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure safe practices were followed according to the manufacturer's guidelines during the transfer of a resident using a mechanical lift. Specifically, two CNAs were observed assisting a resident with a mechanical lift transfer and locked the lift's back wheels while lowering the resident into a wheelchair. Multiple staff members, including CNAs and nursing leadership, provided conflicting information during interviews regarding whether the lift wheels should be locked or unlocked during the lowering process. However, review of manufacturer guidelines and staff competency evaluations confirmed that the wheels should remain unlocked when lowering a resident to prevent the lift from tipping. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease, rheumatoid arthritis, polyneuropathy, and muscle spasms, and was totally dependent on two staff members and a mechanical lift for all transfers. The care plan and staff training materials indicated the correct procedure, but staff practice did not align with these guidelines during the observed transfer. The facility did not have a specific policy for mechanical lift transfers and relied on manufacturer instructions, which were not consistently followed by staff.
Failure to Prevent and Control Scabies Outbreak Among Residents
Penalty
Summary
The facility failed to prevent the spread of a rash, later identified as scabies in multiple cases, among residents across different rooms, halls, and floors. Multiple residents developed rashes over several months, with initial cases appearing as early as July. Despite the presence of rashes and ongoing symptoms, the facility did not implement transmission-based precautions or isolation measures until after a confirmed diagnosis of scabies was received for one resident in mid-November. Prior to this, residents were treated with various medications, including antihistamines, steroids, antifungals, and antiparasitics, but there was no coordinated infection control response or consistent use of personal protective equipment (PPE) by staff. Medical records and interviews revealed that residents with cognitive impairments and complex medical histories, such as Alzheimer's disease, dementia, and stroke, were affected. Several residents had persistent or worsening rashes, and some were transferred to other facilities with active symptoms. Staff interviews indicated confusion and inconsistency in the approach to the rash, with some staff believing it was an allergic reaction and others suspecting a viral cause. Housekeeping staff reported not receiving special cleaning instructions or being informed of isolation protocols until well after the outbreak had spread. The facility's infection prevention and control policies required surveillance and the use of standard and transmission-based precautions for communicable diseases. However, these measures were not implemented in a timely manner. The infection preventionist and other staff confirmed that isolation, PPE use, and enhanced cleaning only began after a scabies diagnosis was confirmed, despite the rash affecting numerous residents and staff over several months. Documentation showed a significant increase in cases in November, with at least 28 residents affected by that time.
Some of the Latest Corrective Actions taken by Facilities in Arkansas
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