Citations in Arkansas
Statistics, citations 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 renal dialysis dependence, muscle weakness, and CVA history was being transported in a wheelchair when a driver started the van before fully securing the wheelchair securement system. While traveling uphill, the wheelchair fell backward, causing a T1 fracture and subdural hematoma. The DON initiated CPR, EMTs transported the resident to the ED, and the resident later died from anoxic brain injury after cardiac arrest.
A resident with severe cognitive impairment, Alzheimer’s disease, and behavioral issues was involved in an incident where the resident threw water on an LPN. Video showed the LPN following the resident, taking a cup from the resident’s hands, and pouring the cup’s contents onto the resident’s head while other staff watched. Interviews also showed staff knew the resident became upset when items were removed from the room in the resident’s presence, and one CNA did not report the incident because they were unsure it needed to be reported.
A CNA and a resident engaged in a verbal confrontation after the resident shouted at the CNA and called her lazy. The CNA responded by telling the resident to shut up and calling the resident racist, while another CNA and an LPN observed the yelling and arguing. The resident had diagnoses including dementia, depression, and mood disorder, and the facility policy stated residents have the right to be free from verbal abuse.
Improper Mechanical Lift Transfer Resulted in Resident Fall: A resident with a history of right hip fracture, weakness, and unsteadiness fell during a mechanical lift transfer after two lift pads were placed under the resident. CNAs used the lift while the resident had two slings/pads under them, causing the pads to separate and the resident to fall to the floor, hit their head on the lift, and land on their right side. The resident was later sent to the ER and hospital records showed a closed right hip fracture.
Failure to report witnessed abuse incident: A resident with severe cognitive impairment and a history of behavioral issues threw water at an LPN, and video later showed the LPN following the resident, taking cups from the resident, and pouring liquid on the resident's head while other staff watched. CNAs who witnessed the event did not report it, and the DON later discovered the incident during video review.
A resident with a history of fractures, falls, neuropathy, and gait impairment was injured after a CNA performed a one-person transfer instead of the required mechanical lift transfer. The resident reported a cracking sound and severe leg pain, but an LPN did not promptly assess the change in condition or notify the provider when pain remained unresolved after PRN medication. Later, two CNAs again transferred the resident without the required lift, despite knowing the care plan, and the resident was ultimately found to have an impacted supracondylar fracture of the distal femur.
Wheelchair Transport Failure Resulted in Resident Injury and Death
Penalty
Summary
The facility failed to ensure that two front locking mechanisms were locked during wheelchair transport for one resident who was being taken to dialysis. The resident had diagnoses including dependence on renal dialysis, muscle weakness, and cerebrovascular disease, was cognitively intact with a BIMS score of 15, and was dependent on staff for all activities of daily living, using a manual wheelchair for mobility. The resident was also on antiplatelet medication and had a care plan noting dialysis three times weekly. On the day of the incident, the driver loaded the resident and another resident into the van and applied the wheelchair brakes and front wheelchair securement straps. The driver then started the van to run the air conditioner before completing the securing process. The driver later stated that the normal process was interrupted because they were in a hurry, and that they thought the front straps were tight enough but they were not. During transport back from the dialysis center, while traveling uphill, the resident's wheelchair fell backward and the driver stopped the van and called the DON. The DON arrived within minutes and found the resident unresponsive with no pulse, began CPR, and EMTs transported the resident to the ED. ED records showed a T1 vertebral fracture and a 3-millimeter subdural hematoma. The resident was later transferred to a tertiary care center and died from an anoxic brain injury resulting from cardiac arrest. Interviews with the other resident, the driver, the DON, and the maintenance director confirmed the sequence of events and that the front securement straps had not remained secured during transport.
Physical abuse of a cognitively impaired resident
Penalty
Summary
The facility failed to ensure a resident with severe cognitive impairment was free from physical abuse and mental anguish. Resident #57 had an annual MDS showing a BIMS score of 06, diagnoses including Alzheimer’s disease, anxiety, bipolar disorder, and psychotic disorder, and a care plan noting confusion, verbal aggression, yelling, physical aggression, and refusal of showers or baths. The care plan also noted the resident was in a secure unit and could become agitated when staff attempted care or when items were removed from the room. On the reported incident, the resident threw water on an LPN, and staff then continued interacting with the resident in a way that escalated the situation. Video footage showed the LPN following the resident down the hall, touching the resident’s arm, taking a cup from the resident’s hands, and then pouring the contents of the cup onto the resident’s head. Other staff were in the area and observed the interaction. The report also described CNA staff removing items from the resident’s room in front of the resident, despite staff interviews indicating they usually removed items when the resident was not present because the resident became upset when seeing items taken away. Staff interviews reflected that the resident had a hoarding behavior and became upset when staff removed items from the room in the resident’s presence. One CNA stated the resident threw water on the LPN and the LPN got into the resident’s face and said, "let's go clean out your room," but did not report the incident because they were unsure it needed to be reported. The LPN stated she was irritated, took the cups from the resident, and gestured like she was going to dump tea on the resident. The DON stated the resident’s behaviors were expected on a dementia unit, and the Administrator stated he believed the LPN went to clean out the room to cause frustration.
Verbal Abuse of Resident by CNA
Penalty
Summary
The facility failed to keep a resident free from verbal abuse when a CNA and Resident #30 became involved in a verbal confrontation in the hallway. Resident #30 was admitted with diagnoses including diabetes, dementia, high blood pressure, coronary artery disease, hearing loss, pain, mood disorder, depression, muscle wasting and atrophy, and breast cancer. The resident’s quarterly MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and also documented verbal behaviors such as screaming and cussing at others one to three days during the look-back period. The resident’s care plan described repetitive anxious complaints, repetitive complaints against staff, attempts to play staff against each other, and provoking other residents to make complaints, with interventions to intervene as needed, maintain a calm environment, establish a trusting relationship, and communicate with family as needed. The MAR showed active medications for anxiety, depression, and dementia, along with behavior monitoring that recorded zero behaviors for the month of July. The facility policy stated residents have the right to be free from verbal, sexual, physical, and mental abuse, and that abuse by anyone, including staff, is prohibited. During the incident, the CNA stated the resident shouted at her and called her lazy, and the CNA responded by telling the resident to shut up and stating the resident was racist. Another CNA and an LPN both observed yelling and arguing between the CNA and the resident, and the LPN heard the CNA tell the resident to shut up talking to her. The DON later stated the CNA was written up, counseled to walk away from altercations, and removed from the hall where the resident lived.
Improper Mechanical Lift Transfer Resulted in Resident Fall
Penalty
Summary
The facility failed to prevent a resident from falling during a mechanical lift transfer. Resident #60 was admitted with diagnoses including a right hip fracture, pressure ulcers, weakness, and unsteadiness on feet. The resident’s significant change MDS showed a BIMS score of 14, indicating the resident was cognitively intact, and the care plan stated the resident required a mechanical lift for transfers with two staff members assisting and equipment kept in proper working condition. According to the reportable event, CNA #5 placed two lift pads under the resident before the resident was moved in a wheelchair for an appointment. CNA #5 stated she did this because the resident slid down in the wheelchair and she thought two lift pads would help staff pull the resident up, although she had not been trained to use two lift pads for a transfer. CNA #5 told the oncoming shift that two lift pads were under the resident. Later, two other staff members used a mechanical lift to move the resident, and the two pads separated, causing the resident to fall onto the floor. CNA #7 stated the resident fell out of the lift pads while staff were moving the lift, and the resident hit their head on the lift and fell onto their right side. CNA #6 stated she knew the resident had two lift pads under them and used the mechanical lift anyway, and that staff were not trained to use the mechanical lift with two lift pads under a resident. The resident was assessed after the fall and sent to the ER, and hospital records later showed an admission for a closed right hip fracture.
Failure to Report Witnessed Abuse Incident
Penalty
Summary
The facility failed to ensure staff reported a witnessed incident of abuse involving a resident with severe cognitive impairment. Resident #57 had a BIMS score of 6, diagnoses including Alzheimer's disease, anxiety, bipolar disorder, and psychotic disorder, and resided in the secured unit with a history of confusion, verbal aggression, yelling, physical aggression, and refusals of showers. On the incident date, the resident threw water at an LPN, and video footage later reviewed by the DON showed the LPN following the resident down the hall, touching the resident on the arm, taking cups from the resident's hands, and pouring the contents of a cup on the resident's head. Other staff, including CNAs and a medication aide, were seen witnessing the incident. Although staff witnessed the event, CNA #5 stated she did not report it because she was not sure it needed to be reported, and CNA #6 stated she did not know it was not a reported incident by another staff member. The DON discovered the incident during a later review of video footage and reported it to the Administrator, who stated the allegation was then investigated and reported to outside authorities. The facility policy required alleged, witnessed, or suspected resident maltreatment to be immediately reported to the Administrator or immediate supervisor and investigated by facility management.
Failure to Follow Transfer Plan and Respond to Acute Pain
Penalty
Summary
The facility failed to protect a cognitively intact resident from neglect when multiple staff members did not follow the resident’s established transfer and pain-management care plan after a shower transfer incident. The resident had diagnoses including diabetes with neuropathy, muscle wasting and atrophy, prior fractures, repeated falls, lack of coordination, and gait abnormalities. The resident’s care plan required two staff members and a mechanical lift for all transfers, but a CNA performed a one-person pivot transfer to a shower chair, and the resident reported hearing a cracking sound and having pain in the leg. After the transfer, staff did not respond appropriately to the resident’s acute change in condition. An LPN was informed that the resident was in pain and that the knee appeared swollen, but the LPN did not immediately assess the resident, did not timely notify the provider, and did not document any assessment when the resident continued to report pain. The MAR showed the resident received PRN pain medication in the morning, and follow-up documentation later that morning recorded the medication as ineffective with pain still rated 7/10, but no further action or provider notification was documented at that time. The facility’s pain policy required acute pain or significant worsening of chronic pain to be assessed every 30 to 60 minutes until relief was obtained and to be reported to the physician or practitioner. Later that day, two CNAs transferred the resident from the shower chair to the bed using a gait belt and a two-person transfer, despite knowing the resident required a mechanical lift and that the sling was not in place. The resident was actively reporting severe pain during this time. The resident was not diagnosed until the next day, when imaging revealed an impacted supracondylar fracture of the distal femur. Interviews showed the CNAs knew the resident’s transfer requirement but chose not to use the lift, and the DON stated the CNAs should not have decided to use a two-person transfer for a resident care planned for a mechanical lift.
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Compliance trends in Arkansas
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
No tags meet the emerging criteria for this period — nothing rare is spiking right now.
Trusted data from CMS and state health departments
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