Citations in Arkansas C

Penalty

Fine: $14,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to develop and implement an effective, updated comprehensive care plan with individualized interventions in response to new onset wandering, exit‑seeking, and elopement‑related behaviors for a resident on a secured unit. The resident had a history of traumatic brain injury, cerebral infarction (stroke), altered mental status, and was admitted to the secured unit due to traumatic brain injury and elopement risk. A quarterly MDS showed the resident was cognitively intact with a BIMS score of 12 and independent with ambulation, but a later BIMS showed a score of 2, indicating moderately impaired cognition. Despite these changes and the resident’s known elopement risk, the care plan initiated months earlier contained only general interventions such as therapeutic activities and medication monitoring, and no additional or revised interventions were added after 08/25/2025 to address later‑emerging behaviors or elopement attempts. On 01/13/2026, multiple progress notes documented significant behavioral changes and explicit exit‑seeking behavior. Early that morning, staff recorded that the resident was up all night walking the halls, refusing to go to bed, entering other residents’ rooms, and voicing that they did not live in the facility. The resident stated an intent to get out of the window. Later that day, another note documented that the resident had been seeking elopement since returning from a home visit, admitted a desire to leave, had been looking for ways to get out, and followed staff out locked doors, showing force when staff tried to return the resident to the unit. A further note that evening described the resident talking loudly, being aggressive toward staff, and again stating a desire to get out of the facility. Although an elopement assessment was completed at that time, there were no new care plan interventions put in place to guide staff in preventing exit‑seeking or managing the aggressive behaviors. In the weeks that followed, staff interviews and documentation showed that the resident continued to exhibit wandering and exit‑seeking behaviors without corresponding care plan revisions. Staff reported that after a family home visit, the resident began trying to leave the unit, walked door to door asking how to get out, watched staff to see if they were paying attention, and talked about leaving. On the night of the elopement, camera footage showed the resident repeatedly moving between the room, day room, and bathroom before entering the room and not re‑emerging. A CNA on duty stated that the resident had been going in and out of the room earlier in the shift, then went back to the room and was not checked on again; the CNA also reported dozing off during the shift and not hearing the window break. In the early morning hours, staff discovered the resident’s window busted and the resident missing, and a progress note documented that the resident had eloped by throwing an end table through the window. A police report and interviews confirmed that the resident was found off‑site after nearly being struck by a vehicle, having left the facility to find family. Throughout this period, the facility did not update the resident’s care plan with individualized, effective interventions to address the clearly documented new onset wandering, exit‑seeking, and elopement behaviors.

Removal Plan

• Revise Resident #1's care plan to include individualized elopement prevention interventions updated to include all interventions per the Plan of Removal.
• Complete new elopement risk assessments for residents residing on the secured unit.
• For any resident scoring moderate or high risk, review care plans to ensure individualized elopement interventions are present.
• Complete environment exit safety checks.
• Revise and update all secured unit residents' care plans based on the Plan of Removal.
• Provide in-service education to nursing and direct care staff on the elopement policy and missing resident procedures.
• Provide in-service education to nursing and direct care staff on the definition and examples of elopement and exit-seeking behaviors, early warning signs requiring interventions, and requirements to notify the nurse, administrator, or DON of new or increased behaviors.
• Provide in-service education to nurse management responsible for updating care plans on mandatory care plan revision following behavior changes with individualized interventions.
• Order shatter-resistant film for front-facing secured unit windows and install it.
• Implement monitoring for the DON or designee to review the 24-hour report to identify new or increasing exit-seeking behaviors.
• Implement monitoring for the DON or designee to complete audits to verify elopement risk assessments are completed, individualized interventions are present, and documentation reflects staff implementation, then transition to routine QAPI monitoring.

Penalty

Fine: $14,020

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with known wandering and elopement risk, resulting in an elopement through a broken bedroom window. The resident had a history of traumatic brain injury, cerebral infarction, altered mental status, and wandering, and had been admitted to a secured unit due to elopement risk. An MDS assessment earlier in the year showed the resident as cognitively intact and independently ambulatory, but a later BIMS assessment showed moderately impaired cognition. The resident’s care plan identified the need for placement on a secured unit related to traumatic brain injury and elopement risk, with interventions focused on therapeutic activities and monitoring of psychotropic medications, but did not include enhanced supervision measures in response to escalating exit-seeking behaviors. In the weeks prior to the elopement, multiple progress notes and staff interviews documented increased exit-seeking and behavioral changes after the resident returned from a home visit. On one day, progress notes recorded that the resident was up all night walking the halls, going in and out of other residents’ rooms, voicing that they did not live in the facility, and stating an intention to get out through a window. Staff documented that the resident had been seeking elopement since returning from a home visit, had been looking for ways to get out, followed staff out locked doors, and showed force when staff tried to return the resident to the unit. Another note from the same day described the resident talking loudly, being aggressive toward staff, and repeatedly expressing a desire to leave the facility. An elopement assessment documented that the resident ambulated independently, had a history of following staff and others, and had been wandering halls and standing by locked exit doors after returning from home. On the night of the elopement, camera footage showed the resident repeatedly moving between the resident’s room, the day room, and the bathroom until entering the room at approximately 3:12 a.m. and not re-emerging. Staff interviews revealed that the CNA assigned to the unit acknowledged that the resident had been trying to start a fight with another resident for two days, that the resident typically went in and out of the room throughout the night, and that staff did not normally go back to check on the resident once the resident returned to the room. The CNA reported that she did not check on the resident after the last interaction around 9:30–10:00 p.m., that she sometimes could not take breaks due to staffing, and that she dozed off for about 30 minutes during the shift. The DON later stated that the CNA reported falling asleep and not hearing the window break. Staff discovered the broken window only when an LPN returned from break around 4:25 a.m., at which point the resident was found to be missing. Law enforcement records and interviews confirmed that the facility reported the resident missing in the early morning hours and that the resident was located off-site by police after a citizen reported almost striking the resident with a vehicle. The police officer stated that the resident was found near a school approximately 1.9 miles from the facility, requiring travel across an intersection and along areas without sidewalks. The resident told police they were walking to find family. Interviews with multiple CNAs and nurses indicated that the resident had been going door to door asking how to get out, watching staff to see if they were paying attention, and walking back and forth to doors after returning from a family visit. The DON and Administrator both stated they were not aware of prior elopement attempts beyond wandering and walking back and forth, and the MDS Coordinator reported she had not been informed of the January incident in which the resident voiced a plan to escape through a window. Facility policies required staff to know the location of residents under their care and to implement care plan strategies for residents at risk of wandering or elopement, but staff interviews showed that routine checks were not performed on the resident during the night of the incident and that the resident’s escalating exit-seeking behaviors were not effectively communicated or translated into increased supervision. A police incident report and witness statements further detailed that the resident exited the building by throwing an end table through the bedroom window. The facility’s own missing resident and wandering/elopement policies stated that staff are responsible for knowing residents’ whereabouts and that care plans for at-risk residents must include safety strategies and interventions. Despite documented behaviors such as wandering, standing at locked doors, following staff out locked exits, verbalizing intent to leave, and specifically stating a plan to get out through a window, there was no evidence in the record that supervision was increased or that staff adjusted monitoring practices during periods of heightened exit-seeking. Staff interviews also revealed that for several weeks there had often been only one CNA on the locked unit at night, and that the CNA on duty the night of the elopement positioned herself in a doorway with hall lights off and later admitted to dozing off. These actions and inactions resulted in the resident being able to break the window, leave the secured unit and facility, and travel a significant distance off-site before being located and returned by police.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to follow care-planned interventions for assistance and supervision for two residents, resulting in falls. Resident #2, admitted with Alzheimer's disease, spastic hemiplegic cerebral palsy, and neuromuscular bladder dysfunction, had a care plan requiring assistance of two staff for bathing/showering, bed mobility, personal hygiene, toilet use, and transferring. On 06/04/2025, the DON and an LPN responded to Resident #2's room and found the resident on their back on the floor after CNA #1 attempted to perform incontinent care alone, contrary to the care plan specifying a two-person assist for bed mobility, transfers, and personal hygiene. CNA #1 later stated that, upon hiring, it was not made clear how to access the electronic care plan system and that initial training on the system was brief and difficult to see. Resident #3 was admitted with spinal stenosis of the cervical region, cervical disc disorder with radiculopathy, generalized muscle weakness, and was receiving surgical aftercare following nervous system surgery. The care plan required assistance of one staff member for toileting, bathing/showering, dressing, and bed mobility, and assistance of two staff members for transferring, including use of a sliding board with two-person assist. A progress note documented that on 01/15/2026, an LPN was called to Resident #3's room and found the resident lying face down on the floor wearing a cervical collar, after the resident reported being told to dress themself. The resident later recounted that a CNA had helped them to a seated position at the edge of the bed, then left the room with another staff member while the resident attempted to dress themself, during which time the fall occurred. Interviews with multiple CNAs and facility leadership confirmed that CNAs were expected to obtain resident care instructions from the electronic care plan/Kardex system and that Resident #3 required staff assistance for all tasks except meals. CNA #2 acknowledged leaving Resident #3 unattended while assisting another staff member, despite the electronic care plan indicating the resident did not perform tasks alone. Another CNA reported sometimes being the only staff member in the room when transferring Resident #3 with a slide board, even though the care plan required two staff. The DON and Administrator stated that aides were trained one-on-one on the electronic care plans after morning huddles and that CNAs were expected to verify care requirements in the electronic care plan before providing care. The Medical Director stated it was his expectation that orders were followed as written in the care plan. Standard of practice cited requires that residents receive treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a newly admitted resident with schizophrenia and multiple comorbidities received prescribed medications according to physician orders and facility policy. The resident was admitted with active diagnoses including schizophrenia, anxiety disorder, moderate intellectual disabilities, thyroid disorder, and hyponatremia, and had a hospital discharge medication list that included medications for extrapyramidal and movement disorders, mood stabilization, antipsychotic treatment, thyroid replacement, hypertension, hyponatremia, sleep, and a vitamin. The admission MDS showed the resident was cognitively intact, and the care plan initiated the day after admission included interventions to administer anxiety and schizophrenia medications, educate the resident about toxic symptoms, and monitor for reactions and side effects, as well as interventions related to elopement risk and placement on a secured unit. On the day following admission, the Medication Administration Record documented that 15 scheduled doses of various medications were not administered. For multiple medications, including mood stabilizers, antipsychotics, thyroid medication, hypertension medication, an NSAID, a vitamin, and a medication for extrapyramidal and movement disorders, the MAR entries showed reasons such as “drug refused,” “meds unavailable,” or “drug not available.” Only one dose of a medication for hyponatremia at 4:00 PM on that day was documented as administered from the time of admission until the resident eloped the next day. Nursing staff interviews revealed that one LPN stated the resident did not receive medications on the day shift because they had not yet been delivered from the pharmacy, and another LPN stated that medications were delivered after the nighttime medication pass and was unsure whether any of the resident’s medications could have been obtained from the Pyxis. Facility records and leadership interviews further clarified the sequence of events. The drug manifest log showed that several of the resident’s medications, including those for hypertension, schizophrenia, extrapyramidal and movement disorders, mood stabilization, antipsychotic treatment, thyroid replacement, and an NSAID, were signed as received from the pharmacy at 8:40 PM on the day after admission. The DON confirmed that the omitted doses and rationales documented on the MAR were accurate and reiterated that facility policy required medications to be administered within one hour before or after the scheduled time. The Administrator confirmed that only one dose of any prescribed medication was administered from admission until the resident’s elopement and stated that certain psychotropic and anxiety medications were available in the Pyxis, but she could not determine why the LPN did not access them or why medications were not administered after pharmacy delivery.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.