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
An LPN found a resident’s insulin vial missing the opened date during administration, and a second vial was also unlabeled. A check of the medication cart found multiple residents’ multi-dose insulin vials without opened dates, while MARs showed the vials had been used repeatedly after pharmacy delivery dates. Staff, including the pharmacist, DON, ADON, and MD, stated the opened date should be on the vial and that opened insulin is limited to 28 days unless the manufacturer states otherwise.
A resident with type-2 diabetes, malnutrition, depression, and unsteadiness on feet required extensive help with bathing, dressing, transfers, toileting, and meals, but the facility repeatedly failed to document ADL care such as bed mobility, dressing, toileting, bowel and bladder elimination, transfers, and snacks. Interviews with the CNA, ADON, and DON confirmed that charting was expected to reflect care provided, and facility in-services directed staff to document meals, bowel movements, grooming, skin changes, refusals, and other assigned tasks accurately and on time.
A resident with HTN, ESRD on dialysis, CKD, DM2, and depression returned from the hospital with an order for an antihypotensive medication to be given TID and held if SBP was greater than 120. Facility staff entered and administered the medication incorrectly, giving it multiple times when SBP was above the ordered parameter and missing doses when SBP was below it. The family questioned the order during a care plan meeting, and the DON acknowledged the issue was a med error; the MD stated staff were expected to follow the order.
Failure to Timely Report Suspected Sexual Abuse: A resident with severe cognitive impairment, dementia, and dependence for ADLs had a suspected rape allegation discovered by staff, but the report was not sent to the State Agency within the required timeframe. The DON stated the facility believed it had 24 hours to report abuse unless bodily injury was involved, while other leadership stated abuse should be reported immediately or within a few hours.
Failure to Report Injury of Unknown Origin Within Required Timeframe: A resident with vascular dementia, contractures, and total dependence on staff was found to have multiple recent rib fractures after being sent to the ER for vomiting. The incident was not reported to OLTC within the required two hours, even though the Administrator and DON stated that injuries of unknown origin must be reported immediately and within two hours, and the facility policy required the same.
A resident with severe cognitive impairment, wandering behavior, and a known elopement risk exited through an alarmed kitchen door after staff cleared the alarm without checking the outside area. Staff later found the resident outside near another entrance and returned the resident inside. The resident had diagnoses including dementia, was care planned for wandering, and had orders and assessments documenting high risk for elopement.
Unlabeled Multi-Dose Insulin Vials
Penalty
Summary
The facility failed to ensure multi-dose insulin vials were labeled with the date they were first accessed. During an observation of insulin administration, an LPN identified that a resident’s fast-acting insulin vial did not have an opened date and stated she could not access it because it was not properly labeled. She stopped the administration process, reported the unlabeled vial to the DON, and the vial was discarded and replaced. A second resident’s rapid-acting insulin vial was then observed to also be missing the opened date. When the remaining insulin in the medication cart was checked, five of seven residents’ multi-dose insulin vials were found without an opened date. These included vials for residents receiving second rapid-acting, fast-acting, rapid-acting, and long-acting insulin. Facility MARs showed that the vials had been administered multiple times after the pharmacy delivery dates, including 31 administrations for one resident’s second rapid-acting insulin, six administrations for another resident’s fast-acting insulin, 31 and 25 administrations for two different vials used by one resident, 11 administrations for another resident’s second rapid-acting insulin, four administrations for another resident’s long-acting insulin, and 13 administrations for another resident’s long-acting insulin. The pharmacist stated the delivery date on the vial was not the opened date and that it was the facility’s responsibility to write the opened date on the vial. Staff interviews reflected that nurses expected the opened date to be on the vial, not only on the bag, and that insulin should not be used past 28 days. The facility policy titled Medication Labeling and Storage stated opened multi-dose vials are to be discarded within 28 days unless the manufacturer specifies otherwise.
Missed ADL Documentation and Assistance for a Resident With Extensive Care Needs
Penalty
Summary
The facility failed to provide and document ADL assistance for one resident who was admitted with type-2 diabetes, malnutrition, depression, and unsteadiness on feet. The resident’s MDS showed cognitive intactness with a BIMS score of 15, but also showed the resident needed substantial to maximal assistance with toileting hygiene, lower body dressing, footwear, chair/bed transfer, toilet transfer, and tub/shower transfer, along with partial to moderate assistance with bed mobility and occasional bowel and bladder incontinence. The care plan identified an ADL self-care performance deficit and directed extensive assistance with bathing and dressing, one-person assistance with transfers, set-up assistance with meals/eating, and limited assistance with bed mobility. Record review of the ADL Task Documentation Survey Report showed multiple missed documentation entries for the resident’s care. In February, bed mobility, dressing, toileting ADLs, and snacks were not documented on several occasions. In March, transferring was not documented on multiple occasions, bowel and bladder elimination was not documented for 13 days, and snacks were not documented on 6 days. In April, bowel and bladder elimination was not documented 22 times, transferring 9 times, and snacks 11 times. The report also included a resident-specific in-service stating the resident was to be assisted as needed and every two hours with all ADL care, and to get up every day for all meals except breakfast unless refused. During interviews, the Lead CNA stated that charting was checked at the end of the day and that in-services had been completed on charting, with disciplinary action possible if charting was not done. The ADON stated that documentation acknowledges what care was done and that if it is not documented, the care was not done; the DON similarly stated that documentation shows the care given and that if documentation is not done, the care was not done. Facility in-services instructed staff to document meals, bowel movements, grooming, skin changes, resident concerns, showers, refusals, and other assigned tasks accurately and before the end of the shift. The facility policy stated that residents unable to carry out ADLs independently are to receive appropriate support and assistance with hygiene, mobility, elimination, and dining.
Medication Administered Contrary to BP Parameters
Penalty
Summary
The facility failed to ensure medication was administered according to accepted professional standards and failed to follow physician orders for one resident who had multiple chronic conditions, including type 2 diabetes mellitus, morbid obesity, hypertension, peripheral vascular disease, chronic kidney disease, dependence on renal dialysis, and depression. The resident was admitted with a care plan noting hypertension, depression, use of an antidepressant, and dependence on hemodialysis for ESRD. After a hospital discharge, the resident returned to the facility with an order for an antihypotensive medication to be given three times daily and held if systolic blood pressure was greater than 120. The medication order summary initially showed the antihypotensive medication was entered with a note that changed the order to give it when the blood pressure was greater than 120, and that order remained until it was discontinued and replaced with the correct hold parameter. Review of the June 2026 MAR showed the medication was administered nine times when the resident's systolic blood pressure was greater than 120 and was not administered two times when the systolic blood pressure was less than 120, for a total of eleven medication errors. The medication was intended for symptomatic orthostatic hypotension and could cause marked elevation of supine blood pressure. During interviews, the resident's family stated they questioned why the medication was being given when the order was to hold it if systolic blood pressure was greater than 120, and the DON acknowledged it was a medication error. The APRN stated the medication should always be given with a blood pressure check before administration, and the MD stated staff were expected to follow orders and should have held the medication when systolic blood pressure was greater than 120. The DON stated the error was identified by staff, the on-call physician was notified, and the facility completed an internal investigation documenting disciplinary action and an in-service, but the report shows the medication had already been administered incorrectly multiple times before the error was identified.
Failure to Timely Report Suspected Sexual Abuse
Penalty
Summary
The facility failed to report a suspected sexual abuse allegation within the required two-hour timeframe. Resident #2 was admitted with diagnoses including muscle weakness, obesity, altered mental status, dementia, and hearing impairment, and a re-entry MDS showed severe cognitive impairment with dependence on staff for toileting, showering, dressing, and several mobility-related activities. The resident’s care plan also documented impaired cognitive skills and impaired communication, along with the need for assistance with activities of daily living and mechanical lift transfers. A facility reportable document identified an allegation of rape discovered at 10:15 AM on 04/27/2026, but the report was not submitted to the State Agency until 11:45 AM on 04/28/2026 by the DON. During interviews, the DON stated the facility believed it had 24 hours to report abuse unless bodily injury was involved, while the Business Office Manager stated abuse should be reported immediately and before leaving for the day. The Administrator stated the facility had about three to four hours to report abuse. The facility policy titled Protecting Resident During a Suspected Abused stated that suspected abuse would be investigated immediately and OLTC would be notified by 11:00 AM the next day.
Failure to Report Injury of Unknown Origin Within Required Timeframe
Penalty
Summary
The facility failed to ensure that an injury of unknown origin was reported to the Office of Long-Term Care within two hours for one resident. The resident was admitted with diagnoses including vascular dementia and contracture of an unspecified joint, was later documented as comatose and dependent on staff for care, and had care plans indicating the need for a mechanical lift with two staff for transfers and two staff for bed mobility. Hospital records showed the resident had multiple rib fractures, including right-sided fractures of the second through seventh ribs and left-sided nondisplaced rib fractures, described as most likely recent. An incident report documented that the resident was sent to the emergency room for vomiting and that hospital records were received showing rib fractures, but it did not indicate when OLTC was notified. The OLTC incident report showed the facility became aware of the fractures at 10:00 AM and submitted the report at 1:16 PM. During interviews, the Administrator and DON stated that an injury of unknown origin should be reported immediately and within two hours, and the DON stated she was not sure why the injury was not reported within that timeframe. The facility policy stated that serious bodily injury and injuries of unknown source should be reported within two hours.
Failure to Supervise a Wandering Resident During an Exit Door Alarm
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for one resident who was reviewed for accident and supervision. The resident had diagnoses including Alzheimer's disease, dementia, unsteadiness on feet, and difficulty walking. The quarterly MDS showed a BIMS of 00, indicating severe cognitive impairment, and the annual MDS showed a SAMS of 3, indicating the resident was severely impaired for daily decision making. The resident was care planned as high risk for wandering, with documentation that the resident liked to walk in the halls independently and that staff were aware of the elopement risk. The care plan included diversional interventions, supervised walks outside, and a wander alert bracelet. Physician orders directed staff to monitor the resident for wandering, pacing, and rummaging. A wandering risk assessment documented that the resident was at high risk for wandering and had a history of wandering behaviors. On the evening of the incident, an alarm sounded from the kitchen exit door. Staff interviews and witness statements showed that one CNA cleared the active alarm without checking the outside grounds or exterior perimeter of the door, even though the facility policy required the outside area of an alerting exit to be searched immediately. Another CNA later found the resident outside the facility near the old dining room area and brought the resident back inside. The administrator’s review of the alarm log confirmed the alarm sounded at the time the resident eloped, and the internal investigation determined the resident exited through the kitchen door, traveled outside across uneven ground and pavement, and re-entered through the old dining room door.
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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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