4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fayetteville, AR
4-star overall rating with 3-star inspections with 4 recent health deficiencies
1179 North College Avenue, Fayetteville, AR
(479) 444-7001
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
90
Certified beds
Average residents
57
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.73
Registered nurse staffing
LPN hours / resident day
1.44
Licensed practical nurse staffing
Aide hours / resident day
2.85
Nurse aide staffing
Weekend hours
4.14
Weekend nurse staffing
RN turnover
71%
Annual RN turnover
Total nurse turnover
62%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
2.0
1.5 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
2.2
2 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.9%
5.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.9%
0.7 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
1.4%
0.1 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.3% |
4.9%
0.6 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.5% |
21.8%
2.7 pts worse
|
19.6%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 43.1% |
12.5%
30.6 pts worse
|
16.7%
26.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.0% |
11.4%
0.6 pts worse
|
16.3%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
10.4%
1.9 pts worse
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
0.7%
2.5 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.1%
1.1 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
14.6%
9.5 pts worse
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
4.6%
1.2 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
81.8%
11.6 pts better
|
81.7%
11.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-02-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-25
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-15
Inspection history
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-04-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-18
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-04-18
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-18
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-02-25
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-25
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-25
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-25
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-02-25
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-02-25
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-25
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-02-25
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-25
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-02-25
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-02-25
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-25
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-04-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-15
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-04-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-15
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-11-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-21
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-21
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-11-15
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-11-21
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-15
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-11-15
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-11-21
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-15
Health
Implement a program that monitors antibiotic use.
Corrected 2022-11-15
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-11-15
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-11-15
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-11-15
Health
Assess the resident when there is a significant change in condition
Corrected 2022-11-21
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-11-21
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-11-15
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-11-15
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-11-15
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-10-21
Penalties and ownership
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Fayetteville, AR
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Fayetteville, AR
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Fayetteville, AR
2-star overall rating with 2-star inspections with $58,006 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Jump out