Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Springs Of Pinnacle Mountain during CMS and state inspections, most recent first.
A resident with a recent abdominal surgery and PEG tube was given a regular meal instead of the prescribed clear liquid diet and tube feedings, due to miscommunication and errors in transcribing dietary orders between nursing and dietary staff. The resident consumed part of the inappropriate meal, experienced ongoing nausea and vomiting, and was not adequately assessed or monitored for changes in condition, ultimately resulting in the resident being found unresponsive.
A resident with chronic pain and multiple comorbidities did not receive scheduled prescription pain medication for over 24 hours due to the facility running out of the medication and delays in obtaining prior authorization. Staff were unclear about the process for reordering and obtaining PAs, resulting in missed doses and unmanaged pain.
A resident with multiple diagnoses and intact cognition made an abuse allegation against a MA-C. The facility's internal investigation indicated law enforcement was notified, but no police report was found, and follow-up to confirm reporting was not conducted by the Administrator or DON, resulting in the allegation not being formally reported as required.
The facility failed to ensure food safety and proper hand hygiene. Food preparation occurred near a dirty sink, and kitchen equipment was not sanitized before storage. During meal service, CNAs did not sanitize hands after touching unclean surfaces or before assisting residents with meals, despite being aware of the facility's hand hygiene policies.
The facility failed to ensure call lights were within reach for two residents, including a non-ambulatory, non-verbal resident. Observations showed call lights on the floor behind residents' chairs. Staff interviews confirmed the expectation for call lights to be accessible, and QA meeting minutes included a Call Light Monitoring Tool.
The facility failed to formulate and document advance directives for two residents, one with epilepsy and another with Alzheimer's disease. Both residents did not have advance directives in their clinical records, and neither could recall being asked to formulate one. The ADON and DON confirmed the absence of these documents, which should have been completed upon admission.
The facility failed to maintain residents' wheelchairs in good repair, with observations showing torn and peeling vinyl/leather on armrests and backrests, posing a hazard for skin tears. The maintenance policy requires safety measures, but no reports were made to address the needed repairs, as confirmed by a CNA and the DON.
A resident with low back pain and polyarthritis did not receive her scheduled Hydrocodone-Acetaminophen on time, resulting in a delay of over an hour. The resident, who was cognitively intact, expressed discomfort due to the delay. The RN responsible admitted to misreading the schedule, and the DON confirmed the importance of timely medication administration to manage pain effectively.
Failure to Follow Dietary Orders and Ensure Proper Communication of Diet Requirements
Penalty
Summary
A deficiency occurred when a resident with a recent Whipple procedure, hernia repair, and PEG tube placement was not provided care in accordance with physician orders and dietary requirements. The resident was admitted with orders for a clear liquid diet and tube feedings, with specific instructions to gradually increase the tube feeding rate if tolerated. Despite these orders, the resident was given a regular meal consisting of a cheeseburger and fries, which was not consistent with the prescribed clear liquid diet. Multiple staff interviews and documentation confirmed that the resident consumed part of this meal and subsequently experienced nausea and vomiting. The facility's process for communicating and verifying dietary orders failed, resulting in the resident receiving the incorrect meal. Staff interviews revealed confusion and miscommunication between the dietary and nursing departments, with discrepancies in how diet orders were transcribed and interpreted. The dietary system listed the resident as having a 'regular' diet, while the medical record and physician orders specified a clear liquid diet. Staff responsible for preparing and delivering meals did not adequately verify the correct diet order before serving the meal to the resident. Following the consumption of the inappropriate meal, the resident experienced ongoing nausea, vomiting, and was later observed with bloody vomitus. Documentation and interviews indicated that the resident's symptoms persisted, and there was a lack of timely and thorough assessment and communication regarding the change in the resident's condition. The resident was ultimately found unresponsive and pronounced deceased. The care plan also failed to address the resident's PEG tube status and feeding requirements, further contributing to the deficiency.
Failure to Administer Scheduled Pain Medication Due to Lapse in Medication Supply
Penalty
Summary
Resident #4, who was admitted with multiple diagnoses including a right ankle fracture, chronic pain syndrome, and various mental health disorders, was prescribed a combination opioid/acetaminophen pain medication to be administered four times daily. The resident was cognitively intact and had a care plan in place for pain management. On observation, the resident was found to be in visible discomfort, reporting severe pain and sweating, and stated that they had requested pain medication but were told none was available. Review of medication records showed that several scheduled doses were not administered as prescribed, with gaps in administration documented on the Medication Administration Record and the Controlled Substance Log. The last dose before the gap was given in the evening, and the next dose was not administered until over 24 hours later. The failure to provide the scheduled pain medication was due to the medication supply running out, as confirmed by the empty medication card and log. Staff interviews revealed confusion regarding the process for obtaining prior authorization (PA) for controlled substances, with nurses unsure of their responsibilities and the timing for reordering. The pharmacy confirmed that a PA was required and that the facility was responsible for obtaining it. The facility did not utilize the emergency medication box because it did not contain the correct dosage, and staff expressed concerns about exceeding safe acetaminophen limits due to the resident's liver condition. Facility policy required medications to be administered according to prescriber orders, but this was not followed in this instance.
Failure to Ensure Timely Reporting of Abuse Allegation to Authorities
Penalty
Summary
The facility failed to properly report an abuse allegation involving a resident with diagnoses including type II diabetes mellitus, cognitive communication deficit, schizophrenia, and bipolar disorder. The resident, who was cognitively intact as indicated by a BIMS score of 15, made an abuse allegation against a Medical Assistant - Certified. The facility's internal investigation report stated that the incident was reported to law enforcement, but the investigation packet did not contain a police report. When the police records department was contacted, they confirmed that no records were found regarding the incident. Further review revealed that the Administrator had left a message with the police department about the incident but did not follow up to ensure the report was received or acted upon. The Director of Nursing confirmed that no follow-up was conducted to verify that the police had been properly notified. This lack of follow-up resulted in the abuse allegation not being formally reported to the appropriate authorities as required by the facility's policy.
Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards in the kitchen and during meal service. Observations revealed that food preparation was conducted in close proximity to a dirty sink containing brown liquid and food debris, which posed a risk of cross-contamination. Additionally, kitchen equipment such as a colander was not properly washed and sanitized before being stored. Interviews with the Dietary Manager and staff confirmed awareness of these issues, attributing some of the problems to a malfunctioning garbage disposal that had been recently repaired. During meal service, staff members did not adhere to hand hygiene protocols. A CNA was observed serving food and assisting a resident with eating without sanitizing hands after touching potentially contaminated surfaces, such as tables and chairs. Another CNA handled a resident's food with bare hands without sanitizing them. Interviews with the CNAs confirmed that they were aware of the hand hygiene policies, which require sanitizing hands before and after handling food and assisting residents with meals.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs for two residents. Resident #11, who was non-ambulatory, dependent on staff for all activities of daily living, and non-verbal, did not have a call light within reach during observations on two separate occasions. On the first occasion, the call light was on the floor behind the resident's chair while they were sitting in front of the TV. On the second occasion, both Resident #11 and their roommate, Resident #26, were observed sitting in chairs with their call lights on the floor behind them, out of reach. Interviews with staff, including a CNA, an MA-C, and an LPN, confirmed that staff should ensure residents have call lights within reach to notify staff if they need assistance. The facility's QA meeting minutes included a Call Light Monitoring Tool, which was issued and signed by staff regarding call light placement and answering.
Failure to Formulate and Document Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were formulated and documented for two residents, as required by their policy. Resident #13, who was diagnosed with epilepsy and had a BIMS score indicating cognitive intactness, did not have an advance directive available in their clinical record. The Assistant Director of Nursing (ADON) confirmed the absence of the document and acknowledged that the resident had not been asked to formulate an advance directive upon admission. Similarly, Resident #23, diagnosed with Alzheimer's disease and having a BIMS score indicating moderate cognitive impairment, also lacked an advance directive in their clinical record. The resident could not recall being asked to formulate one. The ADON and the Director of Nursing (DON) both confirmed that the advance directive was neither acknowledged nor documented, which should have been completed upon admission according to the facility's policy.
Failure to Maintain Wheelchairs in Good Repair
Penalty
Summary
The facility failed to maintain residents' personal wheelchairs in good repair, which could potentially lead to injuries. Observations revealed that the wheelchairs of three residents had significant damage, including torn and peeling vinyl/leather on armrests and backrests, exposing the foam underneath. These conditions were confirmed by a Certified Nursing Assistant (CNA) and the Director of Nursing (DON) to pose a hazard, as they could cause skin tears and were difficult to clean. The facility's maintenance policy, revised in 2009, requires maintenance personnel to ensure the safety and well-being of all concerned by providing services to all areas of the building, grounds, and equipment. However, the CNA was unaware of any reports made regarding the need for wheelchair repairs, and the maintenance staff confirmed that no such reports had been received. The maintenance request book, located at the front nurse's station, was not utilized to report the necessary repairs for the wheelchairs, leading to the deficiency.
Failure to Administer Scheduled Pain Medication on Time
Penalty
Summary
The facility failed to administer scheduled pain medication to a resident diagnosed with low back pain and polyarthritis. The resident, who was cognitively intact with a BIMS score of 15, had a prescription for Hydrocodone-Acetaminophen to be taken four times daily. However, on one occasion, the medication was administered late, at 10:50 AM instead of the scheduled 9:00 AM. The resident expressed that she had been waiting over an hour for her pain medication and was observed clenching her face, indicating discomfort. The delay in administering the medication was confirmed by Registered Nurse #8, who admitted to misreading the schedule. The Director of Nursing emphasized that pain medications should be administered on time, within one hour before or after the scheduled time, to effectively manage pain. Despite the resident stating that she mostly receives her medication on time, there were instances of delays, highlighting a lapse in adhering to the facility's medication administration policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Little Rock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory Heights Health And Rehab, Llc | 2.8 mi | — | 0 | 0 |
| Pleasant Valley Rehabilitation And Nursing | 4.7 mi | — | 0 | 0 |
| The Lakes At Maumelle Health And Rehabilitation | 6.3 mi | — | 5 | 0 |
| The Blossoms At Breckenridge Rehab & Nursing Cente | 6.9 mi | — | 4 | 0 |
| Presbyterian Village, Inc | 7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.