Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Hot Springs Health & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to update and maintain current individualized care plans for several residents, leading to deficiencies in care. For example, a resident's care plan had not been updated since 2018 despite complex diagnoses, and another resident's care plan lacked documentation of sleep apnea equipment refusals. Other residents had care plans that did not accurately reflect their current conditions, indicating a systemic issue with maintaining accurate care plans.
The facility did not ensure staff followed safe food handling practices and proper use of hair and beard coverings. A staff member with a goatee was observed cooking and plating lunch trays without a beard net, and another staff member with long hair and a full beard was in the kitchen without a hairnet or beard net. This was contrary to the facility's Personal Hygiene Standards policy.
The facility failed to implement essential policies for Advance Directives, PASARR Screenings, Care Plans, and Accidents/Hazards. A resident's POLST form was incomplete, another lacked PASARR screenings, and a third had no comprehensive care plan. Additionally, a resident's unsafe interaction with a call light cord highlighted the absence of a safety policy. Staff confirmed the lack of these critical policies, posing risks to resident safety.
The facility failed to implement effective performance improvement actions and lacked necessary policies, affecting resident care. Staff admitted the absence of active PIPs for critical areas like falls and EHR inaccuracies. A draft PIP for falls with fractures was incomplete, missing key components. The QAPI plan was not followed, leading to unaddressed deficiencies impacting residents' medical records and care plans.
The facility failed to ensure complete advanced directives for four residents, risking unmet wishes. One resident's POLST lacked a guardian's signature, another was missing physician details, a third lacked physician information, and a fourth was undated. A staff member confirmed the requirement for complete POLST forms and the absence of an Advanced Directives policy.
The facility physician failed to document assessments or visits for four residents, leading to missing current history and physicals in their electronic medical records. A staff member acknowledged the issue, stating efforts were underway to update documentation, with about half of the records currently up to date.
Expired medications were found in the facility's stock medication cupboard, including Magnesium Chloride, Ferrous Gluconate, Iron 27 mg, Meclizine, COQ10, and Senna Plus, with expiration dates from April to September 2024. A staff member indicated that the pharmacy was responsible for checking expiration dates and removing expired medications.
A facility failed to complete a PASARR Level I or II screening for a resident with potential mental disorders or intellectual disabilities. The resident's EHR showed no PASARR screening since admission. Staff acknowledged the oversight and the absence of a policy for PASARR screenings. It was confirmed that the new facility should complete a PASARR Level I screening by the day of admission for transferred residents.
A facility failed to implement a comprehensive, resident-centered care plan for a resident, addressing their physical and psychological needs. A staff member admitted the absence of a care plan policy, relying instead on the RAI manual. Although a baseline care plan was initiated and revised, a comprehensive care plan was not developed post-admission, highlighting a deficiency in care planning.
A resident did not receive necessary oral care as their dentures were not placed in their mouth, remaining on the sink without adhesive. The CNAs did not assist with the dentures for a few days, as per a nurse's decision to allow the resident's mouth to rest. The staff was unaware of the oversight until it was brought to their attention, after which the dentures were placed, making the resident happy. The resident's care plan required full upper dentures and mouth care, which was not adequately followed.
A resident with dementia in an LTC facility was observed misusing a call light cord, wrapping it around her body and neck, posing a safety hazard. Staff expressed concern and uncertainty about managing the resident's behavior, and the facility lacked a policy for call light safety assessment. The deficiency was noted due to inadequate supervision and failure to address environmental safety.
Deficiencies in Updating and Maintaining Resident Care Plans
Penalty
Summary
The facility failed to update and maintain current individualized care plans for several residents, leading to deficiencies in care. For instance, Resident #1's care plan had not been updated to reflect changes in behavior and care needs since 2018, despite having multiple complex diagnoses such as severe intellectual disabilities, bipolar disorder, and moderate dementia. Staff interviews revealed that care plans were not regularly updated and were often not used by staff due to their cumbersome nature. Instead, staff relied on individualized service plans within the electronic medical record, which were not always up-to-date or comprehensive. Resident #22's care plan did not include any information about his sleep apnea equipment preferences or refusals, despite the resident consistently refusing to use the EPAP machine provided after his CPAP was denied by insurance. Staff interviews confirmed that the resident refused the EPAP every night, yet this was not documented in the care plan. This lack of documentation and communication could lead to misunderstandings and inadequate care for the resident's sleep apnea. Other residents, such as Resident #3, #6, #10, and #20, also had care plans that were outdated or did not accurately reflect their current conditions and needs. For example, Resident #3's care plan did not mention her use of an orthopedic boot or her anxiety about removing it, while Resident #6's care plan inaccurately listed wounds that were no longer present. Resident #10's care plan incorrectly stated that he was weight-bearing and used a walker, despite being confined to bed. Similarly, Resident #20's care plan did not reflect her recent decline in mobility and communication abilities, as observed by staff. These discrepancies indicate a systemic issue with maintaining accurate and current care plans, potentially impacting the quality of care provided to residents.
Failure to Follow Safe Food Handling Practices and Use of Hair and Beard Coverings
Penalty
Summary
The facility failed to ensure staff adhered to safe food handling practices and proper use of hair and beard coverings during meal preparation and service. During an observation, a staff member with a goatee was seen cooking without a beard net, and another staff member with long hair and a full beard was installing equipment in the kitchen without a hairnet or beard net. Additionally, the same staff member with the goatee was observed plating resident lunch trays without a beard cover. The facility's Personal Hygiene Standards policy, updated in June 2021, requires hair restraining devices for all hair and beard guards for employees with beards, which were not followed in these instances.
Deficiencies in Policy Implementation and Resident Safety
Penalty
Summary
The facility's governing body failed to establish and implement necessary policies and procedures, leading to several deficiencies identified during a recertification survey. Specifically, the facility lacked policies for Advance Directives, PASARR Screenings, Care Plans, and Accidents/Hazards. For Advance Directives, a review of a resident's POLST form revealed it was not dated by the resident or the physician, and staff confirmed the absence of an Advanced Directives policy. Regarding PASARR Screenings, another resident's electronic health record showed no Level I or II screening had been completed since admission, and staff were unaware of the reason for this omission, acknowledging the lack of a relevant policy. In terms of Care Plans, a resident's record indicated that while a baseline care plan was initiated, no comprehensive care plan was developed following admission, and staff confirmed the absence of a care plan policy. Additionally, an observation of a resident's interaction with a call light cord highlighted a safety concern, as the resident was seen pulling the cord over her chest and neck. Staff admitted that the facility did not assess for call light safety and lacked a policy or procedure related to this issue. These deficiencies suggest a systemic failure in policy development and implementation, increasing the risk of negative outcomes for residents.
Deficiencies in Performance Improvement and Policy Implementation
Penalty
Summary
The facility failed to implement effective performance improvement actions and measure their success, which led to several deficiencies affecting resident care. During interviews, staff members admitted that the facility lacked necessary policies and procedures, such as Advance Directives Policy, PASARR Level I and II Policy, Care Plan Policy, Significant Change Policy, and Call Light Safety Policy. Additionally, the facility did not have active Performance Improvement Plans (PIPs) in place for critical areas like falls, comprehensive care plans, and electronic health record (EHR) inaccuracies. Staff acknowledged awareness of these issues but had not developed or implemented PIPs to address them. The facility's QAPI team was aware of the deficiencies, such as missing physician history and physicals in residents' EHRs and inaccuracies in comprehensive care plans, but failed to take corrective actions. A draft PIP for falls with fractures was incomplete, lacking essential components like check-in dates, goal statements, team members, and staff education. The QAPI plan from October 2018 outlined a performance improvement process, but the facility did not adhere to it, resulting in unaddressed deficiencies that could potentially affect all residents requiring complete medical records and accurate care plans.
Incomplete Advanced Directives in LTC Facility
Penalty
Summary
The facility failed to ensure that advanced directives were complete for four of the nineteen sampled residents, increasing the risk of the residents' wishes not being met or followed. Specifically, a review of one resident's POLST form showed a verbal consent by the guardian without a physical signature. Another resident's POLST form was missing the physician's date and provider contact information. A third resident's POLST form lacked the physician's printed name, date and time, and provider phone number. Lastly, a fourth resident's POLST form was not dated by either the resident or the physician. During an interview, a staff member confirmed that POLST forms are required to be fully completed, including dates, and acknowledged that the facility did not have an Advanced Directives policy. The State Operations Manual for LTC requires facilities to comply with advance directives requirements, including having a written description of the facility's policies to implement advance directives and applicable State law.
Physician Documentation Deficiency
Penalty
Summary
The facility physician failed to document resident assessments or physician visits for four of the nineteen sampled residents, increasing the risk of not having pertinent medical information available when needed. Specifically, requests for current history and physicals for residents #1, #4, #6, and #20 were not fulfilled, as no current documentation was located in their electronic medical records. Resident #1's record only contained a hospital admission physical from 2014, while no current history and physicals were found for residents #4, #6, and #20. During an interview, a staff member acknowledged the issue, stating that the facility was working to update physician visit documentation, with about half of the resident history and physicals currently up to date.
Expired Medications Not Removed from Stock
Penalty
Summary
The facility staff failed to remove expired medications from the stock medication cupboard, which increased the risk of misuse. During an observation, several expired medications were found, including two bottles of Magnesium Chloride, three bottles of Ferrous Gluconate, one bottle of Iron 27 mg, three bottles of Meclizine, one bottle of COQ10, and one bottle of Senna Plus, all with expiration dates ranging from April to September 2024. In an interview, a staff member stated that the process of checking expiration dates and removing expired medications was supposed to be managed by the pharmacy, as they maintained the medication supply.
Failure to Complete PASARR Screening for Resident
Penalty
Summary
The facility failed to complete a PASARR Level I or II screening for a resident with potential mental disorders or intellectual disabilities. Upon review of the resident's electronic health record, it was found that no PASARR Level I or II had been completed since the resident's admission. During an interview, a staff member acknowledged the absence of the required PASARR screenings and was unable to provide a reason for this oversight. Additionally, it was revealed that the facility lacked a policy regarding the completion of PASARR Level I or II screenings. Another staff member confirmed that when a resident transfers from one nursing facility to another, the new facility is responsible for completing a PASARR Level I screening by the day of admission to ensure the resident receives the necessary services.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered care plan for a resident, which identified the resident's physical and psychological needs and wishes. During an interview, a staff member stated that the facility did not have a care plan policy or a significant change policy and followed the RAI manual instead. The review of the resident's electronic medical record showed that a baseline care plan was initiated shortly after admission, with revisions made a few days later. However, no comprehensive care plan was developed following the resident's admission, indicating a deficiency in meeting the resident's needs.
Failure to Provide Necessary Oral Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living for oral care received the necessary services. During observations and interviews, it was noted that the resident did not have his dentures in place and stated that they were left on the sink without being given to him or having adhesive applied. The resident expressed that the CNAs had not put the dentures in, and they remained on the sink needing glue. A staff member indicated that the CNAs often did not put the dentures in for a few days to allow the resident's mouth to rest, as per the nurse's decision. However, the staff member was unaware that the resident had not received his dentures and subsequently assisted in placing them, which made the resident happy. The resident's care plan indicated the need for full upper dentures and mouth care as part of personal hygiene, but this was not adequately followed.
Resident Safety Hazard Due to Call Light Misuse
Penalty
Summary
The facility failed to ensure a safe environment for a resident with dementia who misused the call light cord, posing a potential hazard. During observations, the resident was seen lying partially off the bed, with her feet and legs hanging off, and her head against the wall. The resident was also observed wrapping the call light cord around her body and head, and later over her chest and neck. Despite the resident's severe decline and increased sleeping, staff did not adequately address the safety concerns related to the resident's misuse of the call light cord. Staff members expressed uncertainty about how to manage the resident's behavior, with one staff member stating that the resident's actions were concerning, including placing a pillow over her head. The facility lacked a policy or procedure for assessing call light safety, and staff acknowledged that the resident had not used the call light appropriately for some time. The facility's failure to assess and address the resident's environment for safety, particularly concerning the call light cord, resulted in a deficiency related to accident hazards and supervision.
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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 Hot Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clark Fork Valley Nursing Home | 13.8 mi | — | 2 | 0 |
| Polson Health & Rehabilitation Center | 24.7 mi | — | 6 | 0 |
| St Luke Community Nursing Home | 25.6 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.