Based on record review and interview, the facility failed to ensure residents and/or their representatives and the Ombudsman were provided in writing the reason for discharge or attempted discharge and the reasons for discharge were documented in the resident's record and appropriate placement was obtained prior to discharge for 1 of 1 (Resident #2) resident who was discharged to a homeless shelter and 1 of 1 (Resident #3) who the facility attempted to discharge to a homeless shelter. This failed practice resulted in actual harm to Resident #2 who was discharged to a homeless shelter without permission and had the potential to cause more than minimal harm to Resident #3 who the facility attempted to discharge to a homeless shelter. The findings are: 1. …
F623 citations in Arkansas
Notice before transfer or discharge · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Arkansas cites F623 more often than its own record predicts
1.33 times the share F623 takes of citations nationally.
Of every deficiency written in Arkansas in 2025, this is the portion that was F623.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Arkansas surveyors wrote
F623 findings written in Arkansas, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and interview, the facility failed to ensure the Ombudsman was notified of residents transferred from the facility and send a copy of the transfer of notification for 2 (Residents #15 and #63) of 2 sampled residents reviewed for hospitalization. The findings are: 1. Review of Nursing Note dated 12/25/2024 at 3:17 PM, indicated Resident #15 had confusion, that was gradually progressing during the shift. At 2:10 PM, the resident's blood pressure (BP) measured 110/60, heart rate (HR) 58, and was receiving oxygen (O2) at a flow rate of 2 liters, through a nasal cannula (NC). Resident #15 was given a breathing treatment (updraft) and the amount of oxygen in the resident's blood continued to stay at 88%. …
Based on interview and record review, the facility failed to provide a written notice of a facility-initiated discharge for 1 (Resident #111) of 2 sampled residents reviewed for discharge. The findings are: Review of Resident #111's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of traumatic brain bleed and dementia with psychotic disturbance. According to the Admission Minimum Data Set with an Assessment Reference Date of 01/08/2024, the resident scored 8 on a Brief Interview for Mental Status indicating moderate cognitive impairment. Review of the Final Discharge Summary dated 02/29/2024, revealed Resident #111 was transferred to an inpatient psychiatric facility for treatment and from that facility was discharged home. …
The short window
Recent years
| Year | Share of Arkansas citations | vs expected |
|---|---|---|
| 2023 | 0.31% | 0.34× |
| 2024 | 1.24% | 1.21× |
| 2025 | 0.54% | 1.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Arkansas surveyors cite →
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