Fayetteville Health and Rehab: Care Order Failures - AR
Federal inspectors found that Fayetteville Health and Rehabilitation Center staff had failed to implement a physician's order requiring Resident #4's head-of-bed to be elevated 30-45 degrees while lying down. The order, dated October 9, 2024, was designed to prevent the resident from choking on feeding tube contents.
The facility's care plan mentioned head-of-bed elevation but omitted the critical degree specification from the doctor's order.
During interviews on September 24, 2025, the MDS Nurse confirmed the physician's order specified the 30-45 degree elevation requirement. However, she acknowledged that Resident #4's care plan stated only "HOB elevated" without including the specific degree measurements from the doctor's order.
The Director of Nursing reviewed the physician's order during her interview and confirmed it required the resident's head-of-bed to be elevated at 30-45 degrees while in bed. She explained the medical necessity: "If the HOB was not elevated, the resident could aspirate."
Aspiration occurs when food, liquid, or other materials enter the airway instead of the esophagus, potentially causing pneumonia or choking. For residents receiving tube feedings, proper positioning becomes critical to prevent this life-threatening complication.
The facility's Medical Director reinforced the importance of the positioning requirement during his interview. He stated that any resident receiving bolus feedings should have their head-of-bed elevated when lying down "so they would not aspirate or regurgitate."
The physician said he was familiar with Resident #4 and confirmed his order for the head-of-bed to be elevated 30-45 degrees while in bed. He emphasized his expectations that facility staff follow physician orders "word for word."
The Administrator acknowledged during her interview that staff were expected to follow both physician orders and care plans when providing resident care.
The violation represents a breakdown in the facility's care planning process. While the physician had provided specific positioning instructions to protect the resident's safety, the care plan that guides daily nursing care failed to include these critical details.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the gap between physician orders and implemented care plans suggests systemic issues in translating medical directives into daily practice.
The case highlights how seemingly minor documentation errors can create serious safety risks for vulnerable residents. Tube feeding patients depend entirely on staff following precise medical protocols to prevent complications that could prove fatal.
Resident #4's situation demonstrates the critical importance of care plan accuracy in nursing homes, where multiple staff members rely on these documents to provide appropriate care across different shifts.
The inspection occurred following a complaint, suggesting someone recognized the potential danger created by the facility's failure to properly implement the physician's positioning order.
For residents requiring specialized feeding procedures, proper head positioning isn't optional. Medical research consistently shows that elevated positioning during and after tube feedings significantly reduces aspiration risk, making compliance with such orders essential for resident safety.
The facility's leadership acknowledged their responsibility to ensure staff follow medical orders precisely, yet the care plan discrepancy indicates a failure in their oversight systems.
Resident #4 remained at risk each time staff relied on the incomplete care plan rather than the specific physician order, potentially facing aspiration complications during routine feeding procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fayetteville Health and Rehabilitation Center from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
FAYETTEVILLE HEALTH AND REHABILITATION CENTER in FAYETTEVILLE, AR was cited for violations during a health inspection on November 21, 2025.
The order, dated October 9, 2024, was designed to prevent the resident from choking on feeding tube contents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.