Baptist Health Medical Center-Hot Springs County
An acute care hospital in Malvern, Arkansas 72104
1001 Schneider Drive, Malvern, Arkansas 72104. (501) 332-1000.
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The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- Not rated patient survey rating
- 6 deficiencies cited in the last three years (needs attention)
- 72 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
The last inspection on record was on Feb 24, 2026: a complaint and standard inspection.
6 deficiencies cited in the last three years, 1 of them at condition level, the most serious.
1 deficiency at condition level, the more serious of CMS’s two levels
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
6 deficiencies in 1 month of the last 36. Last cited Feb 2026. Most serious: Condition-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Feb 24, 2026: complaint and standard inspection6 deficiencies
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Patient Rights
The inspectors’ words, 180 words
“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47688 Based on observation and staff interview, it was determined that the facilitys physical environment was not maintained in a manner that ensured patient safety. The identified environmental deficiencies presented a potential risk for patient self-harm, injury, and compromise of a safe therapeutic setting for individuals receiving behavioral health services A During tour of the Behavioral Health unit on 02/23/2026 at 11:15 AM it was observed that 1. The Wi-Fi routers in the unit were placed below the ceiling in front of every patient room 2. The door leading to the stairway in side of the unit had the wrong type of locking mechanism 3. The fire doors inside the unit had the wrong type of door handles 4. The fire doors inside the unit used the wrong type of door closer The failed practices did not ensure the patient’s right to be free from harm or receive care in a safe setting. See A-0143 and A-0144 for details.”
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Patient Rights: Care In Safe Setting
The inspectors’ words, 155 words
“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47688 Based on observation of the kitchen, , med surgery and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, and visitors, Finding follow: A. Observation of the kitchen on 02/23/2026 at 1:25 PM showed rusted floors in the back area of the kitchen . B. Observation of the Med Surg unit 02/23/2026 @ 1:41 PM showed a damaged and cracked exit sign C. The findings of A and B were verified with the Director of Hospital Operations and the Maintenance Supervisor on 02/23/2026 at 1:45 pm.”
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Medical Staff Periodic Appraisals
The inspectors’ words, 233 words
“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 31039 Based on review facility Medical Staff Bylaws, Physician credential files and interview, it was determined the facility failed to provide evidence of recommendations by qualified medical personnel (peer review) concerning the competence and performance for five of five (Physicians #1-5) whose credential files were reviewed for reappointment. By not reviewing the Physicians’ professional activities, the facility could not ensure that the Physicians were competent and practiced within the boundaries of professionally accepted norms, which improves the quality and safety of the health care provided. The failed practice had the likelihood of affecting all patients that were treated at the facility. Findings follow: A. Record review of the facility’s “Medical Staff Bylaws,” signed 07/28/2005, showed each recommendation concerning reappointment of a staff member shall be based on the individual’s professional and collegial activities, performance and conduct in the hospital. B. Review of Physicians #1-5 credential files on 02/24/2026 at 2:00 revealed no evidence that peer review was used in the consideration of the reappointments to Medical Staff and granting of privileges. D. During an interview on 02/24/2026 at 3:11 PM, the Chief Nursing Officer for Regional Systems verified they could not provide evidence of recommendations by qualified medical personnel (peer review) concerning the competence and performance for Physicians #1-5.”
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Rn Supervision Of Nursing Care
The inspectors’ words, 257 words
“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 40282 Based on record review, policy review and interview, it was determined the Facility failed to ensure a Registered Nurse (RN) completed and documented an emergency department nursing assessment for 5 ( #9, #11, #13, #14, and #15 ) of six (#9, #10, #11, #13, #14, and #15) emergency department records. The failed practice has the likelihood of affecting all patients presenting in the Emergency Department and did not ensure ongoing patient care needs are assessed, monitored and evaluated. Findings follow: 1. Record review of emergency room clinical records #9, #11, #13, #14, and #15 showed no documented RN comprehensive nursing assessment. 2. Review of policy titled “Assessment of Patients” approved on October 2025 showed “The RN will collect and document admission health history and physical assessment in the EMR (Electronic Medical Record) on every patient.” 3. During interview on 02/24/26 at 2:00 PM, the Emergency Room Supervisor acknowledged RN assessments are not consistently completed and documented and identifies this as an ongoing issue. 4. During interview on 02/24/26 at 2:06 PM, the Director of Nursing acknowledged RN assessments are not consistently completed and documented and acknowledges no corrective measures are available at his time. 5. The findings in 1 were confirmed by the Emergency Room Supervisor on 02/24/26 at 1:45 PM. 6. The findings in 2 were confirmed by the Director of Nursing on 02/25/26 at 1:54 PM.”
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Facilities, Supplies, Equipment Maintenance
The inspectors’ words, 174 words
“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 47688 Based on observation, review of policies and procedures and interview, it was determined the facility failed to create and review policies and procedures on a biennial basis for Weekly Checks and Documentation of Generators. By not creating and reviewing the policies and procedures, the facility had the likelihood to not be able to identify hazardous conditions and take steps to minimize the risks to patients and patient care staff. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow: A. Review of the facility’s policy and procedures on 02/23/2026 showed that the facility failed to create and maintain a policy and procedure for weekly checking testing and documentation for generators. Documentation for this procedure was requested and none was provided. B. The finding of A was verified with the director of maintenance on 02/23/2026 at 2:55 pm.”
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Infection Control Surveillance, Prevention
The inspectors’ words, 236 words
“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50014 Based on review of policy and procedures, infection control dashboard, and an interview it was determined that the Infection Control Preventionist did not audit physician’s hand hygiene. By not surveying the physician’s hand hygiene, the hand hygiene audits for quality reports were not accurate and promoted the spread of infection affecting all patients seen by a physician. Findings Follow: 1. Review of Hand Hygiene Policy approved on April 2025, showed “Healthcare workers are expected to perform hand hygiene immediately prior to and after completing patient contact either by washing hands or using ABHR (alcohol-based hand rub) per general instructions in this policy. Healthcare workers are expected to perform hand hygiene with ABHR upon entering and exiting each room ....” 2. Review of Infection Prevention & Control Quarter 1 Data and Summary dated April 29, 2025, showed no audit data for the MD’s (medical doctors) for January, February, March of 2025. 3. In an interview with the Infection Control Preventionist on 02/24/26 at 12:25 PM, she stated “I do not do a hand hygiene audit on medical doctors.” She verified that #1-#3 are correct.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Feb 24, 2026 | Complaint and standard inspection | 6 deficiencies cited |
How do patients fare?
- CMS gives no overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “There are too few measures or measure groups reported to calculate a star rating or measure group score.”
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 2; safety of care, 0 better and 0 worse of 2; readmission, 0 better and 0 worse of 2.
- CMS gives no CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “The number of cases/patients is too few to report a star rating.”
- In CMS’s patient survey (Oct 1, 2024 to Sep 30, 2025): 94% rated it 9 or 10 out of 10, and 76% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): C. diff infections, no different than national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): pneumonia 14%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): pneumonia 17.4%. CMS gives no comparison with the national rate for them in this release.
- Emergency department patients spent a median of 100 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
- Medicare’s spending per patient here is 1.01 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - private.
- It is not accredited by a private organisation, so the state carries out its routine inspections for Medicare.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 6 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- 58% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Baptist Health runs it.
- 21 owners or officers are people: Larry White (corporate director); Ronald Dedman (corporate director); Lamarr Bailey (corporate director); Herren Hickingbotham (corporate director); Judy Simmons Henry (corporate director); Michael Akin (corporate director); Chris Brune (corporate director); Troy Wells (corporate director); Troy Wells (managing employee (on the payroll)); Suzanne Peyton (corporate director); John Mcmorran (corporate director); Lindsey Lorence (corporate director); Steven Booth (corporate director); David Mitchell (corporate director); James S Jones (corporate director); Louis M Lee (corporate director); Teresa Howell (corporate director); Brent Beaulieu (corporate officer); Brent Beaulieu (managing employee (on the payroll)); Glenn Millner (corporate director); Les Warren (corporate director).
- CMS’s Provider of Services file records 4 changes of ownership, the latest on Jan 1, 2014.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
How does it compare nearby?
- No other hospital CMS lists is in Hot Spring County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.