Concordia Nursing & Rehab, LLC

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

How full it usually is: this home is certified for 102 beds and averages 27.2 residents a day — about 27% occupied, or roughly 75 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.32 hrs/resident/day on weekends vs 3.61 on weekdays — 8% thinner on weekends. RN hours go from 0.48 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

37 citations, most serious first. The 17 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · L2025-05-06 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, facility document review, facility policy review, the facility failed to ensure employment of a full-time Director of Nursing to manage the nursing department and provide oversight of care and planning to all residents; and to ensure a registered nurse was available in the building for 8 consecutive hours a day for resident needs. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, 483.35 (Nursing Services) at a scope and severity of L. The IJ began on 02/17/2025 after review of; employee files, timecard reports; Resident #33 TAR; Resident #184's lack of Minimum Data Sheet (MDS) assessments, comprehensive care plan with interventions, and interview; Resident #85's lack of MDS assessment, comprehensive care plan with interventions, and basic…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2025-05-06 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review and policy review the administration (governing body) failed to ensure policies were implemented regarding management and operation of the facility to ensure residents were able to attain or maintain the highest practicable physical, mental, and psychosocial well-being. During the survey, the survey team identified no full-time registered nurse (RN) working 8 consecutive hours per day and licensed practical nurses (LPN) were not certified to assess and manage peripherally insert center catheters (PICC). Additionally, the survey team identified bed rails were installed without consent and residents were not assessed for their needs. The survey team identified residents with falls had not received fall assessments and interventions to prevent further falls. Lastly, the survey team identified a newly admitted resident had not been assessed for mobility function, identify interventions, and provide necessary equipment to maintain their most practicable independence. These identified failed practices resulted in Immediate Jeopardy for F727, F726, F700,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-05-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 25) of 2 residents reviewed for falls/accidents received proper assessments and interventions to prevent falls. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 04/29/2025 at 8:46 AM after review of Resident 25 incidents/accident reports, care plans and closet care plans. The review revealed three interventions for nine documented falls for Resident 25. The Administrator was notified of the IJ on 04/29/2024 at 8:46 AM. A Removal Plan was requested. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-05-06 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility document review, the facility failed to ensure bed rail assessments were completed for resident needs and safety, to obtain informed consent prior to installation of bed rails, and to ensure identified bed rails were applied to a compatible bed based on the assessed resident needs. Bed rails found installed on resident beds for 2 residents (Resident #15 and #25) that were reviewed for bed rails. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 04/29/2025 at 8:46 AM after review of Resident 15 and Resident 25's medical chart and found no bed rail assessments, nor informed consents from residents or power of attorneys, notation of establishment of proper bed rails installed and no…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-05-06 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, facility document review, facility policy review, the facility failed to ensure a nurse with the training and competencies were on staff to provide the ordered necessary care to the residents. Specifically, the facility did not ensure Licensed Practical Nurses (LPNs) with Intravenous (IV) certification accessed and managed Resident #33's Peripherally Inserted Center Catheter (PICC) line including IV antibiotic administration, IV flushes, and assessment of the line's condition and status. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, 483.35 (Nursing Services) at a scope and severity of K. The IJ began on 02/17/2025 after review of; employee files, timecard reports; Resident #33 TAR; Resident #184's lack of Minimum Data Sheet (MDS) assessments,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-05-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #184) of 1 sampled resident did not have a decline in mobility functions with psychosocial harm after admission. Specifically, the facility failed to assess the resident's mobility function, identify interventions, and provide necessary equipment for Resident #184 to maintain their most practicable independence. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to the resident. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 04/02/25 after Resident #184's admission. Through interviews, observations, and record review it was revealed Resident #184 had become totally dependent upon staff for activities of daily living and mobility with worsening psychosocial health. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to promptly notify the Medical Director and the Registered Dietitian of progressive weight loss in order to minimize further weight loss and to maintain nutritional status to the extent possible for 1 (Resident #21) of 3 sampled residents (Residents #9, #21, and #26) who had experienced weight loss. The failed practice resulted in a pattern of actual harm for Resident #21 who experienced a severe unplanned 24lb (24.8%) weight loss in 6 months and had the potential of cause more than minimal harm for 3 residents who had experienced weight loss in the past 6 months, according to list provided by the Director of Nursing on 1/31/24 at approximately 11:50 AM. The findings are: Resident #21 had a diagnosis of cerebral vascular accident (CVA), anemia, gastroesophageal reflux disease (GERD), urinary tract infection (UTI), malnutrition, failure to thrive, and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/23 documented the resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-06 · tag F0577 — widespread
  Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and facility document reviews, it was determined that the facility failed to post the last survey results in an accessible location for the residents' review. The findings include: During an interview on 04/24/25 01:49 PM, with four resident council members and the president of the resident council, it was stated they met monthly. All residents, including Residents # 7, #12, #29, #23, stated they did not know there were survey results posted for them to view. During observation, two surveyors were unable to locate the survey results and requested assistance from staff. The survey results binder was located in a metal and wicker rack on the floor to the right side of a table off the entrance. The last survey results posted were dated 10/03/2023. The facility ' s most recent recertification survey was completed 02/01/2024. During an interview on 04/24/25 at 2:24 PM with the Administrator, she stated, The binder is over here down in this magazine rack. Let's see if it's even been updated. No, it hasn't, I forgot all about it. It probably has dust all…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-06 · tag F0729 — widespread
  Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that the facility failed to ensure Certified Nursing Assistants (CNAs) were certified as CNAs in the State of Arkansas, and failed to ensure background checks were completed for 2 Nurse Aides reviewed for qualified staffing. The findings include: A review of a facility job description titled, Certified Nursing Assistant , undated, indicated qualifications included, Must be a Certified Nursing Assistant and in good standing and currently licensed by the state. A review of a facility policy titled, Nurse Aide Qualifications and Training Requirements, revised on October 2024, indicated, Nurse aides must undergo a state-approved training program. Policy interpretation and implementation indicated, 4. Our facility will not employ any individual . unless: . b. That individual has completed a training program an competency evaluation program, or a competency evaluation program approved by the state; or c. That individual has been deemed competent…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-06 · tag F0838 — failed to assess facility resources and resident needs — widespread
  Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility document review, and facility policy review, it was determined that the facility failed to conduct a thorough self-assessment for facility staffing available, the competencies and training of the staff, conduct community-based risk analysis identifying the potential natural disasters, and formulate a plan for staff recruitment to meet the needs of the residents when the facility assessment was received. The findings include: 1. A review of a facility policy titled, Facility Assessment, revised October 2024, indicated: a. A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in the assessment. The team responsible for conducting, reviewing, and updating the facility assessment includes the Administrator, a representative of the governing body, Medical Director, Director of Nursing, Infection preventionist and a director/designee from the following…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-06 · tag F0842 — failed to keep accurate, complete medical records — widespread
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility document review, it was determined that the facility failed to have an organized record management system, accurately documented and readily available to staff, nor completed medical records of the residents to ensure proper treatment, continuity of care and clarity for the facility's staff to safely care for the residents. Specifically, physician orders, comprehensive care plans, Minimum Data Sets (MDS), Medication Administration Record (MAR), and Treatment Administration Record (TAR). The findings include: During an interview on 04/22/2025 at 12:50 PM with Medical Record/Licensed Practical Nurse (LPN), she stated, I am medical records and have been working the floor for about 6 months and haven't been able to do medical records, but I do it whenever I can. It has been a while since I've been able to do medical records, but resident care comes first, and paperwork comes second. On 04/22/2025 at 4:25 PM during an interview LPN #7 stated no care plans had been…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-06 · tag F0844 — widespread
  Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on interviews, the facility failed to provide disclosure of ownership paperwork upon request. On 04/26/2025 at 10:44 AM, a request was made to the Administrator for disclosure of ownership paperwork. On 04/28/2025 at 12:46 PM, a request was made to the Administrator for disclosure of ownership paperwork. On 04/29/2025 at 8:40 AM, a request was made to the Administrator for disclosure of ownership paperwork. On 04/29/2025 at 8:40 AM, the Administrator reported that the Director of Operations was coming that day and information would be provided as requested. On 05/06/2025 at 11:47 AM, at time of survey exit, disclosure of ownership was never provided as requested.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-06 · tag F0944 — widespread
  Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and facility document reviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training for all staff members in the facility upon hire, and provide in-services to direct staff when reviewed for required QAPI training. The findings include: On 04/24/2025 at 9:17 AM, a record review of the QAPI Binder, revision date of April 2023, reviewed signatures of committee dated 04/09/2025, indicated, staff are trained in QAPI systems and culture as well as QAPIs underlying principles, including the concept that systems of care and business practices must support quality care or be changed; gathering and using QAPI data in an organized and meaningful way, such as monitor and evaluate Minimum Data Set (MDS) assessment data and care plans. No trainings were located in the QAPI binder. On 04/26/2025 at 2:18 PM, a record review of the Facility Assessment, unknown date, indicated, in-services are held monthly for the entire staff, they include: disaster drills, abuse/neglect, staff burnout, resident rights, oral hygiene,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-06 · tag F0946 — widespread
  Provide training in compliance and ethics.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and facility document reviews, it was determined that the facility failed to provide Compliance and Ethics training for all staff members in the facility upon hire, and provide in-services to direct staff, when reviewed for required compliance and ethics training. The findings include: On 04/24/2025 at 9:17 AM, a record review of Required In-Service Book, indicated in-services provided to staff included the following: dementia/behavioral training, resident rights, infection control, emergency response, abuse and neglect and misappropriation of property. These in-services were all checked off by Certified Nurse Assistant (CNA), Licensed Practical Nurse (LPN), and Registered Nurse (RN) staff. On 04/26/2025 at 2:18 PM, a record review of the Facility Assessment, unknown date, indicated in-services are held monthly for the entire staff which included: disaster drills, abuse/neglect, staff burnout, resident rights, oral hygiene, lock out tag out, elopement, dementia training/difficult residents and corona virus . No compliance and ethics in-services were listed.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-06 · tag F0636 — pattern
  Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, facility document review and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment was completed in the required timeframe of 14 days for 4 (Resident #26, #85, #135, #184) of 4 residents reviewed for MDS assessment and timing. The findings include: 1. A review of a facility policy, Resident Assessment Instrument, revision dated September 2024, indicated a comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. The Assessment Coordinator was responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviewed according to the following schedule: Within fourteen (14) days of the resident's admission to the facility; when there had been a significant change in the resident's condition; at least quarterly; and once every twelve (12) months. It revealed the comprehensive assessment helped the staff to plan care that allowed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-06 · tag F0641 — pattern
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 2 (Residents #25, #184) of 3 residents reviewed for MDS accuracy. Specifically, the facility failed to identify and ensure information regarding bedrails was accurately assessed and completed on the MDS for Resident #25; and to identify and ensure the Oxygen Nasal Cannula (NC) and Continuous Positive Airway Pressure (CPAP) were accurately assessed and completed on the MDS for Resident #184. The findings include: 1. A review of facility policy, Resident Assessment Instrument, revised September 2024, indicated the purpose of the assessment was to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity and information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach their highest practicable level of functioning. 2. A…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-06 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility document review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for 4 (Residents #26, # 85, #135, and #184) of 4 residents reviewed for comprehensive care planning. The findings include: 1. A review of a facility policy Care Plans, Comprehensive Person-Centered, revision dated July 2024, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The implementation of the policy stated, the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 2. A review of the MD notes on residents, electronically signed on 04/26/2025, revealed Resident #184 was admitted on [DATE]. a. During a record review for Resident #184, this surveyor noted there was not a Minimum Data Set…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$123,918 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $113,710 — penalty dated 2025-05-06
• $10,208 — penalty dated 2024-02-01
• Medicare payment denial — starting 2025-08-06 for 62 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to BRADFORD MONTGOMERY — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $309K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in AR