No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Highlands Of Bella Vista Health & Rehab, LLC

670 Rogers Road, Bella Vista, AR 72715 · For profit - Limited Liability company · 90 certified beds · (479) 876-1847 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Nov 20251 immediate-jeopardy citation$8,055 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,055 in federal fines (most recent 2023-11-10)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • about 19% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
701 NW McNelly Rd · (479) 254-8563 · Call to confirm hours
Pharmacy
2833 Bella Vista Way · (479) 876-2153 · Call to confirm hours
Grocery
404 Town Ctr · (479) 855-1153 · Call to confirm hours
Park
610 Chelsea Rd · Typically dawn to dusk
Place of worship

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

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.1%9.5%15.4%typical
Long-stay residents who lose too much weight1.1%4.3%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.6%0.9%better
Long-stay residents with a urinary tract infection0.4%1.2%2.0%better
Long-stay residents with depressive symptoms5.8%1.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.0%3.9%3.3%worse
Long-stay residents whose ability to walk worsened15.1%10.1%16.1%typical
Long-stay residents on antianxiety or hypnotic medication8.2%21.7%18.9%better
Long-stay residents given the seasonal flu vaccine95.2%96.1%95.3%typical
Long-stay residents with pressure ulcers0.7%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control25.0%13.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table2.0%10.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine77.7%77.7%79.4%typical
Short-stay residents rehospitalized after admission23.6%24.1%22.6%typical
Short-stay residents with an outpatient ER visit10.3%12.5%12.0%better
Long-stay hospitalizations per 1,000 resident days3.122.011.67worse
Long-stay outpatient ER visits per 1,000 resident days0.932.131.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

62.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 83 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.2%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
71.0%U.S. median 56.6%
Met the expected recovery
0.17U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 71.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 62 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.2%CMS range 51.0–71.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.5–14.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge71.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge69.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge77.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting95.5%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.0%CMS range 6.0–15.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.39
RN hours/ resident / day
1.19
LPN hours/ resident / day
2.86
Aide hours/ resident / day
4.44
Total nurse hours/ resident / day
0.16
RN hoursweekends
45.6%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 90 beds and averages 66.3 residents a day — about 74% occupied, or roughly 24 beds typically open. It usually has some room. 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 4.44 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.86 is at or above 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 3.72 hrs/resident/day on weekends vs 4.73 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.48 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

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

2
deficiencies at the latest standard inspection (2024-11-21)
4
at the previous standard inspection (2023-11-10)

Deficiencies are fewer than at the previous inspection — improving. 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.

ABCDEFGHIJKL

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.

19 citations, most serious first. The 11 most serious are shown; the remaining 8 are one tap away and print in full.

  • Immediate jeopardy · J2023-11-10 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure physician orders were followed to prevent significant medication errors which could result in complications for 1 (Resident #10) of 1 sampled resident. These failed practices resulted in an immediate jeopardy, as defined at 42 CFR §488.301. The survey team provided the State Operations Manual Appendix Q Immediate Jeopardy template to the which Director of Nursing (DON) on 11/9/23 at 1:14 p.m. An Immediate Jeopardy removal was submitted and accepted, on 11/9/23 at 3:06 p.m. The findings are: Resident #10 had a diagnosis of type 2 diabetes mellitus and dementia. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/2023 documented the resident scored 11 on the Brief Interview for Mental Status (BIMS) and received insulin injection 7 times. Review of the lab results report dated 9/7/2023 for Resident #10, .hemoglobin A1c documented .10.5 high . A physician order with a start date of 9/28/2023 documented, .metformin hydrochloride oral tablet 1000 mg (milligrams) by mouth two…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-26 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy, record reviews, interviews, and facility document review, it was determined that the facility failed to ensure an allegation of abuse was immediately reported to the administrator for two (Resident #3 and Resident #7) of three residents reviewed for an allegation of abuse. The findings include: Resident #3 Review of Resident #3's admission Record revealed the facility admitted Resident #3 with diagnoses which included major depressive disorder, generalized anxiety disorder, chronic pain syndrome, blindness in one eye, difficulty swallowing and difficulties in communication stemming from cognitive impairments. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/06/2025 indicated Resident #3 had a Staff Assessment for Mental Status (SAMS) score of 3 which indicated a short- and long-term memory problem with decision making skills that were severely impaired. The MDS also indicated Resident #3 did not usually exhibit behavior problems and could roll side to side independently but was dependent on staff for hygiene. Review…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2024-11-21 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and facility menu and policy review, the facility failed to ensure the planned, written recipe was followed for residents who received meals from 1 of 1 kitchen. Specifically, the recipe was not followed for scrambled eggs, oatmeal, and creamy wheat cereal in accordance with the written recipe. Findings include: A review of a facility policy titled, Food Preparation, dated 05/15/2020, indicated the purpose was to conserve nutritive value, provide palatable flavor, attractive appearance and appropriate temperature of food received by residents. The procedure revealed the cook was responsible for food preparation in accordance with the menu and recipes. A review of the menu used to prepare breakfast on 11/20/2024 included egg of choice and cereal of choice. A review of the Egg 1 oz (ounce) recipe dated 02/22/2024, instructed Prepare according to package directions. A review of the Oatmeal recipe dated 10/01/2023, instructed to prepare according to package directions, omitting salt. A review of the Creamy Wheat recipe dated 10/01/2023, instructed to…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-11-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and facility policy review, the facility failed to maintain overall kitchen sanitation, failed to ensure food was prepared under sanitary conditions, and failed to ensure hand hygiene was performed by dietary staff, in 1 of 1 kitchen. Findings include: A review of a facility policy titled, Food Preparation, dated 05/15/2020, indicated the purpose was to conserve nutritive value, provide palatable flavor, attractive appearance and appropriate temperature of food received by residents. The procedure revealed bare hands should not come in contact any foods, ready to eat or otherwise. A review of a facility policy titled, Cleaning & Sanitation, dated 09/20/2020, indicated the purpose was to ensure a clean, sanitary, and safe environment according to state and federal regulations. The procedure included the Dietary Director (DD) would develop, implement, and monitor cleaning of the kitchen and equipment. A review of the Monthly Cleaning Log for November 2024 revealed the table legs on kitchen worktables were to be cleaned during Week 3. No completion…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-10 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5%. Physician orders were not followed for 2 residents (Resident #10 and #62) of 5 residents observed during the medication passes resulting in medication errors. The medication error rate was 9.09 % based on administration of 33 medications opportunities with 3 errors observed. The findings are: Resident #10 had a diagnosis of type 2 diabetes mellitus and dementia. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/2023 documented the resident scored 11 on the Brief Interview for Mental Status (BIMS) and received insulin injection 7 times. A physician order with a start date of 9/28/2023 documented, .metformin hydrochloride oral tablet 1000 mg (milligrams) 1 tablet by mouth two times a day . A physician order with a start date of 11/7/2023 documented, .NovoLog injection solution 100 unit/ml inject as per sliding scale: if 0 - 60 = 0 give oj (orange juice) and notify provider; 61 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8;…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-10 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 ensure ensure expired liquid nutrition was removed and placed into an area for destruction to prevent potential administration to residents; and failed to ensure residents medications were labeled with name to prevent potential administration to other residents; and failed to ensure a insulin was dated with an open date to ensure medications were stable / compatible for use as observed by surveyor on 2 Halls (Hall 100 and 200) of 3 Halls (100, 200, and 300) that were observed on 11/7/23. The findings are: On 11/07/23 at 2:35 p.m.,100 hall medication cart was assessed with Licensed Practical Nurse (LPN) #3 present. 1- Novolog Pen 100 unit/ml (milliliter) with no open date with a fill date of 10/3/23 for Resident #10. 1- foil package containing 1 vial of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution 05. mg/3 mg (milligram) per 3 ml found in the medication cart with no name. Licensed Practical Nurse (LPN) #3 was asked how long is the Novolog Pen good for once it has been opened? LPN #3 stated, 28…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-10 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure that meals were prepared and served according to the planned written menu for 1 (#24) of 2 residents with a physician's order for a pureed diet for one of two meals observed according to a list provided by the Director of Nursing on 11/9/23 at 2:33 PM. The findings are: On 11/06/23 at 12:07 PM, lunch trays for resident's receiving a pureed diet were observed and contained a container of apple juice, a container of snack pack pudding, pureed goulash, pureed bread and a salt and pepper packet. The resident's diet card was also on the tray and read: Puree, *Regular Diet, Apple Juice, Fortified Soup. On 11/06/23 at 12:48 PM the Dietary Manager provided a copy of the menu for the pureed, regular diet. The menu called for goulash, seasoned squash, dinner roll, margarine spread, pound cake/chilled peaches. On 11/09/23 at approximately 2:00 PM, the dietary manager was asked to review the contents of resident's meal from 11/06/23. The Dietary manager (DM) stated, There is no vegetable. Upon further examination…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-08-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure foods stored the freezer, refrigerator, and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; and failed to ensure 1 of 2 ice machines was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 65 residents who receive meals from the kitchen (total census: 65), as documented on a list provided by Dietary Supervisor. The findings are: 1. On 8/08/22 at 10:13 AM, The following observations were made in the storage room: a. There were six, 5-pound (lb.)…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-08-11 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, facility failed to ensure residents' preferences were accommodated and had the right to choose their schedule and make choices regarding when they bathe and not develop a schedule for bathing without the input of the residents. This failed practice had the potential to effect 45 resident's dependent or requiring assistance for showers/baths per list provided by Administrator 8/10/22. The findings are: 1. On 08/08/22 during initial rounds of facility, Resident # 41 stated there are not enough staff to get showers during the day. R # 41 stated she has not had a shower in 2 weeks because she refused one Thursday when they tried to give her a shower at 9 PM and she was tired. R # 41 stated, they should not bring in any more people if they cannot take care of who they already have. R # 41 stated I know I get impatient, but I should not have to wait until 9 PM or 2 weeks to get a shower. They tell me I cannot ask for a shower when it is not my shower day. a. On 08/10/22 at 03:12 PM, R # 41, was lying in bed on left side was asked, What is your…

    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 · E2022-08-11 · tag F0637 — pattern
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) within 14 days of determining a decline in Activities of Daily Living (ADLs) for 2 (Resident #10, 20) sampled residents. This failed practice had the potential to affect 65 residents in the facility as documented on the Resident Census and Conditions of Residents which was provided by the Administrator on 8/10/22 at 9:21 AM. The findings are: 1. Resident #10 had a Diagnosis of Chronic Obstructive Pulmonary Disease. The Quarterly MDS with an Assessment Reference Date (ARD) of 5/7/22 documented a score of 01 (00 - 07 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). a. The Quarterly MDS with an ARD of 2/4/22 documented Resident #10 required extensive assistance from one staff member for bed mobility, transfers, and toilet use. She required limited assistance from one staff member for eating. b. There was no Significant Change in Status MDS completed in May 2022. 2. Resident #20 had diagnoses of Dementia, Diabetes, Urinary Tract…

    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 · E2022-08-11 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to review and revise the resident care plan to meet the residents' needs to reflect the use of oxygen for 1 (Resident #10) of 5 (Resident #26, 40, 33, 28, 10) sampled residents who had a Physician's Order for oxygen, and to reflect the use of Anticoagulant medications for 1 (Resident #16) of 9 (Resident #41, 209, 17, 46, 44, 31, 27, 16, 49) sampled residents who had a Physician's Order for Anticoagulant medications. The findings are: 1. Resident #10 had a diagnosis of Chronic Obstructive Pulmonary Disease. The Quarterly MDS with an Assessment Reference Date of 5/7/22 documented a score of 01 (00 - 07 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). She received oxygen while a resident. a. On 08/08/22 at 11:13 AM, Resident #10 was in her wheelchair in the Activity Room. A portable oxygen cylinder was on the back of her wheelchair. The oxygen tubing was not connected to the cylinder. b. On 08/08/22 at 12:35 PM, Resident #10 was in the dining room. The oxygen tubing was not connected to portable…

    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
Show the remaining 8 citations
  • Potential for harm · E2022-08-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure an oxygen nasal cannula tubing was stored in accordance with professional standards of practice when not in use for 2 (Resident #10, 33) of 5 (Resident #26, 40, 33, 28, 10) sampled residents who had a physician's order for oxygen, and the facility failed to administer oxygen at the prescribed rate for 1 (Resident #33) of 5 (Resident #26, 40, 33, 28,10) sampled residents who had a physician's order for oxygen, as documented on a list provided by the Administrator on 08/10/22 at 2:48 PM. The findings are: 1. Resident #10 had a diagnosis of Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 5/7/22 documented a score of 01 (00 - 07 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). She received oxygen while a resident. a. On 08/08/22 at 11:13 AM, Resident #10 was in her wheelchair (w/c) in the Activity Room. A portable oxygen cylinder was on the back of her wheelchair. The oxygen tubing was not connected to 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
  • Potential for harm · Ecited before2022-08-11 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure that an unattended medication cart was secured, and the resident Medication Administration Record (MAR) was locked and off screen. This failed practice had the potential to affect 34 residents who receive medications from the 100-hall medication cart, as documented on a list provided by the Administrator on 8/11/22 at 8:00 AM, and the facility failed to ensure that unlabeled medications were not stored at the bedside for 1 (Resident #19) sampled resident. This failed practice had the potential to affect all 65 residents in the facility as documented by the Resident Census and Conditions of Residents, which was provided by the Administrator on 8/10/22 at 9:21 AM. The findings are: 1. Resident #19 has diagnoses of Paroxysmal Atrial Fibrillation, Schizoaffective disorder, Bipolar type, Unspecified Dementia without behavioral disturbance, and Chronic Kidney Disease Stage 2 (mild). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/30/22 documented a Brief Interview of Mental Status…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-08-11 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    F867 483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies. Based on observation, record review and interview the facility failed to use the Quality Assessment and Assurance to develop and implement appropriate plans of action to correct identified quality deficiencies. This failed practice had the potential to affect all 63 residents as documented on the Census and Condition provided by the Administrator on 10/17/22 at 12:57 p.m. The findings are: 1. On 10/19/22 at 9:31 a.m., the Surveyor asked the Administrator, did the facility identified the survey issues on 8/11/22 to QA&A? The Administrator replied, I think so, let me look for them. 2. On 10/19/22 at 9:48 a.m. a review of the Grievance Log for September 2022 documented a Grievance from a non-sampled resident 0n 9/15/22 regarding showers. A review of the Grievance Log for October 2022 documented two grievances from two non-sampled residents on 10/11/22 regarding showers. 3.…

    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 · D2022-08-11 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure each resident in a nursing facility was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 (R #19) of 26 (R #7, 22, 29, 258, 26, 46, 56, 31, 50, 38, 8, 24, 40, 19, 42, 55, 20, 49, 41, 52, 15, 209, 28, 16, 45, 23 and 42) sample selected residents according to a list provided by the Administrator on 8/11/22 at 9:05 am. The findings are: 1. Resident #19 had diagnoses of Schizoaffective disorder, Bipolar type, and Unspecified Dementia without Behavioral Disturbance. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/27/21 documented a Brief Interview of Mental Status (BIMS) of 10 (7-12 indicates moderate cognitive impairment) cognitive status. The MDS also documented, Is the resident currently considered by the state level II PASRR (Pre-admission Screening and Resident Review) process to have 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-11 · tag F0656 — failed to write and follow a full care plan — isolated
    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

    F657 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Based on observation, record review and interview 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to identify and provide needed care and services in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for 1 (R#258) of 5 (R #1, 52, 110, 209 and 258) sample selected residents according to the Matrix for Providers (802) provided by the Administrator on 8/8/2022 at 11:57 am. The findings are: 1. Resident #258 has diagnoses of Gout, unspecified and Type 2 Diabetes Mellitus with Hyperglycemia. Resident does not have a completed Minimum Data Set (MDS). a. R #258 Care plan does not document any red area to left great toe. b. R #258 has no Physician Order for redness to right great toe. c. Admit skin note documented, .Patient has some edema to lower legs, patient has MASD (Moisture Associated Skin Damage) to left buttock, barrier cream applied. Patient has tx (treatment) orders in place. No other areas of noted concern at this time . d. Progress note dated 8/9/22 at 11:56 AM documented, .Floor nurse reported to this nurse that patient has some…

    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 · Dcited before2022-08-11 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the resident for 2 of 2 meals observed. This failed practice had the potential to affect 1 resident (Resident#14) who received a puree diet, from 1 of 1 kitchen, according to a list provided by the Dietary Supervisor on 8/09/2022. The findings are: 1. On 8/08/2022, the menu for the lunch meal documented resident who received a puree diet was to receive a #8 scoop of pureed taco meat (4 ounces) of taco meats which is equivalent to ½ cup, a #8 scoop of pureed refried beans which is equivalent to ½ cup and a #8 scoop of Mexican rice which is equivalent to ½ cup. a. On 8/08/2022 at 1:16 PM, Resident #14 was served pureed cut green beans, pureed ground beef, a packet of sour cream, a cup of magic cup, 2 cartons of nectar cranberry juice, a carton of nectar water and a bowl of pureed cheesecake. There was no pureed refried beans and pureed Mexican rice served to the resident. b. On 8/08/2022 at 1:56 PM,…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-11 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 3 meals observed. The failed practice had the potential to affect 1 resident who received a puree diet as documented on the Diet List provided by the Food Service Supervisor on 8/09/2022. The findings are: 1. On 8/09/2022 at 11:35 AM, The following observations were made on the steam table: a. Dietary Employee #2 placed a pan of pureed baked beans on the steam table. The consistency of the pureed baked beans was dried, lumpy and not smooth. There were pieces of bean skin still visible in the mixture. b. A pan of pureed barbeque chicken was on the steam table. The consistency was gritty and not smooth. A bowl of pureed potato salad was on the tray in the food cart. There were pieces of pimento still visible in the mixture. c. On 8/09/2022 at 11:52 PM, The Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items…

    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.

    Nutrition and Dietary 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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,055 in federal fines across 1 penalty.

  • $8,055 — penalty dated 2023-11-10

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 CENTRAL ARKANSAS NURSING CENTERS — 38 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 →

RatingThis homeChain avg
Overall 2 of 53.6-1.6 vs chain
Health inspection 1 of 53.2-2.2 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 5 of 54.2+0.8 vs chain
The other 37 homes this chain runs (chain average 3.6★, per CMS)
1 of 5Alma Nursing and RehabAlma, AR 1 of 5Jamestown Nursing And Rehab, LLCRogers, AR 2 of 5Apple Creek Health And Rehab, LLCCenterton, AR 2 of 5Belvedere Nursing And Rehabilitation Center, LLCHot Springs, AR 2 of 5Colonel Glenn Health And Rehab, LLCLittle Rock, AR 2 of 5Innisfree Health And Rehab, LLCRogers, AR 2 of 5Robinson Nursing And Rehabilitation Center LLCNorth Little Rock, AR 3 of 5Aspen Health and RehabBroken Arrow, OK 3 of 5Bradford House Nursing and Rehab, LLCBentonville, AR 3 of 5Briarwood Nursing And Rehabilitation Center, INCLittle Rock, AR 3 of 5Brooken Hill Health And Rehab, LlcFort Smith, AR 3 of 5Eufaula Manor Nursing And Rehabilitation CenterEufaula, OK 3 of 5Hickory Heights Health And Rehab, LlcLittle Rock, AR 3 of 5Lake Hamilton Health And RehabHot Springs, AR 3 of 5Quapaw Care And Rehabilitation Center LLCHot Springs, AR 3 of 5Russellville Nursing And Rehabilitation CenterRussellville, AR 3 of 5Sherwood Nursing & Rehabilitation Center, IncSherwood, AR 4 of 5Ashton Place Health And Rehab, LLCBarling, AR 4 of 5Cabot Health And Rehab, LLCCabot, AR 4 of 5Chapel Ridge Health And RehabFort Smith, AR 4 of 5Cherokee County Nursing CenterTahlequah, OK 4 of 5Dardanelle Nursing And Rehabilitation Center,incDardanelle, AR 4 of 5Heather Manor Nursing And Rehabilitation CenterHope, AR 4 of 5Johnson County Health And Rehab, LLCClarksville, AR 4 of 5Lakewood Health And Rehab, LLCNorth Little Rock, AR 5 of 5Atkins Nursing And Rehabilitation CenterAtkins, AR 5 of 5Greenbrier Nursing And Rehabilitation CenterGreenbrier, AR 5 of 5Greystone Nursing And Rehab, LLCCabot, AR 5 of 5Hampton Place Healthcare, LLCRogers, AR 5 of 5Legacy Heights Nursing And Rehab, LLCRussellville, AR 5 of 5Lonoke Health And Rehab Center, LLCLonoke, AR 5 of 5Nursing And Rehabilitation Center At Good ShepherdLittle Rock, AR 5 of 5Oak Manor Nursing And Rehabilitation Center INCBooneville, AR 5 of 5Perry County Nursing And Rehabilitation CenterPerryville, AR 5 of 5Salem Place Nursing And Rehabilitation Center, INCConway, AR 5 of 5Shiloh Nursing And Rehab, LLCSpringdale, AR 5 of 5Superior Health & Rehab, LLCConway, AR

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

Owner / managerTypeRoleSince
BROCK, MICHELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/20/2024
BELLA VISTA ESTATES LLCOrganizationADP OF THE SNFsince 12/12/2024
CENTRAL ARKANSAS NURSING CENTERS INCOrganizationADP OF THE SNFsince 01/01/2025
NURSING CONSULTANTS INCOrganizationADP OF THE SNFsince 01/01/2025
DOUGLAS, DONALDIndividualADP OF THE SNFsince 12/10/2024
MORTON, MICHAELIndividualADP OF THE SNFsince 12/12/2024
NORSWORTHY, DAVIDIndividualADP OF THE SNFsince 08/01/2025

CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

$7.3M
Net patient revenuemost recent cost report
-2.0%
Operating marginrevenue minus expenses
$1.4M
Related-party expense19% of expenses
Who pays — share of resident-days
Medicaid 54%Medicare 6%Other / private 40%

This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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.

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

$309per resident / day
operating cost
$9,402per month
≈ monthly operating cost
$303per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arkansas Medicaid page.

Typical monthly cost in Arkansas
$7,452/mo
Nursing home (semi-private)
$8,060/mo
Nursing home (private)
$4,637/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045402. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next