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Cabot Health And Rehab, LLC

200 Northport Drive, Cabot, AR 72023 · For profit - Individual · 89 certified beds · (501) 843-6181 Medicare & Medicaid certified

Call the home — (501) 843-6181 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 27 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 20% 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 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 — 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
205 Westport Dr Ste 1 · (501) 843-6585 · Call to confirm hours
Pharmacy
1848 W Main St · (501) 843-1489 · Call to confirm hours
Grocery
304 S Rockwood Dr · (501) 941-5200 · Call to confirm hours
Park
503 Richie Rd · (501) 605-1506 · Typically dawn to dusk
Place of worship
3400 W Main St

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 improved from 1 to 2 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 rating2★
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 increased2.9%9.5%15.4%better
Long-stay residents who lose too much weight0.0%4.3%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.6%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%1.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.2%3.9%3.3%better
Long-stay residents whose ability to walk worsened9.4%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.6%21.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers5.7%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control20.0%13.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table4.5%10.9%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine98.6%77.7%79.4%better
Short-stay residents rehospitalized after admission19.1%24.1%22.6%better
Short-stay residents with an outpatient ER visit4.5%12.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.512.011.67typical
Long-stay outpatient ER visits per 1,000 resident days1.082.131.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ 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.

45.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 74 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.4%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
65.4%U.S. median 56.6%
Met the expected recovery
0.10U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 65.4% 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 26 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 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF45.4%CMS range 37.1–55.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.2–15.010.7%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 discharge65.4%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 discharge50.0%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 discharge57.7%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 stay3.2%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 worsened3.2%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 hospitalization11.4%CMS range 7.7–16.87.1%Oct 2023–Sep 2024worse than U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 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

0.34
RN hours/ resident / day
1.06
LPN hours/ resident / day
2.81
Aide hours/ resident / day
4.20
Total nurse hours/ resident / day
0.46
RN hoursweekends
48.9%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 89 beds and averages 73.5 residents a day — about 83% occupied, or roughly 16 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 4.20 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.81 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 3.49 hrs/resident/day on weekends vs 4.49 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.28 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% 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

1
deficiencies at the latest standard inspection (2026-05-21)
11
at the previous standard inspection (2024-12-12)

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · E2026-05-21 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined the facility failed to ensure that the resident's transfer or discharge was reported to the ombudsman for two (Resident #75 and Resident #77) of two residents reviewed. The findings include: Resident #75 Review of Resident #75's Medical Diagnosis revealed diagnoses which included respiratory failure, congestive heart failure (CHF) and atrial fibrillation. Review of Resident #75's admission Record revealed the facility admitted Resident #75 on 02/20/2026. Review of Resident #75's Medicare 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2026 revealed Resident #75 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of Progress Notes dated 02/21/2026 revealed Resident #75 was admitted to the nursing home on [DATE] from [Named] hospital for skilled services with severe abdominal distention, low fluid output and…

    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 · Fcited before2024-12-12 · 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, it was determined that the facility failed to prepare, distribute, and serve food under sanitary conditions. Specifically, the facility failed to ensure that dietary staff performed hand hygiene in between tasks for three (3) of three (3) staff (Dietary Aide #1, Dietary Aide #2 and Cook) observed in the kitchen. The findings are: A review of a facility policy titled Handwashing dated 05/15/2020, indicated, Purpose: To remove contamination after entering the kitchen, touching bare human body parts, using the toilet, coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating or drinking, handlining soiled utensils or equipment, during food preparation, when switching between raw food and working with ready to eat food, before donning gloves for working with food, and after engaging in other activities that contaminate the hands A review of a facility policy titled Safe Food Handling Practices dated 10/23/2019, indicated, Policy: All food is purchase, stored, prepared, and distributed in a clean,…

    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 · Ecited before2024-12-12 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interviews, and facility document review, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for 1 (Resident #52) of 8 sample mix residents. The findings are: On 12/9/24 at 9:29 AM, the surveyor observed Resident #52 lying in bed on their back at a thirty-degree (30') angle with eyes closed. Oxygen (O2) concentrator present in the room and running at two (2) liters per minute (LPM) through a nasal cannula with humidification. Tubing, humidification, and storage bag date 12/03/2024. Review of Resident #52's Medication Administration Record (MAR) for November 2024, did not provide an area to document oxygen use. Review of Resident #52's Baseline Care Plan dated 11/04/2024 noted in section 4. Health Conditions: A. Health Conditions/ Special Treatments: 1a. Oxygen therapy- while a resident. Review of Resident #52's Order Summary Report dated 11/05/2024, noted change O2 tubing, clean filter and O2 cabinet, date all tubing every Monday night on 11-7 shift and for maintenance, O2 at two to four (2-4) LPM though nasal cannula.…

    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 before2024-12-12 · 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

    Based on observation, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 6 (Residents #52, #38, #60, #3, #44, and #377) of 15 sample mix residents reviewed for care plan. The Findings are: 1. On 12/09/24 at 9:29 AM, the surveyor observed Resident #52 lying in bed on their back at a thirty-degree (30') angle with eyes closed. Oxygen (O2) concentrator present in the room and running at two (2) liters per minute (LPM) through nasal cannula with humidification. Tubing, humidification and storage bag were dated 12/03/2024. Review of Resident #52's Medication Administration Record (MAR) for November 2024, did not provide an area to document oxygen use. Review of Resident #52's Baseline Care Plan dated 11/04/2024, noted in section 4. Health Conditions A. Health Conditions/ Special Treatments 1a. Oxygen therapy- while a resident. Review of Resident #52's Order Summary Report dated 11/05/2024, noted change O2 tubing,…

    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 · E2024-12-12 · 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 meals were prepared and served according to the planned written menu to ensure that nutritionally balanced meals were provided for the residents for 1 of 1 meal observed. The findings are: During an observation on 12/09/24 at 1:02 PM, the [NAME] asked the Dietary Manager (DM) to open more green beans to be cooked because there were not enough green beans to finish serving the residents. The DM confirmed there were no more green beans to cook and opened a can of spinach. The DM placed a partial can of spinach on the stove and placed a portion of the spinach in the microwave to cook. The DM obtained spinach temperature on the stove at 140.4 degrees. The DM removed spinach from stove and placed it on the steam table. The [NAME] began to serve spinach for the rest of the trays needed. During an observation on 12/09/24 at 1:19 PM, the [NAME] requested the dietary aide to make more puree chicken and dumplings, spinach, and bread. During an interview on 12/10/24 at 3:07 PM, the DM confirmed the kitchen ran…

    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 · Ecited before2024-12-12 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    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 observations, interviews, and record review, the facility failed to ensure pureed food was blended to a smooth consistency to meet the needs of residents who required a pureed diet during one (1) of one (1) meal service observed. The findings are: A review of a facility policy titled Therapeutic and Modified diets dated 08/24/2020, indicated, Purpose: To ensure residents receive foods with the appropriate textures and nutrient contents as prescribed by the physician to promote treatment and plan of care. Modified Consistency: Residents who require a modified consistency diet may be at risk for developing a foodborne illness due to the increased number of food handling steps required when preparing pureed and other modified consistency foods During an observation on 12/09/2024 at 11:49AM, pureed bread was prepared using milk, cornbread, white bread and milk. The consistency was thick and was not pudding like. During a concurrent observation and interview on 12/09/2024 at 12:18PM, pureed green beans were a thin runny consistency, and the [NAME] verbalized the pureed green…

    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 · D2024-12-12 · tag F0577 — isolated
    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 observation and interview it was determined that the facility did not ensure the survey inspection book was kept in a place where residents and family members could reach the book without asking. The findings are: On 12/11/2024 at 10:07 AM, during the resident council meeting Resident #7, Resident #49, Resident #61, and Resident #65 indicated that they did not know where the survey inspection book was located. On 12/11/24 at 10:12 AM, the survey inspection book was observed behind the nurse's station in a rack. The survey inspection book was not where the residents could reach it. During an interview on 12/11/2024 at 10:14 AM, the Director of Nursing (DON) indicated that the survey inspection book was kept behind the nurse's station. The DON indicated that a resident would not be able to reach the survey inspection book if they were in a wheelchair. On 12/11/24 at 3:00 PM, the survey inspection book was observed behind the nurse's station in a rack. The survey inspection book was not where the residents could reach it. On 12/12/24 at 10:14 AM, the survey inspection book was…

    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 · D2024-12-12 · tag F0636 — isolated
    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

    Based on observation, interviews, record review, and facility document review, it was determined that the facility failed to ensure a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) within 14 calendar days after admission to identify issues needed for comprehensive care plan development for 1 (Resident #52) of 8 sample mix residents. The findings are: On 12/9/24 at 9:29 AM, this surveyor observed Resident #52 lying in bed on their back at a thirty-degree (30') angle with eyes closed. Oxygen (O2) concentrator was present in the room and running at two (2) liters per minute (LPM) through a nasal cannula with humidification. Tubing, humidification, and storage bag were date 12/03/2024. Review of Resident #52's Medication Administration Record (MAR) for November 2024, did not provide an area to document oxygen use. Review of Resident #52's Baseline Care Plan dated 11/04/2024 noted in section 4; Health Conditions A. Health Conditions/ Special Treatments, 1a. Oxygen therapy- while a 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0657 — failed to keep the care plan current — isolated
    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 interview and record review, it was determined that the facility failed to ensure resident Care Plan meetings were attempted every quarter for one (Resident #38) of one resident reviewed for Care Plan meetings. The findings include: On 12/12/2024 at 2:20 PM, the Minimum Data Set (MDS) Coordinator stated they spoke with the facility consultant, the facility does not have a policy for Care Plan meetings. Review of an admission Record indicated that the facility admitted Resident #38 with a diagnosis of cerebral infarction due to occlusion or stenosis of the right middle cerebral artery (stroke). The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/05/2024, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the Resident had moderate cognitive impairment. During an interview on 12/09/2024 at 2:54 PM, Resident #38 stated I ' ve been to one [Care Plan] meeting in the last 5 years. During an interview on 12/11/2024 at 8:34 AM, the MDS Coordinator stated Resident #38 has not had a care plan meeting this year…

    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 · D2024-12-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that the facility failed to remove facial hair for 1 (Resident #69) of 4 sampled residents reviewed for activities of daily living. The findings are: A review of an Order Summery Report indicated that Resident #69 had a diagnosis of dementia. The significant change Minimum Date Set (MDS) with an Assessment Reference date (ARD) of 9/09/2024, revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment and required supervision for personal hygiene. Review of Resident #69's Care Plan initiated 09/08/2024, revealed that Resident #69 required supervision to partial assistance by one staff for personal hygiene. On 12/09/24 at 10:18 AM, Resident #69 was observed sitting in a wheelchair outside the resident ' s room. Resident #69 had facial hair on the resident ' s chin and above the upper lip. On 12/09/24 at 10:25 AM, Resident #69 was observed in the resident ' s room. Resident #69 had facial hair on the resident ' s chin and above the upper lip. On…

    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
Show the remaining 17 citations
  • Potential for harm · Dcited before2024-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    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

    Based on interview and record review it was determined that the facility failed to carry out interventions after a fall for 1 (Resident #2) of 4 sampled residents reviewed for falls. The findings are: A review of an Order Summery Report indicated that Resident #2 had a diagnosis of osteoarthritis of both knees. The significant change Minimum Date Set (MDS) with an Assessment Reference date (ARD) of 09/25/2024 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated that Resident #2 has had a fall with a major injury. Review of Resident #2's Care Plan revised 12/11/2024 revealed that Resident #2 had a fall on 10/24/2024. Interventions included to submit a therapy request for possible services. The Care Plan revised on 12/11/2024, indicated that Resident #2 had an unwitnessed fall. The intervention was to refer to therapy for an evaluation. A review of Resident #2's hospital records dated 09/19/2024 indicated Resident #2 had a fall with a nasal fracture. A review of a facility…

    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 before2024-12-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    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, interviews, record review, and facility document review, it was determined that the facility failed to ensure that an accurate Physician ' s Order was in place for oxygen for 1 (Resident #52) of 1 sample mix residents who received oxygen. The findings are: On 12/09/24 at 9:29 AM, this surveyor observed Resident #52 lying in bed on back at a thirty-degree angle with eyes closed. Oxygen (O2) concentrator present in the room and running at two (2) liters per minute (LPM) through a nasal cannula with humidification. Tubing, humidification, and storage bag date 12/03/2024. Review of Resident #52's Medication Administration Record (MAR) for November 2024, did not provide an area to document oxygen use. Review of Resident #52's Baseline Care Plan dated 11/04/2024 noted in section 4. Health Conditions A. Health Conditions/ Special Treatments 1a. Oxygen therapy- while a resident. Review of Resident #52's Order Summary Report dated 12/09/2024 noted change O2 tubing, clean filter and O2 cabinet, date all tubing every Monday night on 11-7 shift and for maintenance, O2 at…

    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 · Fcited before2023-12-08 · 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 leftover food items were discarded to maintain food quality; foods stored in 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; failed to ensure dented food cans were promptly removed/ discarded to prevent the growth of bacteria; failed to properly clean and sanitize food thermometer between raw ground meat and cooked meat; failed to properly store frozen raw beef in freezer to prevent cross contamination; failed to removed expired food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen. The findings are: 1. On 12/05/23 at 2:16 PM, the following observations were made on a shelf in the refrigerator: a. A polystyrene foam container labeled cheese with a date of 11/22/23. b. One gallon of soy sauce without an open date. c. Sliced cheese in open plastic bag not sealed. d. A twenty ounce bottle of ketchup without 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-08 · tag F0557 — pattern
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review the facility failed to ensure that 2 Residents (Resident #26 and #320) were properly clothed and covered in common areas. This failed practice was a violation of res resident's right to have dignity. The Findings are: 1. Resident #26 had a diagnosis of dementia without behavior disturbance, psychotic disturbance, mood disturbance and anxiety. According to Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/17/23 resident required extensive assist with dressing. It was documented Quarterly MDS with ARD 10/9/23 Resident 26 had a Brief Interview of Mental Status (BIMS) of 3. Resident #26 required staff to assist with choosing simple comfortable clothing. A. On 12/05/23 at 2:30 PM, Surveyor observed Resident #26 sitting by nurses' station wearing a shirt that could be seen thru and did not have on a brassiere undergarment. B. 12/05/23 2:37 PM, Surveyor observed Activity Director Assistant (ADA) observed walking with Resident#26 away from the nurse's station. C. 12/05/23 02:37 PM, the Surveyor asked (ADA)…

    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 · Ecited before2023-12-08 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to accurately record on the resident assessment to ensure the Minimum Data Set [MDS] accurately reflected section for special treatments, procedures, and programs including oxygen to facilitate the ability to plan, coordinate, and provide necessary care for 1 (Resident #23) of 6 Sample Residents (R#2, R#23, R#39, R#53, R#55, R#64) receiving oxygen therapy. The facility failed to have a procedure in place to monitor activities of daily living [ADL] decline in Residents. The facility failed to ensure the Minimum Data Set [MDS] assessment accurately reflected a level II Preadmission Screening and Resident Review [PASARR] evaluation with recommendations to facilitate the ability to plan, coordinate and provide necessary care for 1 (Resident #31) of 1 sampled resident requiring a level II PASARR. The findings are: Resident #23 with diagnoses of Chronic Respiratory Failure with Hypoxia (below normal level of oxygen in your blood. Minimum data set [MDS] with an assessment reference date [ARD] on 09/24/2023 and a brief interview for…

    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 before2023-12-08 · 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, record review and interview, the facility to ensure the environment was free of potential accident hazards by failure to ensure manufacture guidelines were followed when using a lift for transfer assistance affecting 1 (Resident #25) of 6 sampled (Residents #10 #25, #31, #32, #35, #46) requiring a lift for transfer assistance. The facility failed to ensure interventions were implemented to attempt to prevent falls as evidenced by Resident #64 falling. The findings are: Resident #25 with a diagnosis of Alzheimer ' s disease, dementia, and neurocognitive disorder. A significant minimum data set [MDS] with an assessment reference date [ARD] 0f 11/27/2023, and a staff assessment for mental status [SAMS] shows moderately impaired memory problems. The Resident requires total assistance with bed bed mobility, eating, transfers, dressing and personal hygiene. Review of care plan (05/24/2023, Revision) .Resident has an activity of daily living [ADL] self-care performance deficit r/t Alzheimer's,…

    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 before2023-12-08 · 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 observations, interviews and record review, the facility failed to follow the oxygen safety policy by not posting cautionary and safety signs indicating the oxygen in use 1 Resident (Resident #10) for the use of oxygen therapy of 1 sampled resident. The facility failed to complete a comprehensive care plan for 1 Resident (Resident #23) and failed to follow physician orders for 1 Resident (Resident #53). Findings are: Resident #10 had the following diagnosis dyspnea, chronic obstructive pulmonary disease, shortness of breath, acute respiratory failure with hypoxia. According to admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/2/23 Resident was receiving oxygen therapy 2 liters via nasal cannula for shortness of breath as needed. According to Quarterly (MDS) with (ARD) 10/30/23 Resident was receiving oxygen therapy while a resident. On 12/05/23 at 3:19 PM, Resident #10 was receiving oxygen at 2 liters via nasal cannula and there is no oxygen sign on or around door. On 12/05/23 at 6:05 PM, Resident #10 was receiving oxygen at 2 liters via nasal…

    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 · E2023-12-08 · 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 and interview, the facility failed to ensure that the medication cart for 100 Hall was locked and secured at the nurses station when the nurse was not in eyesight of the medication cart. This failed practice affected 10 sampled Residents (#3, #21, #23, #26, #34, #39, #53, #55, #64, and #170), and had the potential to affect 47 Residents in the facility that are capable of ambulating or self-propelling in the facility. The findings are: a. On 12/07/23 at 2:46 PM, the Surveyor observed the 100 Hall cart unlocked and unattended. The Surveyor asked Licensed Practical Nurse (LPN) #2 what is wrong with the medication cart? LPN #2 said it is unlocked for restocking. b. On 12/07/2023 at 2:48 PM, the Surveyor observed the narcotic box was locked, and easily assessed and counted the top drawer with LPN #2. The top drawer of the medication cart contained the following: 1. 2 insulin pens 2. 1 Lidoderm 3. 4 insulin vials 4. insulin syringes 5. 43 bottles of OTC meds 6. 4 prescriptions 7. 10 eye drops c. On 12/07/2023 at 2:50 PM, the Surveyor asked the Director of Nursing…

    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 · E2023-12-08 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 served in a method that maintained the nutritional value of the pureed food items to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 12 residents who receive a puree diet, as documented on a list 12/07/2023 at 04:40 PM. The findings are: 1. On 12/06/23 at 11:00 AM, cooked lima beans without bean juice placed in food processor with hot water and pureed. 2. On 12/06/23 at 11:31 AM, 16 servings of meatloaf placed in food processor and then added water and pureed. 3. On 12/06/23 at 1:08 PM, DE #2 was asked, What was mixed with the pureed lima beans and meatloaf? DE #2 stated, hot water. The Surveyor asked, Why was stock not used as the recipe required. DE #2 stated, It would have been cold if stock was used. 4. On 12/06/23 at 1:11 PM, the Surveyor asked the Dietary Manager, Why does the recipe include the puree ingredient of broth? Dietary manager stated, To add extra flavor Dietary manager stated, Sometimes…

    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 · Ecited before2023-12-08 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    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 1 meal observed. The findings are: 1. On 12/6/23 at 11:00 PM, the following observations were made of the steam table and foods prepared and served. a. 12/06/23 11:31 AM, staff pureed 16 servings of meatloaf with hot water from the faucet. The pureed meatloaf was found to be thick, lumpy and not smooth. This pureed meatloaf was served to the residents. b. On 12/6/23 at 11:00 AM, staff pureed cooked lima beans in the food processor with hot water from a faucet. The lima beans were found to be thick, lumpy with pieces of beans and not smooth. These pureed lima beans were served to the residents. c. 12/06/23 1:05 PM, the Surveyor asked Certified Nursing Assistant (CNA) #6, how should puree foods be when served? CNA #6 stated, Smooth with no lumps. The Surveyor asked CNA #6 to describe the puree that was being fed to residents. CNA #6 stated, It could…

    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 · E2023-12-08 · tag F0808 — failed to follow doctor-ordered diets — pattern
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 mechanical soft items were chopped or ground to minimize the risk of choking or other complications for residents who required a mechanical soft diet for 1 of 2 meals observed. This failed practice affected 1 Resident #55 of 1 sampled Resident who is on a mechanical soft diet. The findings are: a. On 12/05/23 at 6:21 PM, the Surveyor asked Certified Nursing Assistant [CNA] #2 to describe Resident #55's meal compared to the meal slip. Resident #55's meal slip indicates a mechanical soft diet. CNA #2 said the plate does not look like a mechanical soft diet and should probably be sent back to the kitchen. b. On 12/05/2023 at 6:25 PM, the Surveyor asked the Dietary Manager [DM] what process was used to determine what foods Resident #55 would be served on a mechanical soft diet. The DM said the only food substituted on Resident #55's plate was green beans, because zucchini squash was not available. The potato wedges appear dry, hard, and large. The Surveyor asked the DM if potato wedges are mechanically…

    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 · E2023-12-08 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    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 provide a safe, functional environment for residents, staff, and the public for 1 of 1 cook stoves. This failed practice had the potential to affect 69 residents as documented on the Daily Census provided by the Administrator on 12/05/2023 at 2:05 PM. The findings are: a. On 12/06/23 at 11:48 AM Dietary Employee #2 turned on the gas stove top burner and it did not ignite. DE #2 lit the stove top burner with a shorthand held lighter. b. On 12/06/23 at 01:08 PM DE #2 was asked, Why did you light the stove top with a lighter? DE #2 responded, The pilot goes out. The Surveyor asked, How long have you been lighting it with a lighter? DE #2 replied It's been a while. The Surveyor asked, Is there another way to light it and have you informed maintenance? DE #2 replied, There is no other way to light the stove and I have no notified maintenance. c. On 12/06/23 at 1:11 PM Dietary manager was asked, How long has the staff been lighting the stove with a lighter? The Dietary Manager replied, I was not aware. I have not…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-08 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review facility failed to sit next to residents while assisting them to eat, rather than standing over them to promote care in a manner and environment that enhances each resident ' s dignity and respect. This failed practice affected 1 (Resident #25) and had the potential to affect 2 sampled (Residents #25, and #26) residing on 200 Hall requiring assistance with meals and snacks. The findings are: a. On 12/05/23 at 2:27 PM, the Surveyor observed Certified Nursing Assistant [CNA] #4 standing over resident #25 feeding resident vanilla pudding with a spoon. b. On 12/05/23 at 2:37 PM, the Surveyor asked CNA #4 what the procedure was for providing feeding assistance to residents. CNA #4 said there is not a chair in the room for her to sit and feed Resident #25 a snack. CNA #4 said the CNA's can sit beside residents to feed them in the dining area, but the CNA's must stand over residents in patient rooms because there are no chairs in the Resident rooms. c. On 12/07/2023 at 4:00 PM, the Administrator provided the policy titled Resident Rights…

    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 · D2023-12-08 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 the confidentiality of resident records were kept private by not closing the electronic medication administration record when not in use. This failed practice had the potential to affect 28 residents who receive medication from medication carts in the facility on hall 100 as documented on a list provided by the Administrator on 12/06/23 at 9:55 AM. The findings are: 1. On 12/06/2023 at 11:16 PM during a medication pass being observed by the Surveyor, Licensed Practical Nurse (LPN) #2 walked away from the medication cart with the medication administration record left open visible to anyone walking by the medication cart . LPN #2 walked back to the medication cart at 11:19 PM then returned again to the cart at 11:21 PM. 2. On 12/06/2023 at 11:22 PM, the Surveyor asked LPN #3 what should you do prior to leaving the medication cart? LPN #2 stated, Close the medication administration record. LPN #2 was asked, why should the medication administration record be closed before leaving the medication cart? LPN…

    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 · Dcited before2023-12-08 · 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

    Based on observations, record review and interviews the facility failed to complete comprehensive care plan for 1 (Resident 10) of 1 sampled resident for the use of oxygen therapy. The Findings are: 1. Resident #10 had the following diagnosis dyspnea, chronic obstructive pulmonary disease, shortness of breath, acute respiratory failure with hypoxia. According to admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 5/02/23 Resident was receiving oxygen therapy 2 liters via nasal cannula for shortness of breath as needed. According to Quarterly (MDS) with (ARD) 10/30/23 Resident was receiving oxygen therapy while a resident. A. On 12/05/23 at 3:19 PM, Resident #10 was receiving oxygen at 2 liters via nasal cannula and there is no oxygen sign on or around door. B. On 12/05/23 at 6:05 PM, Resident #10 was receiving oxygen at2 liters via nasal cannula and there is no oxygen sign on or around door. C. On 12/05/23 at 6:07 PM, Resident #10 was receiving oxygen at 2 liters via nasal cannula and there is no oxygen sign on or around door. d. On 12/05/23 at 6:22 PM, a review of…

    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 · D2023-12-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 that 1 of 24 residents receiving incontinence care in 100 hall (Resident #35) received proper incontinence care. This failed practice had the potential to cause skin breakdown, poor hygiene, and/or infection. The findings are: According to Annual Minimum Data Set (MDS) with an Assessment reference Date (ARD) of 4/5/2023 and Quarterly MDS with ARD 10/4/2023 Resident #35 was always incontinent of bowel and bladder. A. On 12/05/23 at 2:19 PM, Surveyor observed 2 Certified Nursing Assistants (CNA)s provide incontinence care to Resident #35. CNA #1 and CNA #2 rolled the resident to remove the lift pad and put clean incontinence brief under him at the same time. CNA #1 sanitized hands then change gloves following glove change CNA #1 removed soiled incontinence brief. Resident #35 was incontinent of bowel and bladder. CNA #1 with her right hand, cleaned stool from the resident placing the dirty wipe in the dirty brief then tucking the dirty brief under the Resident. CNA #1 with dirty glove on her right hand…

    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 · D2023-12-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review the facility failed to ensure peripherally inserted central catheter (PICC) care was provided and the dressing was changed in a timely manner affecting 1 (Resident #39) receiving PICC line care. This failed practice had the potential to cause skin breakdown and/or infection. The Findings are: 1. Resident #39 ' s orders showed on 12/5/23 to monitor Resident's PICC line for leakage, redness, pain, tenderness, and swelling. An order dated 12/7/23 showed change dressing to right brachial using sterile technique once weekly on Sunday and as needed if soiled/damaged. The Residnet ' s care0 plan showed to treat the PICC line per Medical Doctor orders. A. On 12/05/23 at 1:59 PM, Surveyor observed Resident #39 with a yellow, discolored dressing to the right upper arm over a peripherally inserted central catheter (PICC) line. B. On 12/05/23 at 5:47 PM, Surveyor Surveyor noted Resident #39 ' s PICC line dressing with no date on the dressing and the cap was missing from one of the lumens on the catheter. C. On 12/05/23 at 6:01 PM, the Surveyor…

    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.

    Infection Control 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

No federal fines in the current CMS record.

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 4 of 53.6+0.4 vs chain
Health inspection 3 of 53.2-0.2 vs chain
Staffing 3 of 53.3-0.3 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 5Highlands Of Bella Vista Health & Rehab, LLCBella Vista, 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 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 / managerTypeRoleShareSince
HURSH, PARALEAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 12/12/2024
SAMS, JERRYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF10%since 12/12/2024
FISHER, KATHERNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/20/2004
CABOT MANOR 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
MORTON, MICHAELIndividualADP OF THE SNFsince 12/12/2024
NORSWORTHY, DAVIDIndividualADP OF THE SNFsince 12/12/2024
PASTOR, RANDYIndividualADP OF THE SNFsince 12/10/2024

CMS files one row per role, so the 11 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$8.0M
Net patient revenuemost recent cost report
+9.0%
Operating marginrevenue minus expenses
$1.5M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 8%Other / private 32%

This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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

$281per resident / day
operating cost
$8,541per month
≈ monthly operating cost
$309per 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 045208. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, 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.

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