The Springs Of Camden
900 Magnolia Road, Camden, AR 71701 · For profit - Limited Liability company · 106 certified beds · (870) 836-6833 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- 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
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 29% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 3 to 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.9% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.3% | 4.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.3% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 8.6% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 28.4% | 21.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.0% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.8% | 10.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 96.0% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.2% | 24.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 22.0% | 12.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.20 | 2.01 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.05 | 2.13 | 1.80 | worse |
* 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.
Met the expected recovery: 67.9% 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 28 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.0–16.3 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 67.9% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 60.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.7% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 106 beds and averages 68.9 residents a day — about 65% occupied, or roughly 37 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.96 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 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 3.41 hrs/resident/day on weekends vs 4.18 on weekdays — 19% thinner on weekends. RN hours go from 0.67 to 0.43 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%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Ecited before2025-05-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, interview, and facility policy review, the facility failed to ensure foods stored in the dry storage area were covered and sealed; expired food items were promptly removed / discarded, on or before the expiration or use by date; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment; and the ice machine was maintained in a clean sanitary condition for one of one meal observed. The findings are: On 05/05/2025 at 10:09 AM, the following observations were made on a shelf above the food preparation counter: a. An opened bag of grits, the bag was not sealed. b. An open box of salt, the box was not covered. On 05/05/2025 at 10:12 AM, this surveyor observed a box of baking soda, on a shelf in the storage room, that had an expiration date of 12/18/2023. On 05/05/2025 at 10:35 AM, Dietary [NAME] (DC) #6 turned the water on and washed her hands. After washing her hands, she turned off the faucet with her hands, contaminating her clean hands. Without washing her hands again, she removed 20 slices of bread from 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.
- Potential for harm · D2025-05-08 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and policy review, the facility failed to ensure that interest was paid on a resident trust account. This failed practice affected one (Resident #3) of three sampled residents, for whom the facility maintained trust accounts, per a list provided by the Business Office Manager (BOM) on 05/07/2025. The findings are: A review of Resident Statement Landscape, for Resident #3 on 01/03/2025, revealed a balance of $2,025.36, prior to the withdrawal on 01/28/2025. A review of Trial Balance dated 05/07/2025, provided by the Business Office Manager (BOM) on 05/07/2025, revealed a balance for Resident #3 of $1,141.17. A review of Resident Statement Landscape , for Resident #3 provided by the BOM on 05/07/2025, revealed that on 01/28/2025, a withdrawal was made in the amount of $1,025.00 for personal needs. During an interview on 05/08/2025 at 12:13 PM, the Business Office Manager (BOM) was asked how much money she withdrew from Resident #3 ' s account? The BOM indicated $1,025.00 was withdrawn from Resident #3 ' s account on 01/28/2025. The BOM indicated she…
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.
- Potential for harm · Dcited before2025-05-08 · tag F0641 — isolatedEnsure 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, it was determined that the facility failed to ensure the comprehensive assessment for the current and previous year accurately reflected the Pre-admission Screening and Resident Review (PASRR) status of one (Resident #4) of two sampled residents reviewed for comprehensive assessments. The findings include: A review of the annual Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 03/13/2025, revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #4 had active diagnoses, which included: psychotic disorder, anxiety, and depression. According to the MDS, Resident #4 was not considered by the state, level II PASRR process, to have serious mental illness and/or intellectual disability or a related condition. A review of the annual MDS with the ARD of 03/21/2024, revealed Resident #4 had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #4 had diagnoses, which included: psychotic…
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.
- Potential for harm · Fcited before2024-03-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, interview, and record review, the facility failed to ensure that temperatures were monitored in the refrigerators and freezers to prevent cross contamination and food borne illness for residents who received meals from the facility kitchen. This failed practice had the potential to affect 70 residents who receive meals from the facility kitchen The findings are: 1. On 03/11/2024 at 09:23 AM, between the kitchen and pantry (hallway) is a chest freezer, the freezer was checked and did not have a thermometer in place. The freezer held frozen vegetables. 2. On 03/11/2024 at 09:25 AM, Dietary Employee [DE] #3 was asked about the dented cans in the pantry. DE #3 advised that they are putting the dented cans down on the bottom shelf that is marked for dented cans. DE #3 admitted , In the past I have used a can off the dented shelf before when we were out in the pantry, but it has been a while. Surveyor asked DE #3 if she could remember when the last time was, she used a dented can. DE #3 stated I can't remember it had been a while ago. 3. On 03/11/2024 at 09:29 AM,…
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.
- Potential for harm · E2024-03-15 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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, the facility failed to ensure that each Resident was treated with respect and dignity during meal service, in a manner that promotes maintenance or enhancement of his/her quality of life for 4 (Resident #19 #28, #37, and #64) of 5 sampled residents that required assistance with meal service. The findings are: 1. Resident #19 was unable to answer questions for the Brief Interview of Mental Status (BIMS) according to the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/02/2024. The care plan documented that Resident #19 required set-up assistance with meals/eating, verbal cues, and staff assistance at times of confusion. Resident #28 scored 06 (0-7 indicates severe cognitive impairment) on a BIMS according to the Quarterly MDS with ARD of 01/31/2024. The care plan documented Resident #28 required extensive assistance with meal /eating. Resident #37 scored 02 on a BIMS according to the Significant Change MDS with Assessment Reference Date of ARD 01/22/2024. The care plan documented that Resident #37 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.
- Potential for harm · E2024-03-15 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 medications were not stored at the bedside and on top of the medication carts to prevent the potential of misappropriation of resident property. This failed practice had the potential to affect 4 (Residents #15, #17, #27, #177) sampled residents and had the potential to affect 15 residents that ambulate and/or self-propel on East Hall. The findings are: 1. Resident #177 had diagnoses of Schizophrenia, Major depressive disorder, and post-polio syndrome. The admission Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 03/05/2024 documented a Brief Interview for Mental Status (BIMS) score of 11 (8-12 indicates moderate cognitive impairment). a. On 03/11/2024 at 10:30 AM, the Surveyor observed a bottle of Bicalutamide (a treatment for prostate cancer) sitting at bedside. The Surveyor asked Resident #177 if he/she takes this medication or does nursing give it to him/her. Resident #177 reported taking one every morning, and that it was obtained from [named] healthcare. b. On 03/11/2024 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.
- Potential for harm · Ecited before2024-03-15 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 at a palatable, attractive, and safe appetizing temperature to one 1 Resident #15 of 7 Sampled Residents that eat from the kitchen on East Hall. The findings are: a. On 03/11/24 at 11:11 AM, Resident #15 complained that food is always abnormally cold from the kitchen. Resident #15 said the turnip greens from the kitchen last night tasted straight from the refrigerator. b. On 03/13/24 at 01:20 PM, Dietary #1 provided trays from East Hall. The Surveyor asked Dietary #1 if the temperatures were acceptable to serve to residents. Dietary #1 said the meat should be about 130 degrees, and she expected the cauliflower to be warmer than 116 degrees. The food temperatures were as follows: Pork loin 99.3 degrees Cauliflower 116 degrees Mashed potatoes 136 degrees c. On 03/14/24 at 10:33 AM, the Dietary #2 said the the meat and cauliflower should be about 120 degrees. Dietary #2 said hot hold food at 135 degrees. The Surveyor asked for a policy on food temperatures during service. d. 03/14/24…
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.
- Potential for harm · E2024-03-15 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
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 failed to ensure Droplet Precautions were followed and appropriate PPE was worn in COVID isolation rooms preventing the potential risk for spread of infection and cross contamination affecting all 74 residents in the facility. The facility failed to ensure food and beverages were not used on the plywood table in the laundry room to prevent cross contamination with the potential to affect 67 residents who wash their clothing at the facility, and the facility failed to follow their Legionella Water Management Programing policy by ensuring interventions were in place to prevent the spread of waterborne pathogens, and monitoring effectiveness. This failed practice had the potential to affect all 74 residents. The findings are: 1.a. On 03/11/24 02:10 PM, the Surveyor was walking down East Hall and observed the door was open to room [ROOM NUMBER]-B, and the housekeeping cart was resting outside the door. The Surveyor observed Housekeeping #1 wearing…
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.
- Potential for harm · D2024-03-15 · tag F0583 — failed to protect personal privacy — isolatedKeep 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 protect the privacy of 1 (Resident #38) sampled resident by leaving medication cards face up and unattended on the medication cart on East Hall. This failed practice had the potential to affect all 74 residents that are receiving medication in the facility. The findings are: Resident #38 had diagnoses of Cerebral infarctions, Dysphagia (difficulty with swallowing), and Chronic respiratory failure with Hypoxia (decreased level of oxygen in blood). The Modified Medicare Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 02.16.2024 documented a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact) in non-verbal resident. Resident #38 is dependent for tube feeding, bed mobility, transfers, toileting, bathing, dressing and personal hygiene. a. On 03/12/2024 at 09:24 AM, the Surveyor observed 2 medication cards with prednisone 20 mg (milligram), and hydrochlorothiazide 12.5 mg tablets laying on the East Hall medication cart, facing up, with Resident #38's name…
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.
- Potential for harm · D2024-03-15 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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, the facility failed to conduct meetings about resident care planning and/or notified family representatives of any such meeting for 1 (Resident #28) sampled resident. The findings are: Resident #28 had diagnoses of Neurocognitive disorder with Parkinsonism. Resident #28 scored 06 (0-7 indicates severe cognitive impairment) on a Brief Interview of Mental Status according to the Quarterly Minimum Data Set with Assessment Reference Date of 01/31/2024. Resident #28's spouse was the responsible party, power of attorney for care and finances. On 03/11/2024 at 01:30 PM, the Surveyor asked Resident #28's spouse, Are you invited to attend the care plan meetings for Resident #28? The Resident #28's spouse stated, I don't know what that is I have never been to one of those meeting. On 03/12/2024 at 03:20 PM, the Surveyor asked the Social Worker, Who does the care plan meetings? The Social Worker voiced, I do. The Surveyor asked the Social Worker, How do you notify family and/ resident the facility is planning a meeting? The Social Worker voiced, I call…
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.
Show the remaining 13 citations
- Potential for harm · D2024-03-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a mechanical lift was maintained in a safe, operational condition to prevent possible injury for 1 (Resident #22) sampled resident with the potential to affect 17 residents on East Hall requiring mechanical lift assistance. The findings are: a. On 03/11/2024 at 10:45 AM, the Surveyor observed a mechanical lift machine resting on the left side of East Hall. The Surveyor observed a missing clip on the front of the hanger bar. b. On 03/11/2024 at 01:10 PM, the Surveyor observed Certified Nursing Assistant (CNA) # 3 come out of room [ROOM NUMBER]. The Surveyor observed the mechanical lift being pulled away from room [ROOM NUMBER] A ' s ' bed through the door opening. CNA #3 confirmed she just transferred Resident #22 to his/her bed. The Surveyor asked what procedure is used for connecting the lift pad to the hanger bar. CNA #3 said she connects the lift pad to the hooks and pointed to the hanger bar. The Surveyor asked how the lift pad…
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.
- Potential for harm · Dcited before2024-03-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 proper incontinence care was provided to 1 (Resident #64) of 4 sampled residents dependent on staff for incontinence care on Co-ed [NAME] Hall. This failed practice had the potential affect 9 Residents dependents on staff for incontinence care and cause skin breakdown, poor hygiene, and/or infection. The findings are: Resident #64 had diagnoses of Alzheimer's disease and Dementia with other behavior disturbances. Resident #64 was unable to answer questions for the Brief Interview of Mental Status according to the Quarterly Minimum Data Set with Assessment Reference Date of 12/19/2023 and was always incontinent of bowel and bladder. On 03/11/24 at 01:50 PM, the Surveyor observed Certified Nursing Assistant #1 and #2 place Resident #64 on a dry incontinence pad. After incontinence care was complete, CNA #1 and #2 rolled Resident from left to right to remove incontinence brief and pad. When Resident #64 was rolled onto his left side the Surveyor observed a wet circular spot on the incontinence pad that…
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.
- Potential for harm · Fcited before2023-01-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 and interview the facility failed to ensure that food was prepared under sanitary conditions; that food and equipment was stored in a manner that did not promote foodborne illness; and resident trays were free of chips and cracks. The failed practice had the potential to effect 64 residents who received their meals from one of one kitchen according to a list provided by the Administrator on 1/12/23 10:10 AM. The findings are: a. On 1/09/23 at 5:13 PM, there was a black substance that outlined the circumference of the door on the stainless-steel front of the freezer where the rubber seal closures met the back of the unit. Multiple boxes of food had water from the condenser frozen on top of them. Areas of rust were on the shelves of the freezer. b. On 1/09/23 at 5:14 PM, the deep fryer was uncovered. The front of the appliance was covered in a greasy substance with food particles adhered to it. The top of the unit and the area surrounding the fat well was covered in a light brown substance that was shiny and contained food particles. The floor under and around 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.
- Potential for harm · F2023-01-13 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
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 kitchen freezer operated in a manner that was safe and minimized the possibility of food cross contamination which could result in food borne illness. The failed practice had the potential to affect the 64 residents who obtain their meals from 1 of 1 Kitchen according to a list provided by the Administrator on 1/12/23 at 10:10 AM. The findings are: a. On 1/9/23 at 5:13 PM, a 2-door freezer had rivulets of water streaming down from the condenser that was located at the top of the unit. The Dietary Manager stated, we are getting a new company on Wednesday, so I hope they will fix that. The Surveyor asked the Dietary Manager if the Maintenance Department was aware of the problem. She stated, yes, we have had this problem for about 6 months. b. On 1/10/23 at 1:00 PM, the Maintenance Worker was in the Administrator's office. The Surveyor asked if they were aware of the problems with the freezer in the kitchen. The Administrator reported that the facility had had the freezer worked on multiple times. c. On 1/12/23…
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.
- Potential for harm · Ecited before2023-01-13 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS) were accurately encoded for oxygen for 1 (Resident #41) of 2 (Resident #41 and R #71) sample selected residents with Physician Orders for Oxygen; and failed to ensure MDS were accurately encoded for Anticoagulants (AC) for 2 (Resident #1 and #55) of 3 (Resident #1, #11, and #55) sample selected residents with Physician Orders (PO) for Plavix. The findings are: 1. Resident #41 had a diagnosis of Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries, Peripheral Vascular disease, and chronic kidney disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/22 documented a Brief Interview of Mental Status (BIMS) score of 14 (13-15 indicates cognitively intact). a.On 01/10/23 at 02:05 PM, a review of R #41's Care Plan (CP), PO, and MDS showed oxygen usage. The Annual MDS dated [DATE] did not show oxygen usage. b. On 01/10/23 at 03:26 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.
- Potential for harm · E2023-01-13 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) care was provided to 1 (Resident #41) of 5 (Resident #3, R #20, R #35, R #36, and R #41) sample selected residents who were dependent on staff for ADL care as documented on the list provided by Consultant #1 on 1/12/23. The findings are: 1. Resident #41 had a diagnosis of Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries, Peripheral Vascular disease, and chronic kidney disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/22 documented a Brief Interview of Mental Status (BIMS) score of 14 (13-15 indicates cognitively intact) and documented R #41 required total assistance of 1 person for transfers, extensive assistance of 1 person for toileting and eating, and limited assistance of 1 person for bed mobility. a. On 01/09/23 at 05:43 PM, during initial rounds, the Surveyor asked R #41 if he was receiving his showers or bed baths. R #41 shrugged his shoulders. The Surveyor asked if he 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.
- Potential for harm · Ecited before2023-01-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 catheter bags were maintained in a manner to minimize the risk of contamination for 1 (Resident #50) of 4 (Resident #11, R #20, R #40, and R #50) sample selected residents with catheters and failed to ensure catheter care and catheter output was completed and documented per Physicians Orders for 1 (Resident #40) of 4 (Resident #11, R #20, R #40, and R #50) sample selected residents with catheters as documented on the list of residents with catheters provided by Consultant #2 at 9:08 AM on 1/12/23. The findings are: 1. Resident #50 had diagnoses of NEUROMUSCULAR DYSFUNCTION OF BLADDER and Diabetes Mellitus, Type II. On the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/22 the resident received a score of 11 (8-12 Moderately impaired) on the Brief Interview of Mental Status (BIMS). The resident required Extensive Assistance for bed mobility, transfers, locomotion on and of the unit, dressing, toileting, and personal hygiene. Resident was totally dependent for bathing…
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.
- Potential for harm · E2023-01-13 · tag F0865 — failed to run a quality-improvement (QAPI) program — patternHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee put forth good faith attempts to correct, monitor, and reassess its own quality deficiencies for proper respiratory care for residents who were on Oxygen Therapy, and for Activities of Daily Living (ADL) Care for residents who were dependent on staff's physical assistance for ADL tasks. This failed practice had the potential to affect (how many residents?) The findings are: 1. On 01/09/23 at 08:20 PM, the Administrator provided the Facility assessment dated [DATE]. (All the rest of this was not pertinent) 2. On 01/09/23 at 08:20 PM, the Administrator provided a QAPI Plan dated 2023 which documented .Guiding Principle #2: The Outcome of QAPI in our organization is to improve the quality of care and the quality of life for our residents . and .the team will thoughtfully and thoroughly consider the progress made in the last year toward achieving the designated QAPI goals and current…
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.
- Potential for harm · E2023-01-13 · tag F0888 — patternEnsure staff are vaccinated for COVID-19
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure all staff were fully vaccinated, had an approved or pending medical or religious exemption, or a temporary delay per the Center for Disease Control (CDC) per the Centers for Medicare and Medicaid Services (CMS) COVID-19 Health Care Staff Vaccination Regulations Quality, Safety and Oversight on 01/14/22 (QSO). The findings are: 1. On 01/09/23 at 08:03 PM, the Administrator provided the Assistant Director of Nursing/Infection Control & and Preventionist's (ADON/ICP) [named] Infection Prevention Certificate dated 11/28/20. 2. On 01/09/23 at 08:27 PM, the Minimum Data Set (MDS) Coordinator provided a list for the last 4 weeks that contained the names of 5 Covid-19 positive residents and 5 Covid-19 positive staff. 3. On 01/10/23 at 09:00 AM, the ADON/ICP provided the COVID-19 staff Matrix. 4. On 01/10/23 at 10:00 AM, the Surveyor asked the ADON/ICP to review the Matrix as there were 20 staff listed in the column titled Not vaccinated without exemption/delay. 5. On 01/10/23 at 03:50 PM, the Administrator provided an…
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.
- Potential for harm · D2023-01-13 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 investigate an injury in a timely manner and investigate for other possible injuries to 1 (Resident #40) sample selected residents who was injured due to an improper transfer performed by a staff member. The findings are: 1. Resident #40 had diagnoses of Hemiplegia and Hemiparesis following cerebral infarction, Type II Diabetes Mellitus, and Cognitive Communication Deficit. On the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/20/22 the resident received a score of 4 (0-7 indicated severe impairment) on the Brief Interview for Mental Status (BIMS). The MDS documented the resident required limited assistance for bed mobility, transfer, and extensive assistance for toileting. a. On 01/09/23 at 06:30 PM, Resident #17, the roommate of R #40, stated on Thursday [1/5/23], during evening shift, R #40 was jerked from her wheelchair by her forearms by Certified Nursing Assistant (CNA) #7 to get R #40 into bed and R #40 screamed for a while. R #17 stated she reported this incident 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.
- Potential for harm · D2023-01-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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, interview, and record review, the facility failed to ensure pain management and pain medication side effect care areas and interventions were included in the Individualized Care Plan for 1 (Resident #40) of 18 (Resident #1, R #4, R #8, R #9, R #11, R #13, R #18, R #19, R #26, R #28, R #35, R #37, R #40, R #41, R #50, R #66, R #71, and R #73) sample selected residents who required Individualized Care Plans. The findings are: 1. Resident #40 had a diagnoses of Hemiplegia and Hemiparesis following cerebral infarction, Type II Diabetes Mellitus, and Cognitive Communication Deficit. On the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/20/22 the resident received a score of 4 (0-7 indicated severe impairment) on the Brief Interview for Mental Status (BIMS). The MDS documented the resident required limited assistance for bed mobility, transfer, and extensive assistance for toileting. a. On 01/09/23 at 06:40 PM, R #40 was in bed with a distorted face saying oh, oh, ow, ow, oh, oh over and over. The Surveyor asked if she was in pain, R…
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.
- Potential for harm · D2023-01-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, interview, and record review, the facility failed to ensure oxygen was set at the Physician ordered flow rate for 1 (Resident #41) of 2 (Resident #41 and R #71) sample selected residents as documented by a list of residents on Oxygen provided by the Consultant #2 on 1/12/23. The findings are: 1. Resident #41 had diagnoses of Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries, Peripheral Vascular disease, and chronic kidney disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/22 documented a Brief Interview of Mental Status (BIMS) score of 14 (13-15 indicates cognitively intact). a. On 01/09/23 at 05:43 PM, R #41 was lying in bed wearing oxygen via nasal cannula at 2 liters per minutes (lpm). b. On 01/09/23 at 10:58 PM, a review of R #41's PO [physician orders] dated 6/16/2022 documented, .May have Oxygen (O2) via nasal cannula at 3 lpm as needed every shift for oxygen sats [saturation] below 92% [percent]. c. On 01/10/23 at 09:20 AM, R #41 was lying in bed coughing and wheezing…
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.
- No harm found · Bcited before2025-05-08 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 observations and interviews, the facility failed to ensure hot foods were served hot and cold foods/beverages were served cold to maintain palatability and encourage adequate nutritional intake for two meals at which food temperatures were checked. The findings are: On 05/05/2025 at 12:12 PM, the first lunch meal tray for the female unit was placed on a shelf inside the food cart, by License Practical Nurse (LPN) #1. The food cart was located by the kitchen door in the dining room. On 05/05/2025 at 12:25 PM, a cart that contained 16 lunch trays was delivered to the [NAME] Hall (Female unit) by Certified Nursing Assistant (CNA) #2. At 12:37 PM, immediately after the last resident was served in the [NAME] Hall (Female Unit) dining room, the temperatures of the food items from the test trays on the cart were checked by CNA #2, with the following results: a) Pudding: 59 degrees Fahrenheit b) Purred vegetables: 113 degrees Fahrenheit c) Pureed chicken tender: 105.2 degrees Fahrenheit d) Ground chicken tender: 98 degrees Fahrenheit e) Cut green beans: 103.8 degrees Fahrenheit…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE SPRINGS ARKANSAS — 26 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.4 | +0.6 vs chain |
| Health inspection | 4 of 5 | 3.2 | +0.8 vs chain |
| Staffing | 4 of 5 | 3.0 | +1.0 vs chain |
| Quality measures | 3 of 5 | 3.8 | -0.8 vs chain |
The other 25 homes this chain runs (chain average 3.4★, per CMS)
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 / manager | Type | Role | Since |
|---|---|---|---|
| GUTMAN, ISAAC | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 03/31/2022 |
| TAUB, JACOB | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 03/31/2022 |
| BLACK RIVER HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/31/2022 |
| FERGUSON, CLAY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/31/2022 |
| HERZBERG, CHAIM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/31/2022 |
| WEST, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/31/2022 |
| PINE HILLS REALTY HOLDINGS LLC | Organization | ADP OF THE SNF | since 03/31/2022 |
| HOFFMAN, ALEXANDER | Individual | ADP OF THE SNF | since 03/31/2022 |
CMS files one row per role, so the 14 rows in the source record cover these 8 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.
2 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.
This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 29% 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). 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
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.
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 045189. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-08, 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 →
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