Chambers Health And Rehabilitation
1001 East Park Street, Carlisle, AR 72024 · For profit - Corporation · 90 certified beds · (870) 552-7150 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- about 23% 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 | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 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 | 5.1% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 4.3% | 5.4% | check this* — see note marked star below the table |
| 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 | 4.8% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 12.3% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 5.8% | 21.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.1% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 11.6% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 10.9% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 47.5% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 33.1% | 24.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.2% | 12.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.28 | 2.01 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.54 | 2.13 | 1.80 | better |
* 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.
49.3% 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 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 74.1% 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 27 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 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 49.3%CMS range 33.8–63.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.8–16.0 | 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 | 74.1% | 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 | 55.6% | 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 | 70.4% | 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 | 2.2% | 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 | 0.0% | 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 | 7.2%CMS range 3.2–15.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 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 90 beds and averages 46.1 residents a day — about 51% occupied, or roughly 44 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 4.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 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 3.53 hrs/resident/day on weekends vs 4.38 on weekdays — 19% thinner on weekends. RN hours go from 0.36 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below 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
Deficiencies are unchanged from the previous inspection. 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.
- Potential for harm · D2025-12-11 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Number of residents sampled: Number of residents cited: Based on observation, record review, interview and facility policy review, the facility failed to ensure a nurse demonstrated competency in the administration of an intramuscular (IM) injection for one (Resident #6) of one resident reviewed for administration of an IM injection. The findings include: During an observation of an 8:00AM medication administration pass on 12/10/2025, Licensed Practical Nurse (LPN) #1 took a one-gram (gm) vial of antibiotic injection powder and injected 3.2 milliliters (ml) of a local numbing agent into the vial of antibiotic powder to reconstitute the medication for use. After the medication was completely dissolved in the local numbing agent, LPN #1 took a five cubic centimeter (cc) syringe with a 23 gauge (g) (x) 1 inch needle attached and withdrew the liquid medication from the antibiotic vial. After LPN #1 put on Personal Protective Equipment (PPE), she entered Resident #6's room to administer the medication. LPN #1 held a 5-cc syringe with a 23 g x 1 inch needle attached, in her hand and 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 · Dcited before2025-12-11 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Number of residents sampled: Number of residents cited: Based on observation, record review, interview and facility policy review, the facility failed to ensure the medication error rate was less than five percent (%) during the medication administration of one (Resident #6) of seven residents who received medications from three Licensed Practical Nurses (LPNs). Twenty-six opportunities of medication administration were observed, and two errors were observed, resulting in a medication error rate of 7.69%. The findings include: During an observation on 12/10/2025 at 8:00AM, Licensed Practical Nurse (LPN) #1 took a one-gram (gm) vial of antibiotic injection powder and injected 3.2 milliliters (ml) of a local numbing agent into the vial of antibiotic powder to reconstitute the medication for use. After the medication was completely dissolved in the local numbing agent, LPN #1 took a five cubic centimeter (cc) syringe with a 23 gauge (g) (x) 1 inch needle attached and withdrew the liquid medication from the antibiotic vial. After LPN #1 put on Personal Protective Equipment (PPE), 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 · E2024-08-01 · 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 and interview, the facility failed to ensure expired food items were promptly removed from stock to maintain freshness and prevent potential cross contamination, failed to ensure dietary staff practiced good hand washing to prevent potential cross contamination, and manufacturer specification was followed to maintain food quality. These failed practices had the potential to affect 47 residents who received meals from the kitchen (Total Census: 47), as stated on a list provided by the Dietary Manager on 07/30/24 at AM. The findings are: 1. On 07/29/24 at 9:30 AM, a container of grated parmesan cheese on a shelf in the 2-door refrigerator had an expiration date 6/4/2024. 2. On 07/29/24 at 9:45 AM, the following observations were made on a shelf in the kitchen storge room: a. A box of white cake mix with an expiration date of 6/24/2024. b. A container of chili powder with an expiration date of 5/28/2024. c. An opened gallon of parsley flakes with an expiration date of date of 1/24/2023 d. At 9:46 AM, an opened bottle of pancake syrup was in a container under 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 · D2024-08-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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 required personal protective equipment (PPE) was utilized by staff prior to entering a resident's room who was on contact and droplet precautions for 1 (Resident #153) of 1 sampled resident who was reviewed for transmission-based precautions. The findings are: A review of the July 2024 Order Summary indicated Resident #153 had a diagnosis of coronavirus disease 2019 (COVID-19) and an order for contact/droplet isolation that started on 7/26/2024 through 7/30/2024. A review of the Care Plan dated 7/26/2024 indicated Resident #153 had tested positive for COVID-19 and was to be monitored for signs and symptoms of respiratory distress and to use contact and droplet precautions. On 07/29/2024 at 11:41 AM, a droplet precautions sign on Resident #153's door indicated, .Everyone must: clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry [There was a picture of a person wearing a face shield or goggles] .Remove face…
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 · D2024-03-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 residents medication were not left at bedside for one (Resident #4) of four sampled residents. The findings are: Resident #4 had diagnoses which included Hypertension and Cirrhosis of the liver. The admission Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 01/22/2024 documented a Brief Interview of Mental Status [BIMS] of 11 (7-12 indicates moderately impaired). On 03/25/2024 at 10:27 AM, Resident #4 was observed lying in bed in their room. A plastic cup of medication and plastic cup of water was observed sitting on top of a miniature refrigerator on the bedside table to the left of the resident. The cup contained 3 round white tablets, a small blue oblong tablet, a pinkish round tablet, and a red gel tablet. When the resident was asked if [he/she] had taken [his/her] medication that morning, [he/she] confirmed they had. Physician orders documented, Furosemide .Give 1 tablet by mouth one time a day related to Essential hypertension, Lactulose Oral Solution .Give two times a day…
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 · E2023-08-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 maintain the hot water temperature in resident rooms at a safe temperature to prevent scalding of residents in 20 (Rooms 201-219) resident rooms on the 200 Hall in the facility. On 08/07/2023 at 9:35 AM the surveyor tested the water temperature in the bathroom in room [ROOM NUMBER]. The surveyor was unable to hold their hand in the water due to the temperature being too hot. On 08/07/2023 at 11:00 AM Maintenance #1 tested the water temperature in room [ROOM NUMBER] in the presence of the surveyor. Maintenance #1 stated the temperature was 145 degrees Fahrenheit and stated, I usually try and keep it between 110 and 115 degrees Fahrenheit. Maintenance #1 confirmed the temperature of the water was too hot and would burn the residents. On 08/09/2023 at 3:25 PM the Administrator confirmed the residents on the 200 hall were in danger of being burned due to the temperature of the water. A review of the policy titled, Water Temperatures, Safety…
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 before2023-08-10 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility medication error rate was 5.71%. The findings are: During the medication pass observation, the error rate was 5.71 %. A review of Resident #21 August physicians order noted an order for, Neurontin Capsule 400 MG three times a day related to pain in the right foot, with an order date of 9/11/20. The order further stated to be given in addition to 100mg to =500mg. A review of Resident #21 Medication Administration Record (MAR) for 8/1/23 through 8/31/23 noted the Neurontin was administered at 8:00 AM, 12:00 PM, and 4:00 PM. On 8/09/23 at 8:09 AM during an observation of medication pass, Licensed Practical Nurse (LPN) #1 administered Resident #21 Neurontin 100mg capsule. She stated, pharmacy is going to bring the 400 mg this morning. The surveyor informed LPN #1 to let her know when she gets ready to administer the 400mg of Neurontin otherwise it would be considered a missed dose. On 8/09/23 at 10:57 AM LPN #1 stated, I'm getting ready to give the Neurontin. The surveyor asked, What dose will you be giving? She stated, I…
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 · D2023-08-10 · 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 record review, and interview, the facility failed to review and revise the care plan with change of resident orders for oxygen therapy for 1 (Resident #15) of 2 sampled residents (resident #15 and #37). The findings are: A review of Resident #15 physician's orders with a start date of 7/17/23 indicated the resident to receive oxygen as needed for shortness of breath. A review of resident #15 Progress Notes dated 7/23/2023 at 6:15 pm noted the resident was in bed with oxygen on via nasal canula. A review of resident #15 Progress Notes dated 7/24/2023 at 11:52am noted the resident was in a chair with oxygen on via nasal canula. A review of resident #15 care plan revealed a care plan for altered respiratory status/difficulty breathing, but failed to include an intervention for oxygen therapy, as ordered by the physician. On 08/09/2023 at 2:30 pm the surveyor asked the (Director of Nurses), DON, if a resident has orders for oxygen should the care plan be revised to show the focus, goal and interventions related to oxygen therapy? She replied, yes, I would put it on the care…
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 ANTHONY & BRYAN ADAMS — 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.8 | +1.2 vs chain |
| Health inspection | 5 of 5 | 3.5 | +1.5 vs chain |
| Staffing | 4 of 5 | 3.0 | +1.0 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 37 homes this chain runs (chain average 3.8★, 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 |
|---|---|---|---|
| HENDERSON, EMMITT | Individual | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 08/01/2022 |
| HENDERSON, KAYE | Individual | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 08/01/2022 |
| IVIE, BOBBIE | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 08/01/2022 |
| MORAN, MICHELLE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/16/2013 |
| TALBOT, LAUREN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; ADP OF THE SNF | since 08/01/2022 |
| ADAMS, ANTHONY | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 06/14/2022 |
| ADAMS, BRYAN | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 06/14/2022 |
| ELLIS, JOHN | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 08/01/2022 |
| KOEHLER, TOBEY | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 08/01/2022 |
| 3B HOLDINGS, LLC | Organization | ADP OF THE SNF | since 08/01/2022 |
| LTC SYSTEMS/RX, LLC | Organization | ADP OF THE SNF | since 08/01/2022 |
| NV RE, LLC | Organization | ADP OF THE SNF | since 08/01/2022 |
| PHARMACY CONSULTS, LLC | Organization | ADP OF THE SNF | since 08/01/2022 |
| RELIANCE HEALTH CARE, INC. | Organization | ADP OF THE SNF | since 08/01/2022 |
| MCGINNIS, LARRY | Individual | ADP OF THE SNF | since 08/01/2022 |
| MORGAN, CHRISTOPHER | Individual | ADP OF THE SNF | since 08/28/2024 |
CMS files one row per role, so the 27 rows in the source record cover these 16 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.
5 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 $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AR
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 045318. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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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