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Conway Healthcare And Rehabilitation Center

2603 Dave Ward Drive, Conway, AR 72034 · For profit - Limited Liability company · 105 certified beds · (501) 329-2149 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited May 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$25,483 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • 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
  • the CMS record shows $25,483 in federal fines (most recent 2024-05-06)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (61%) runs well above the national median (45%)
  • about 56% 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2510 Dave Ward Drive, Suite A-13 · (501) 513-0300 · Call to confirm hours
Pharmacy
2425 Dave Ward Dr · (501) 336-8188 · Call to confirm hours
Grocery
625 Salem Rd · (501) 358-3868 · Call to confirm hours
Park
Highway 365 · Typically dawn to dusk
Place of worship
10 Edgewood Dr

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

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

Trend — is this home getting better or worse?

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

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.5%9.5%15.4%better
Long-stay residents who lose too much weight3.4%4.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.8%1.2%2.0%better
Long-stay residents with depressive symptoms4.8%1.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.7%3.9%3.3%better
Long-stay residents whose ability to walk worsened7.4%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication29.8%21.7%18.9%worse
Long-stay residents given the seasonal flu vaccine92.6%96.1%95.3%typical
Long-stay residents with pressure ulcers5.4%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control15.2%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.4%10.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine51.4%77.7%79.4%worse
Long-stay hospitalizations per 1,000 resident days1.122.011.67better
Long-stay outpatient ER visits per 1,000 resident days1.112.131.80better

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

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

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

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

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

58.3%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 58.3% 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 24 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 0.20 therapist hours per resident per day in 2026Q1 — more than 22% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge58.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge41.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge54.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified41.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

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

Staffing

0.35
RN hours/ resident / day
0.79
LPN hours/ resident / day
2.78
Aide hours/ resident / day
3.91
Total nurse hours/ resident / day
0.23
RN hoursweekends
60.7%
Total nursing turnover
76.9%
RN turnover

How full it usually is: this home is certified for 105 beds and averages 69.7 residents a day — about 66% occupied, or roughly 35 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 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.78 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 3.39 hrs/resident/day on weekends vs 4.12 on weekdays — 18% thinner on weekends. RN hours go from 0.39 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above 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

6
deficiencies at the latest standard inspection (2025-08-21)
8
at the previous standard inspection (2024-05-06)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · J2024-05-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    According to observation, record review, and interview the facility failed to ensure residents were free from abuse with continuous altercations of verbal abuse and physical abuse between two residents (Resident #47 and Resident #54). This failed practice had the potential to affect all 66 residents currently in the facility to psychosocial harm from repeated resident to resident abuse altercations. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 03/12/2024 at 12:30 PM, when Resident #47 and Resident #54 had an altercation in the dining room. The altercation from witness statements began when Resident #54 was impatient at the coffee area and rammed into Resident #47, which caused an argument between the two residents. A few minutes later after separation Resident #47 bumped into Resident #54's…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-21 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, interview, and facility policy review, the facility failed to ensure resident centered care was provided to two of two (Resident #8 and Resident #69) sampled residents dependent on staff for care based on one of one observation to ensure residents physical and psychosocial needs were met. Specifically, staff did not respond to a feeding tube alarm in a timely manner, a call light was placed out of the reach of a resident, and pain was not addressed in a timely manner. The findings include: Resident #8: During an observation on 08/18/2025 at 2:13 PM, this surveyor observed Resident #8 resting with their eyes closed, their tube feed was beeping, and the pump was not running. The resident's feeding pump said, tube slip detected, remove and reload cassette. This surveyor observed the resident's feeding supplement of 1.5 calories was hanging on a pump, and 60 milliliters (mL) an hour was written on the bottle. Resident #8 was not responding verbally and was not able to demonstrate use of the call light to report continuous beeping. The resident's bed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-21 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview it was determined that the facility failed to ensure proper hand hygiene during perineal care to prevent cross contamination for two (Resident #69 and Resident #74) of two sampled residents observed for bowel and bladder care. The findings include: Resident #69: During an observation on 08/18/2025 at 2:54 PM, this surveyor observed Certified Nursing Assistant (CNA) #4 and CNA #5 assist Resident #69 to bed and inform the resident that their brief would be checked, without further instruction. Then this surveyor observed CNA #5 pull down Resident #69's wet brief. CNA #4 used wipes to clean Resident #69's front perineal area and placed the wipes in a trash bag. CNA #5 rolled the resident onto their right side and CNA #4 wiped Resident #69's buttocks using one wipe in one direction. Resident #69 complained of buttocks pain. CNA #4 inspected Resident #69's buttocks, then opened the resident's bedside drawer, without changing gloves, and found a non-prescription ointment to use on Resident #69's buttocks. CNA #4 informed Resident #69…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-21 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, facility document review, interview, and facility policy review, it was determined that the facility failed to not discharge on e (Resident #81) of one sampled resident after an appeal was filed. The findings include: A review of Resident #81’s admission Record indicated the facility admitted the resident on 12/23/2024, with diagnoses which included anxiety disorder. A review of Resident #81’s discharge Minimum Data Set with an Assessment Reference Date of 07/24/2025, revealed a Brief Interview of Mental Status score of 15, which indicated the resident was cognitively intact. A review of Resident #81’s Care Plan Report, revised on 12/26/2024, revealed there were no discharge plans anticipated. Resident #81’s Care Plan Report indicated plans for the resident to remain in the facility for long-term care. Resident #81’s Care Plan did not indicate that the resident smoked. A review of a Discharge Notice, dated 07/23/2025 and signed by the Administrator, indicated that a decision had been made to discharge Resident #81 effective 30-days from 07/23/2025. The…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-21 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, interview, and facility policy review, the facility failed to ensure the medication error rate was less than 5%, to prevent potential complications for two (Residents #35 and #76) of two sampled residents observed during the medication pass. The medication error rate was 6.67%, based on observations of 30 medications administered. The findings include: A review of Resident #35's Order Summary Report revealed an order for [Brand Name] eye drops for dry eyes, with the order to instill two drops in both eyes twice a day for dry eyes. The eye drops started on 11/18/2024. A review of Resident #76's Order Summary Report indicated an order for 80 milligrams (mg) of an anti-flatulent medication twice a day for gas. During an observation on 08/19/2025 at 8:14 AM, this surveyor observed Licensed Practical Nurse (LPN) #12 administer Resident #35 one drop of [Other Brand Name] eye drops in each eye, for dry eyes. During an observation on 08/19/2025 at 8:57 AM, this surveyor observed Medication Assistant Certified (MAC) #11 administer one 125mg chewable…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-21 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility document review the facility failed to ensure one (Resident #52) of one sampled resident was free of a significant medication error, which caused Resident #52 to be hospitalized for acute toxic encephalopathy. The findings include: During an interview on [DATE] at 3:23 PM, Resident #52 revealed they went to the hospital around [DATE], due to being given the wrong medications. Resident #52 said they spent the night at the hospital and almost died, because the medicine they were given was not theirs, but belonged to a resident who lived down the hall. A review of Resident #52's Medical Diagnosis revealed the facility admitted the resident with diagnoses which included high blood pressure, reflux, diabetes mellitus, hyperlipidemia, Alzheimer's disease, anxiety disorder, post-traumatic stress disorder (PTSD), chronic obstructive pulmonary disease, constipation, history of falling, sleep apnea, and insomnia. A review of Resident #52's annual Minimum Data Set (MDS) with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-21 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, the facility failed to ensure one of four medication carts were always locked to prevent accidents. The findings include:During an observation on 08/20/2025 at 10:18 AM, this surveyor observed a medication cart was parked in front of the nurse's station, unlocked.During an observation on 08/20/2025 at 10:21 AM, the Director of Nursing walked by the medication cart and locked it. She confirmed medication carts should be locked, to prevent the residents from going into the carts.During an observation on 08/20/2025 at 10:28 AM, this surveyor observed Licensed Practical Nurse (LPN) #12 walk to the unlocked medication cart. She indicated the cart was for the residents on the 200 and 300-halls. LPN #12 stated she did not realize the medication cart was unlocked and confirmed the cart should always be locked for the safety of the residents.During an interview on 08/21/2025 at 4:33 PM, the Administrator revealed the medication carts should be always locked to keep the residents safe.A review of a policy titled, Medications Storage…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-31 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 a safe and homelike environment, ensuring safety from floor clutter, detached wall vinyl, and detached wall rails posing potential hazards for falls. The findings are: 1. Review of an undated policy titled, Accidents, Hazard Prevention, specified, the frailty of some residents increases their vulnerability to hazards in the resident environment and can result in life-threatening injuries. It is important that all facility staff understand the facility's responsibility, as well as their own, to ensure the safest environment possible for residents. 2. On 10/30/2023, at 9:15 AM, environmental rounds were made in the facility, the following were observed: a. Standing at the front of the 100 Hall, and facing room [ROOM NUMBER], in the middle of the room, on the floor, between Bed A, located horizontal on the left side of the room, against the wall and Bed B, located vertical under the wall light, on the right side of the room, were…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-06 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure interventions were utilized to prevent worsening of contractures for 2 (Residents #40 and #66) of 2 sampled residents. The findings are: 1. A review of the Order Summary indicated Resident #40 had diagnoses of abnormal posture, stiffness of left shoulder, and stiffness of left elbow. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/2024 indicated Resident #40 had a Staff Assessment for Mental Status (SAMS) completed with a memory problem for short-term and long-term and has impairment on both sides of upper and lower extremities. A review of the Care Plan with an initiated date of 01/10/2024, indicated Resident #40 required, Problem: .is receiving a restorative program . Goal: Will maintain a ROM (range of motion), balance in order to reduce risk for contractures and skin breakdown by next review .Approaches/Tasks Left Elbow Extension [NAME] up to 4 hours . Further review indicates…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-06 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure dishes/utensils were stored under sanitary conditions and food preparation equipment was cleaned properly in the kitchen. These are the findings: A review of the Cleaning Schedule indicated the following were to be completed weekly: ovens inside and outside, Aide tables/microwave area, Outside of the refrigerator, Refrigerator inside cleaning, plate warmer, under cooks table, fryer-cleaning inside and outside, dish machine-cleaning on top of dish machine, steam table under, coffee pots and tea pots, carts-daily. The Dietary Manager stated on 05/01/24 at 3:30 PM, that this is the only cleaning schedule they use. On 04/30/24 at 9:10 AM, the Surveyor observed the hand washing station in the kitchen, the hot water side had water coming from the base, creating a red brown stain inside of the sink. The Surveyor then observed the eye wash station was covered in red/brown spots, and that the left cover was missing with debris on the inside of the gray plastic piece. On 04/30/24 at 9:18 AM, the Surveyor observed…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-06 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 observations, interviews, record reviews, facility document review, and facility policy review, it was determined that the facility failed to ensure hand hygiene was performed between resident rooms while delivering clean laundry. This failed practice had the potential to affect 14 residents residing on the secure unit, and the facility failed to keep a trash barrel covered to prevent residents from digging through trash on the secure unit for 1 (Resident #32) of 1 sampled resident observed. This failed practice had the ability to affect 14 residents residing on the secure unit. Findings include: A review of a document to Environmental Services Account Managers and Laundry Employees on 05/02/2024 at 09:40 AM regarding Reminder - Handling, Transport and Storage of Laundry, with a revised date of 10/2023, indicated, Page 2 Transport of Laundry indicates laundry will be handled and transported with appropriate measures to prevent cross-contamination and prevent the spread of infection. During 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · E2024-05-06 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, it was determined that the facility failed to provide a pneumonia vaccine for 2 (Residents #63 and #69) of 2 residents reviewed for immunizations. Findings include: Review of a facility policy titled, Pneumococcal Vaccine (Series) with a Copyright date of 2022, specified, 1. Each resident will be assessed for pneumococcal immunization upon admission.2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders . A review of the Consent for Vaccinations dated 07/24/2023, documented Resident #63 authorized the facility to administer a one-time pneumococcal vaccine. A review of the Immunizations tab in, the electronic health record, Resident #63 did not have information entered that the pneumonia vaccine was received. A review of the Consent for Vaccinations dated 02/26/2024, documented Resident #69 authorized the facility 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, it was determined the facility failed to ensure residents call devices were in reach in the resident's room for 1 (Resident #29) of 1 sampled resident with call devices not in reach. The findings include: A review of Resident #29's admission Record indicated the facility admitted Resident #29 on 05/17/2019 and listed diagnoses to included Parkinson's Disease with dyskinesia, Altered mental status, Repeated falls, Supraventricular tachycardia, Headache, Type 2 diabetes, and Unspecified pain. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 02, which indicated the resident had severe cognitive impairment. The resident was dependent on staff for oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and with transfers from chair/bed-to-chair transfer. Resident #29 was independent with eating and used…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-06 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to update a care plan regarding a resident's placement on the unit for 1 (Resident #54) of 1 sampled resident. The findings are: 1. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/2024 indicated Resident #54 had a score of 7 (0-7 indicates severe cognitive impairment) on a Brief Interview of Mental Status (BIMS). 2. A review of the Order Summary indicated Resident #54 had diagnoses of Down Syndrome, Generalized Anxiety Disorder, and Unspecified Intellectual Disabilities. 3. A facility review of the Care Plan indicated on 03/12/2024 a revision was made that stated, [Resident #54] is obsessed with certain other resident's and becomes physically and verbally aggressive towards them. placed on male secured unit for decreased stimuli . 4. A review of the Care Plan with a revision date of 04/23/2024 indicated [Resident #54] can be disruptive. Yelling at other residents and staff, will throw food, plastic wrappers, other items on the floor. Also, will throw food on the walls. Sits in…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and medication prescribing information, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medication for 1 (Resident #51) of 2 residents reviewed for unnecessary psychotropic medications. The findings include: A review of physician orders revealed Resident #51 had Depakote Oral Tablet Delayed Release (a medication used to treat manic episodes associated with bipolar disorder, seizures and migraine headaches) 250 milligrams (mg), Give 1 tablet by mouth three times a day for seizures/behaviors related to Alzheimer's disease with late onset. The order status is Active, with an order date of 03/08/2024, a start date of 03/08/2024, and no end date indicated. A review of medical diagnoses revealed Resident #51 had Alzheimer's disease with late onset, unspecified dementia, depression, post-traumatic stress disorder (PTSD), and unspecified convulsions. A review of the Depakote Full Prescribing Information, Revised March 2024, available through the Food and Drug Administration at www.accessdata.fda.gov,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-21 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents were showered/bathed as scheduled, fingernails were kept clean, and male residents were shaved to promote good personal hygiene for 02 (Resident #02 and #03) sample mix residents. The findings are: Facility provided procedure document titled 'Bath (Shower)' with a Revision Date of 01/03 that documented, Basic Responsibility: Licensed Nurse and Nursing Assistant Purpose: 1. To cleanse and refresh the resident. 2. To observe the skin. 3. To provide increased circulation . General Guidelines for Assessment may include, but are not limited to: Condition of skin, range of motion limitation, ADL function, resident's preference for time of day, frequency and type of bath, skin allergies .Procedure . 12. Report any reddened areas, skin discolorations of skin breaks to the charge nurse. General documentation guidelines Frequency of documentation should follow facility policy. Date, time (or shift), as appropriate. Other documentation may include amount of assistance required, reports of unusual…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-17 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 residents received notification that their Medicare Part A Services were being terminated for 1 (Resident #25) of 3 (Residents # 21, #25 and #124) sampled residents who were reviewed for beneficiary notification. The findings are: 1. Resident #25 had a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. The 5 Day admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 01/09/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. The Beneficiary Protection Notification provided by the Administrator on 03/16/23 at 10:50 AM documented, .Medicare Part A Skilled Services episode start date: 1/04/23; Last covered day of Part A Service: 1/13/23 . b. On 03/16/23 at 10:50 AM, the Administrator stated, I don't have the forms that were given to him. The old Social Worker was in charge of that, and I'm not sure why she didn't scan it in, or what she did with the forms. c. On 03/16/23 at 11:02 AM, the Surveyor asked Resident #25, In…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-17 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure showers were given as scheduled for 1 (Resident #47) of 6 (Residents #5, #17, #26, #47, #51 and #58) sampled residents who were dependent on staff for showers. The findings are: Resident #47 had diagnoses of Major Depressive Disorder and Seborrheic Dermatitis. The Quarterly Minimum Data Set (MDS) an Assessment Reference Date of 01/09/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive two plus persons physical assistance with bed mobility, dressing and toilet use; was totally dependent of two plus persons physical assistance for transfers and required supervision with one person physical assistance with personal hygiene. Bathing activity was marked as did not occur during the 7 day look back period. a. The Care Plan with a completion date of 01/24/23 documented, .I have ADL [activities of daily living] self-care performance deficit . I will be clean and well-groomed daily throughout review date . Bathing: Extensive assist…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-17 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 11 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 03/16/23. The findings are: 1. On 03/15/23 at 11:24 AM, Dietary Employee (DE) #1 placed 13 servings of polish sausages into a blender, added beef broth and pureed. At 11:26 PM, She poured the pureed polish sausages into a pan. She covered the pan with foil and placed it in the oven to serve to 11 residents who had Physician Orders for pureed diets. The consistency of the pureed polish sausage was gritty and was not smooth. 2. On 03/15/23 at 11:41 AM, DE #1 used a 4 ounce spoon to place 15 servings of fried potatoes into a blender, she added beef broth and pureed. At 11:46 AM, she poured the pureed fried potatoes into a pan. She covered the pan with a piece of foil and placed…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-17 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 residents were provided with information on their right to formulate an advance directive and/or that their decisions to formulate or not formulate advance directives were documented in the medical record, to ensure residents and/or their responsible parties were able to make advance decisions regarding end-of-life care if they wished to do so for 1 (Resident #10) of 19 (Residents #10, #16, #17, #19, #26, #29, #45, #46, #47, #48, #51, #58, #60, #69, #120, #121, #122, #123 and #220) sampled residents whose advance directives were reviewed. The findings are: a. Resident #10 had diagnoses of Alzheimer's Disease, Unspecified and Major Depressive Disorder, Recurrent, Unspecified. The Quarterly, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/23 documented the resident was moderately impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Assessment (SAMS). b. On 03/13/23 at 8:43 PM, review of the medical record was completed. Resident #10 did not have an Advance…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-17 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 provide referral to appropriate state-designated authorities for Level II Preadmission Screening and Resident Review (PASARR) evaluation concerning residents who had a negative Level I pre-screening, and were later identified with newly evident or possible serious Mental Disorder/Intellectual Disorder (MD/ID) or related conditions for 1 (Resident #48) of 6 (Residents #5, #8, #46, #121, #122 and #220) sampled residents with a new diagnosis requiring a Level II PASARR screening since admission to the facility. The findings are: 1. Resident #48 had diagnoses of Multiple Sclerosis (MS), Major Depressive Disorder, Recurrent, Unspecified, and Delusional Disorders. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/23 documented the resident scored 13 (11-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received antidepressant and hypnotic medications 6 of the 7 day look back period and did not receive an antipsychotic during the 7 day look back…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-17 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) screening was conducted for 1 (Resident #5) of 6 (Residents #8, #46, #48, #121, #122 and #220) sampled residents who had a Mental Disorder/Intellectual Disability (MD/ID), or a related condition since the last annual survey. The findings are: Resident #5 had diagnoses of Psychotic Disturbance and Schizotypal Disorder. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received an antipsychotic and an antianxiety medication 7 days of the 7 day look back period. Preadmission Screening and Resident Review (PASRR) . Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? . No . a. The [State Designated Professional Associates] document dated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents received oxygen therapy as ordered by the Physician for 1 (Resident #26) of 7 (Residents #10, #17, #26, #45, #46, #58 and #122) sampled residents who received oxygen. This failed practice had the potential to affect 17 residents who received oxygen therapy in the facility as documented on a list provided by the Director of Nursing (DON) on 03/16/23 at 12:14 PM. The findings are: 1. Resident #26 had diagnoses of Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, and Unspecified Sequelae of Unspecified Cerebrovascular Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/02/23 documented the resident scored 3 (0 to 7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received oxygen therapy. a. The Physicians Order dated 09/24/22 documented, .Oxygen 2 LPM [liters per minute] Via N/C [nasal cannula] every shift for Oxygen Therapy related to ACUTE RESPIRATORY DISTRESS SYNDROME . b. On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$25,483 in federal fines across 1 penalty.

  • $25,483 — penalty dated 2024-05-06

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

Part of a chain

This home belongs to SOUTHERN ADMINISTRATIVE SERVICES — 35 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.8-0.8 vs chain
Health inspection 2 of 53.2-1.2 vs chain
Staffing 3 of 53.9-0.9 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 34 homes this chain runs (chain average 3.8★, per CMS)
2 of 5Des Arc Nursing And Rehabilitation CenterDes Arc, AR 2 of 5The Green House Cottages of Southern HillsRison, AR 3 of 5Arbor Oaks Healthcare And Rehabilitation CenterMalvern, AR 3 of 5Ash Flat Healthcare And Rehabilitation CenterAsh Flat, AR 3 of 5Encore Healthcare And Rehabi Of MalvernMalvern, AR 3 of 5Lake Village Rehabilitation and Care CenterLake Village, AR 3 of 5Ouachita Nursing And Rehabilitation CenterCamden, AR 3 of 5Pocahontas Healthcare And Rehabilitation CenterPocahontas, AR 3 of 5River Ridge Rehabilitation And Care CenterWynne, AR 3 of 5Rogers Health And Rehabilitation CenterRogers, AR 3 of 5Sheridan Healthcare And Rehabilitation CenterSheridan, AR 3 of 5Southern Trace Rehabilitation And Care CenterBryant, AR 3 of 5The Cottages At TexarkanaTexarkana, AR 3 of 5The Green House Cottages Of Belle MeadeParagould, AR 3 of 5Willowbend Health And Rehabilitation, LLCMarion, AR 4 of 5Brookridge Cove Rehabilitation And Care CenterMorrilton, AR 4 of 5Pleasant Valley Rehabilitation And NursingLittle Rock, AR 4 of 5St Johns Place Of Arkansas, LLCFordyce, AR 4 of 5The Green House Cottages Of Poplar GroveLittle Rock, AR 4 of 5The Pines Nursing And Rehabilitation CenterHot Springs, AR 4 of 5Three Rivers Health And Rehabilitation CenterMarked Tree, AR 4 of 5Twin Rivers Rehabilitation And Healthcare CenterArkadelphia, AR 4 of 5Valley Springs Rehabilitation And Health CenterVan Buren, AR 5 of 5Belle View Estates Rehabilitation And Care CenterMonticello, AR 5 of 5Courtyard Rehabilitation And Health Center, LLCEl Dorado, AR 5 of 5Greenhurst Nursing CenterCharleston, AR 5 of 5Heartland Rehabilitation And Care CenterBenton, AR 5 of 5Highland Court, A Rehabilitation And Resident CareMarshall, AR 5 of 5Ozark Nursing And RehabOzark, AR 5 of 5Summit Health & Rehab CenterTaylor, AR 5 of 5The Green House Cottages Of HomewoodMena, AR 5 of 5The Green House Cottages Of Northwest ArkansasBentonville, AR 5 of 5The Green House Cottages Of Walnut RidgeWalnut Ridge, AR 5 of 5The Green House Cottages Of Wentworth PlaceMagnolia, AR

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

Who owns this facility

Owner / managerTypeRoleShareSince
4P2T1 OPS HOLDING LPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2019
JEJ ASSETS LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2022
PONTHIE, SHARLOTIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2022
POORE, MELISSAIndividualW-2 MANAGING EMPLOYEEsince 02/24/2022
PONTHIE, JOHNIndividualCORPORATE OFFICERsince 09/01/2019
ALEXARK1 LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 01/01/2022
JEJ MANAGEMENT, LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 01/01/2022

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

Follow the money — this home’s finances

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

$7.9M
Net patient revenuemost recent cost report
+5.9%
Operating marginrevenue minus expenses
$4.2M
Related-party expense56% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 3%Other / private 40%

This home reported $4.2M paid to related parties — landlords or management companies under common ownership — equal to about 56% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$293per resident / day
operating cost
$8,921per month
≈ monthly operating cost
$312per day
avg. revenue, all payers

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

What families pay in AR

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045245. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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