Salem Place Nursing And Rehabilitation Center, INC
2401 Christina Lane, Conway, AR 72034 · For profit - Corporation · 103 certified beds · (501) 327-4421 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 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 | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.6% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.2% | 4.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.6% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.0% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.4% | 21.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 61.0% | 96.1% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 1.1% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.8% | 13.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.1% | 10.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 42.6% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.9% | 24.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.9% | 12.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.15 | 2.01 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.90 | 2.13 | 1.80 | typical |
* 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.
52.9% 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 139 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 39.1% 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 46 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 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 52.9%CMS range 44.2–59.6 | 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 | 13.7%CMS range 10.7–17.8 | 10.7% | Oct 2022–Sep 2024 | worse than 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 | 39.1% | 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 | 37.0% | 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 | 43.5% | 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 | 96.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 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 | 7.5%CMS range 4.4–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 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 103 beds and averages 82.5 residents a day — about 80% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.36 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 4.19 hrs/resident/day on weekends vs 4.79 on weekdays — 12% thinner on weekends. RN hours go from 0.34 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Fcited before2024-08-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff practiced good hand washing to prevent potential cross contamination, Dairy products were maintained frozen to prevent the growth of bacteria, and hot food items were maintained at above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 84 residents who received meals from 1 of 1 kitchen, as indicated by a list provided by the Dietary Manager on 8/15/2024 at 8:30 AM. The findings are: 1. On 8/13/24 at 5:16 PM, Dietary [NAME] (DC) #5 was wearing gloves on his hands when he pulled his pants up, contaminating the gloves. Without changing gloves and washing his hands, he picked up chicken patties, buns, lettuce, tomatoes, and tarter tots, and placed them on the plates to be served to the residents for supper meal. DC #5 was asked what he should have done after touching dirty objects and before handling food items. DC #5…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-15 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined the facility failed to ensure a discharge Minimum Data Set (MDS) assessment to accurately reflect the residents discharge status for 1 (Resident #13) sampled resident. The findings are: Facility provided the Resident Assessment Instrument (RAI) assessment for discharge instructions on 8/15/2024 and was reviewed. The instructions indicated a discharge assessment must be completed when a resident is discharged from the facility and the resident is not expected to return to the facility within 30 days; must be completed within 14 days after discharge date , must be submitted within 14 days after the MDS completion date, and for unplanned discharges. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/19/2024 indicated Resident #13 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. During a closed record review, the surveyor was unable to locate an MDS Discharge Summary for Resident #13. In an interview 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.
- Potential for harm · E2024-08-15 · 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
Based on observation, interview, and record review, the facility failed to ensure hazards were removed from resident areas as evidenced by medications left at the bedside for 1 (Resident #64) of 1 resident; and a handrail on the Rehab hallway had an end-cap cover on the end of the handrail to prevent exposure of rough edges. Findings include: 1. A review of the facility's undated policy titled, Medications, Oral, indicated staff were to remain at the bedside until all medications are swallowed. A review of the admission Record, indicated the facility admitted Resident #64 with diagnosis that included fracture around internal prosthetic joint. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/2024, revealed Resident #64 had a Brief Interview of Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. During an observation on 08/12/2024 at 10:46 AM, Resident #46 had a medication cup with one green pill and one yellow pill located on the resident's overbed table. During a concurrent observation and interview 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.
- Potential for harm · Ecited before2024-08-15 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure all medications were safely stored and secured in to prevent accidental ingestion and or injury, as evidenced by a tube of anti-fungal medication left at Resident #15's bedside. The findings are: 1. Resident #15 had a diagnosis of brain bleed, heart failure and stroke, as indicated in the Physician's Orders dated August 12, 2024. a. Review of the Care Plan dated 07/23/24, Resident #15 had impaired cognitive function/dementia or impaired thought processes with a Brief Interview for Mental Status (BIMS) score of 6 severely impaired. b. On 08/13/24 at 9:33 AM, the surveyor observed a tube of anti-fungal medication lying on the residents over bed table. A review of the information located on the back of the tube indicated the active ingredient was Miconazole Nitrate 2% (antifungal medication). On the back of the tube was warnings for external use only; keep out of reach of children; and if swallowed, get medical help or contact a Poison Control Center right away. c. On 08/14/24 at 8:20 AM, the surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-15 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to 8 affect residents who received regular diets from 1 of 1 kitchen according to a list provided by the Dietary Manager on 8/15/2024. The findings are: 1. On 8/13/24, a facility supper meal menu indicated residents on mechanical soft diets were to receive 3 ounces of chicken with bun and 1/2 cup of chopped lettuce with tomatoes. Residents on pureed diets were to receive two #8 scoops (#8 scoop is 1/2 cup) of pureed breaded chicken with bun. 2. On 8/13/24 at 5:51 PM, the following observations were made during supper meal service: a. Dietary [NAME] (DC) #5 used a #16 scoop (1/4 cup or 2 ounces) to serve a single portion of ground breaded chicken to the residents on mechanical soft diets, instead of 3 ounces. b. Used a 2-ounce spoon to serve a single portion of chopped lettuce with tomatoes to the residents on mechanical soft…
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 · E2024-08-15 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure meals were served in a method that maintained nutritive value and taste that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 7 residents who receive their meal from 1 of 1 kitchen, as documented. on a list provided by Dietary Manager on 8/15/2024 at 8:30 AM. The findings are: 1. Review of a facility titled recipe for pureed herbed pork loin initiated on 2/20/2024, indicated for 10 residents to use ten 3 ounce herbed pork loins and add 1.25 cups of water or stock. 2. On 8/14/2024 at 10:58 AM, Dietary [NAME] (DC) #7 placed 6 thick slices of pork lion into a blender, added 2 cups of water, instead of 1.25 cup, and pureed. At 11:01 AM, DC #7 poured the pureed meat into a pan and placed it in the oven. 3. Review of a facility titled recipe for pureed brussels sprouts initiated on 2/20/2024, indicated for 10 residents use 10.5 cups of brussels sprouts, three tablespoons plus 2…
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 · E2024-08-15 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 the influenza and/or pneumococcal immunizations were administered and/or offered and documented for 4 (Resident #18, Resident #19, Resident #60, and Resident #64) of 5 (Resident #18, Resident #19, Resident #60, Resident #64, and Resident #92) sampled residents reviewed for the compliance of immunizations. The findings are: On 8/14/24 at 3:09 PM, the Administrator provided a form titled, Immunizations, Influenza, Pneumococcal and Covid 19. It indicated that the influenza, pneumococcal, and the Covid 19 immunizations will be administered unless medically contraindicated. The immunization policy indicated that the immunizations will be documented in the medical record when administered or refused. On 8/14/24 at 10:47 AM, review of Resident #64's Physician Orders indicated Resident #64 was admitted on [DATE]. There was no documentation that Resident #64 received the pneumonia or influenza immunization. The immunizations were reviewed in 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 · D2024-08-15 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to notify the ombudsman of a hospital transfer for 1 (Resident #95) of 1 resident reviewed for hospitalization. Findings include: A review of Progress Notes revealed Resident #95 had been sent to the hospital for low blood pressure and abdominal cramping on 6/12/2024. A review of Emergency Transfers from the Facility document sent to the ombudsman provided by the Business Office Manager revealed Resident #95 had not been included on the list. During an interview on 08/15/2024 at 8:57 AM, the Business Office Manager confirmed by reviewing the list with the surveyor that Resident #95 was not included and should have been to reflect the hospital transfer and the ombudsman should have been notified. During an interview on 08/15/2024 at 9:05 AM, the Administrator confirmed the hospital transfer and reviewed the provided list with the surveyor and stated Resident #95 should have been included on the list sent to the ombudsman to notify of 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 · Dcited before2024-08-15 · 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 observations, interviews, and facility policy review, the facility failed to ensure a laundry linen delivery cart on W Hall was covered during delivery of clean personal laundry to prevent the possible spread of harmful bacteria. Findings include: On 08/14/2024 at 2:47 PM, during an interview, the Laundry and Housekeeping Supervisor stated the facility did not have a policy for the delivery of clean resident laundry. During an observation on 08/12/2024 at 12:14 PM, a linen cart was parked against the wall on W Hall with the cover open and laid on top of the cart. Laundry Employee #11 was going in and out of resident rooms delivering laundry from the opened linen delivery cart. During an observation on 08/12/2024 at 12:16 PM, Laundry Employee #11 was observed pushing the linen cart down the W Hallway with the front cover open and continued to pass out resident's laundry. During an observation on 08/12/2024 at 12:33 PM, there was a clean linen laundry cart on the other end of W Hall with the front cover open, exposing the resident's clean laundry as Laundry Employee #11…
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 · D2023-10-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure call lights were within reach to enable residents to call for any necessary assistance for 1 (Resident #1) of 3 sample mix residents. The findings are: Review of Resident #1's care plan dated 06/03/2020 showed encourage Resident to use the bell to call for assistance. During observation on 10/26/2023 at 9:49 AM, the Surveyor observed Certified Nurse Aide (CNA) #1 clip Resident #1's soft call light to the right side of the bed on the quarter siderail and position the Resident onto his left side with a blue wedge placed behind him for positioning. During observation on 10/26/2023 at 11:38 AM, Resident #1 was in bed on his left side with a blue wedge behind him, and his soft call light clipped onto the right side of the bed on the quarter siderail. During interview on 10/26/2023 at 11:39 AM, CNA #1 confirmed based on the placement of the call light and Resident #1's current position in bed, he could not reach the call light. During interview on 10/26/2023 at 11:41 AM, Registered Nurse #1 confirmed based 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.
Show the remaining 13 citations
- Potential for harm · Fcited before2023-08-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure food items stored in the two door ice cream freezer were properly sealed to prevent freezer burn dietary employees used clean utensils when preparing food to maintain food quality and dietary employees used clean utensils when preparing meals to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 82 residents who received meals from the kitchen (total census: 82), as documented on a list provided by the Dietary Manager on 08/11/23 at 9:50 AM. The findings are: 1. On 08/07/23 at 10:00 AM, during the initial tour of the kitchen, the following observations were made in the two door ice cream freezer: a. An opened box of approximately 24 single serving cups of vanilla ice cream, with ice cream dripped down the side of the cup and ice cream smears on the box. The Surveyor asked the Dietary Assistant Manager why the ice cream containers look like that. She stated, It looks like they have thawed and been refrozen. b. An opened ziplock bag…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-08-11 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 a multi-resident use glucometer was disinfected after use to prevent potential spread of infection for 2 (Residents #19 and #236) of 2 sampled residents; staff followed clean technique during the administration of medications to prevent potential infection for 3 (Residents #19, #41 and #236) of 3 sampled residents who received medications from Licensed Practical Nurse (LPN) #2. The findings are: On 08/09/23, the following observations were made during medication pass by Licensed Practical Nurse (LPN) #2 on the Rehab Hall: 1. Resident #236 a. On 08/09/23 at 11:44 AM, LPN #2 used an alcohol prep pad to wipe the top of the glucometer and then sat the glucometer on top of the medication cart. b. On 08/09/23 at 11:45 AM, LPN #2 applied gloves. LPN #2 did not perform hand hygiene. c. On 08/09/23 at 11:46 AM, LPN #2 cleaned Resident #236's right middle finger with an alcohol prep pad and pricked the finger. d. On 08/09/23 at 11:47 AM, LPN #2 exited Resident #236's room and placed the lancet and blood glucose…
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 · E2023-08-11 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
Based on observation, interview, and record review, the facility failed to ensure wheelchair arm rests were free of rips and tears for 2 (Residents #1 and #2) of 2 sampled residents and failed to ensure the flooring was free of rips and tears. The findings are: 1. Resident #2 ' s Care Plan with a revision date of 05/24/22 documented, The resident has potential impairment to skin integrity . Identify/document potential causative factors and eliminate/resolve where possible . Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface . a. On 08/07/23 at 10:33 AM, Resident #2 observed sitting in room. The left wheelchair arm rest was peeling with foam exposed. b. On 08/07/2023 at 1:11 PM, Resident #2 observed sitting in wheelchair in the dining room. The left wheelchair arm was peeling with foam exposed. 2. Resident #1's Care Plan with a revision date of 06/11/21 documented, The resident has potential/actual impairment to skin integrity . Identify/document potential causative factors and eliminate/resolve where possible .…
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 · E2023-08-11 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the annual comprehensive resident assessments were completed and transmitted within 14 calendar days to facilitate appropriate care planning and maintain current and accurate assessment records for 8 (Residents #5, #11, #18, #23, #27, #47, #51 and #65) of 8 sampled residents whose comprehensive assessments were reviewed. The findings are: During resident record review the following annual resident assessments were not completed within the regulatory time frame: 1. Resident #5's Annual Assessment with an Assessment Reference Date (ARD) of 06/23/23 was still in progress. 2. Resident #11's Annual Assessment with an ARD of 06/16/23 was still in progress. 3. Resident #18's Annual Assessment with an ARD of 06/05/23 was still in progress. 4. Resident #23's Annual Assessment with an ARD of 05/18/23 was still in progress. 5. Resident #27's Annual Assessment with an ARD of 06/14/23 was still in progress. 6. Resident #47's Annual Assessment with an ARD of 06/06/23 was still in progress. 7. Resident #51's Annual Assessment 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.
- Potential for harm · E2023-08-11 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the completion of the quarterly resident assessments within 14 days of the Assessment Reference Date (ARD) and submitted no later than an additional 14 days after completion to meet requirements for 6 (Residents #9, #19, #31, #36, #55 and #58) of 6 sampled residents whose Quarterly Assessments were reviewed. The findings are: During resident record review, the following quarterly assessments were not completed within the regulatory time frame: 1. Resident #9's Quarterly Assessment with an ARD of 06/19/23 was still in progress. 2. Resident #19's Quarterly Assessment with an ARD of 06/14/23 had a completion date of 08/07/23. 3. Resident #31's Quarterly Assessment with an ARD of 06/11/23 had a completion date of 08/07/23. 4. Resident #36's Quarterly Assessment with an ARD of 06/12/23 was still in progress. 5. Resident #55's Quarterly Assessment with an ARD of 06/12/23 had a completion date of 08/07/23. 6. Resident #58's Quarterly Assessment with an ARD of 6/10/23 had a completion date of 08/07/23. 7. On 08/11/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-11 · tag F0657 — failed to keep the care plan current — patternDevelop 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 ensure comprehensive care plans were revised quarterly, to accurately identify care area needs and provide care for 4 (Residents #13, #40, #46 and #130) of 22 (Resident #1, #3, #5, #7, #8, #9, #10, #13, #16, #18, #19, #23, #27, #29, #31, #32, #36, #40, #41, #43, #46, #55, #57, #58, #67, #69, #71, #75, #77, #78, #130, #180 and #236) sampled residents whose care plans were reviewed. The findings are: 1. A review of Resident #13's resident profile in the electronic medical record noted diagnoses of Unspecified Dementia, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure and Acute Kidney Failure. a. A Physician Order dated 05/24/23 documented the resident was to receive Lasix, a diuretic medication one time a day related to acute kidney failure. b. A Physician Order dated 08/01/23 documented the resident was to receive Sertraline (an antidepressant medication) one time a day related to other recurrent depressive disorders and Hydrocodone-Acetaminophen (an opioid pain reliever) every 8 hours as needed for pain. c. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the Physician for 2 (Residents #40 and #46) of 2 sampled residents; staff were trained on Continuous Positive Airway Pressure (CPAP) equipment and interventions and nebulizer masks/tubing were contained in a plastic bag or container when not in use for 1 (Resident #40) to prevent potential contamination or infection. The findings are: 1. A Physicians Order dated 09/21/20 documented Resident #46 was to receive oxygen at 2 liters per minute via nasal cannula as needed. a. A Physicians Order dated 06/05/23 documented Resident #46 was to use Continuous Positive Airway Pressure (CPAP) at bedtime. b. On 08/07/23 at 11:42 AM, Resident #46 was sitting in a chair in her room with oxygen on at 3 liters per minute via nasal cannula. c. On 08/07/23 at 2:13 PM, Resident #46 stated the nurses don't know anything about my CPAP. I was having trouble breathing Sunday morning and the nurse came in and said, I don't know anything about that (CPAP). d. On 08/10/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-11 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 licensed staff accurately documented the removal of narcotics at the time of administration, to ensure periodic accurate reconciliation and accounting for all controlled medications. The findings are: 1. On 08/08/23 at 2:28 PM, the following observations were made on the medication cart on the Observation Hall/Women's Unit with Licensed Practical Nurse (LPN) #1: a. A medication card of Lorazepam 0.5 mg. (milligram) with 40 tablets in the card. The Narcotic Book documented there were 42 tablets. LPN #1 stated, I haven't signed them out. The Surveyor asked, What time did you give them? LPN #1 replied, It's scheduled for 8:00 AM and 2:00 PM. I gave it around 1:00 PM and the first dose around 8:30 AM. The Surveyor asked when the medications should be signed out. LPN #1 replied, When we give them. The Surveyor asked who was responsible for signing medications when giving them. LPN #1 replied, The nurse that has the keys or gives the medications. LPN #1 said she usually signs out the narcotics after…
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 before2023-08-11 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure vials of insulin, nasal sprays, and inhalers were dated, and disposed of in accordance with manufacturer's instructions, and medications were stored in a locked Medication Cart/Medication Room and not at the bedside for 4 (Residents #1, #36, #40 and #59) of 4 sampled residents. The findings are: 1. On [DATE] at 1:58 PM, the following observations were made on the [NAME] Hall Medication Cart with Licensed Practical Nurse (LPN) #3: a. One vial of Novolog 100 unit/ml (milliliter) Insulin with a fill date of [DATE] and had an opened date of [DATE]. The label reads, Discard 28 days after opened. b. One vial of Lantus 100 unit/ml Insulin with a fill date of [DATE] and had an open date of [DATE]. The label reads, Discard 28 days after opened. c. One canister of Symbicort 80 mcg/4.5 mcg (micrograms) with a fill date of [DATE] and no open date. The order reads inhale 2 puffs orally 2 times a day. The dose counter on top of the canister…
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 before2023-08-11 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately record the Resident Assessment for 1 (Resident #13) of 14 (Residents #5, #9, #11, #13, #18, #19, #23, #27, #31, #36, #47, #55, #58 and #65) sampled residents. The findings are: 1. Resident #13 had diagnoses of Unspecified Dementia, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure and Acute Kidney Failure. The Quarterly MDS with an Assessment Reference Date (ARD) of 05/10/23 was currently in progress. The electronic medical record documented The next Quarterly: ARD: 5/11/2023 currently 77 days overdue. a. A Physicians Order dated 05/24/23 documented the resident was to receive Lasix 20 milligrams one time a day related to acute kidney failure. b. A Physicians Order dated 08/01/23 documented the resident was to receive Hydrocodone-Acetaminophen 5-325 milligrams 1 tablet every 8 hours as needed for pain and Sertraline (Zoloft) 50 milligrams 1 tablet one time a day related to other recurrent depressive disorders. c. On 08/11/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, interview and record review, the facility failed to ensure Physician Orders were transcribed accurately for 1 (Resident #8) of 1 sampled resident to ensure residents orders received by the Advance Practice Nurse (APN) were followed. The findings are: 1. On 08/07/23 at 12:58 PM, Resident #8 had a reddish substance on several upper teeth. Resident #8 stated she has a gum infection, and it has prevented her from eating her breakfast. That the blood is making her nauseated and that her teeth feel slimly. They are supposed to be getting me something to put on my gums. a. On 08/08/23 at approximately 9:15 AM, Resident #8 was lying in bed. The Surveyor asked if she received a treatment for her gums. She stated, No, not yet. Resident #8's teeth had a white substance between them and some brownish discoloration. b. On 08/09/23 at 8:15 AM, Resident #8 was in bed eating breakfast. The Surveyor asked if she had received a treatment to her gums/teeth. c. On 08/09/23 at approximately 2:00 PM, the Surveyor reported to Licensed Practical Nurse (LPN) #1 that Resident #8 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 · D2023-08-11 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for 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 observation, interview and record review, the facility failed to provide routine dental services for 1 (Resident #8) of 1 sampled resident who required oral care. The findings are: 1. On 08/07/23 at 12:58 PM, Resident #8 described having a gum infection. Resident #8 had a reddish substance on several upper teeth. Resident #8 describes that the infection has prevented her from eating her breakfast, that the blood is making her nauseated and that her teeth feel slimly. Resident #8 stated, They are supposed to be getting me something to put on my gums. a. On 08/08/23 at approximately 9:15 AM, Resident #8 was lying in bed. The Surveyor asked if she received a treatment for her gums. She stated, No, not yet. Resident #8's teeth appeared to be plaque covered. A white substance was between some teeth and there was some brownish discoloration. The Surveyor asked when she had seen a dentist. Resident #8 stated, Oh goodness. I'm not sure. b. A Physicians order dated 11/20/20 documented Resident #8 to the dentist…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-08-11 · tag F0656 — failed to write and follow a full care plan — widespreadDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to develop and implement a care plan for 3 (Residents #8, #29 and #75) of 3 sampled residents. The findings are: 1. Resident #8 had diagnoses of Candidiasis of Skin and Nail, Glaucoma and Macular Degeneration. a. On 08/07/23 at 2:07 PM, observed Resident #8 lying in bed. Her fingernails protruded past the end of the fingers approximately 1/8 inch. The Surveyor asked Resident #8 if she had requested her nails be cut. She stated, That goes back to them having enough staff. I hate to ask them. b. On 08/09/23 at 8:15 AM, Resident #8 stated that she was given a bath on Monday (08/07/23) afternoon, however her fingernails were not cut or trimmed. c. On 08/10/23 at 1:46 PM, Resident #8's Comprehensive Care Plan with a revision date of 06/01/21 did not address nail care. d. On 8/10/23 at 1:57 PM, the Surveyor asked Licensed Practical Nurse (LPN) #5 when nail care should be provided. LPN #5 stated, Per the schedule and as needed. The Surveyor asked if nail care should be addressed on the resident's Care Plan. LPN #5…
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 CENTRAL ARKANSAS NURSING CENTERS — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.6 | +1.4 vs chain |
| Health inspection | 4 of 5 | 3.2 | +0.8 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.2 | +0.8 vs chain |
The other 37 homes this chain runs (chain average 3.6★, 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 |
|---|---|---|---|
| MORTON, MICHAEL | Individual | CORPORATE OFFICER | since 04/24/1989 |
| SAMS, JERRY | Individual | CORPORATE OFFICER | since 04/01/2007 |
| SMITH, LANDER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/10/2024 |
| CENTRAL ARKANSAS NURSING CENTERS INC | Organization | ADP OF THE SNF | since 10/21/2025 |
| NURSING CONSULTANTS INC | Organization | ADP OF THE SNF | since 10/21/2025 |
| HOLLINGSWORTH, SHERI | Individual | ADP OF THE SNF | since 10/20/2024 |
CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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
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 045183. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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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