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Dermott City Nursing Home

702 West Gaines St, Dermott, AR 71638 · Government - City · 70 certified beds · (870) 538-3241 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 immediate-jeopardy citation$48,527 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
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $48,527 in federal fines (most recent 2026-07-08)
  • its independent health-inspection rating is low (1/5)
  • it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
  • its facility-reported quality-measure rating is low (1/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Walmart7.0 mi
1001 Highway 65 S · (870) 222-6233 · Call to confirm hours
Pharmacy
111 E Peddicord St · (870) 538-5233 · Call to confirm hours
Grocery
1009 Highway 65 S · (870) 222-4872 · Call to confirm hours
Park
901 Holly St · Typically dawn to dusk
Place of worship

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 1 of 5
Long-stay residentspeople who live here 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 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 rating1★
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 increased17.6%9.5%15.4%worse
Long-stay residents who lose too much weight1.2%4.3%5.4%better
Long-stay residents with a catheter left in their bladder1.9%0.6%0.9%worse
Long-stay residents with a urinary tract infection1.7%1.2%2.0%better
Long-stay residents with depressive symptoms0.6%1.4%6.5%better 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 injury5.8%3.9%3.3%worse
Long-stay residents whose ability to walk worsened13.6%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.3%21.7%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers11.3%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control14.8%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table17.7%10.9%17.1%typical
Long-stay hospitalizations per 1,000 resident days1.802.011.67typical
Long-stay outpatient ER visits per 1,000 resident days3.082.131.80worse

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.

78.3%U.S. median 56.6%
Met the expected recovery

Met the expected recovery: 78.3% 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 23 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.

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 discharge78.3%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 discharge65.2%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 discharge69.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 SNFs1.141.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

4
deficiencies at the latest standard inspection (2025-02-27)
13
at the previous standard inspection (2024-01-05)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-12-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and facility policy review, the facility failed to ensure Certified Nursing Assistants (CNAs) #1 and #2 demonstrated competency in the care of a resident by moving a resident prior to a nurse assessment following a fall, and by not following the resident's care plan, which indicated the use of a mechanical stand-up lift with two-person assist for transfers, for one (Resident #1) of three residents reviewed for falls. 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, 483.35 (Nursing Services) at a scope and severity of J. The IJ began on 12/02/2025 around 10:34 AM, when CNA #1 performed an improper transfer of Resident #1 from the bed to a wheelchair without the use of a mechanical stand-up lift or a second person to assist, which resulted in Resident #1 falling to their knees on the floor. CNA #1 requested CNA #2 assist in moving…

    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
  • Actual harm · Gcited before2024-10-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, Interview, Record Review and Facility Policy Review; the facility failed to transfer one (Resident #1) of five (Resident #1, #2, #3, #4 and #5) sampled residents safely and in accordance to the care plan, resulting in a major injury. The findings are: Review of Resident #1's Medical Diagnosis record revealed the resident had diagnoses of renal osteodystrophy (a complication of chronic kidney disease that weakens the bones), cerebral infarction, hemiplegia affecting the right dominant side, and osteoporosis. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/2024 noted a Brief Interview for Mental Status (BIMS) of 15, (cognitively intact). The MDS revealed Resident #1 had unclear speech but was able to make self-understood and understands, had an impairment of upper and lower extremities on one side and was dependent for transfers and ambulated via wheelchair. Review of Resident #1's care plan with a revision date of 11/10/2022 revealed the resident had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-12-23 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview and facility policy review, the facility failed to ensure a Licensed Administrator was hired to oversee the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities for one of one facility reviewed for administrative duties. The findings include: Review of a facility Administrator Job Description, with a revision date of October 2022, indicated that the primary purpose of the position is to direct the day-to-day functions of the facility in accordance with current, federal, state and local standards, guidelines and regulations that govern the nursing facilities to assure the highest degree of quality care can be provided to residents at all times. Experience indicated as, must have a current unencumbered nursing home Administrator's license or meet the license requirements of the state. Review of a facility policy titled Administrative Management Governing Body with a revision date of January 2025, indicated that the governing body shall be…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and facility policy review, the facility failed to ensure a comprehensive care plan was consistently implemented for one (Resident #1) of three residents whose care plans were reviewed. The findings include: Review of an admission Record, indicated the facility admitted Resident #1 on 10/03/2024 with diagnoses which included scoliosis (lateral deviation of the spine), unsteadiness on feet, and dementia (loss of memory, thinking, and reasoning skills). Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/07/2025, revealed a Brief Interview for Mental Status (BIMS) score of 09, which indicated Resident #1 had moderate cognitive impairment and was dependent on staff for toileting hygiene, shower/bathe self, chair-/bed-to-chair transfers. The MDS indicated active diagnoses which included fractures and other multiple trauma; falls since admission/entry or reentry or prior assessment; recent surgery requiring active Skilled Nursing Facility (SNF) care and surgical procedures for repair of fractures of the pelvis,…

    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 · F2025-02-27 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 the required staffing data was posted daily as evidenced by the daily staffing logs did not display the total number and actual worked hours for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs) and resident census. The findings are: On 02/24/2025 at 9:38 AM, a review of the nursing schedules posted in the clear glass of the Director of Nursing (DON) office, which was to the right of the nursing station, was dated February 20, 2025, through March 05, 2025. The RN and LPN schedule; 7/3 (7:00 AM to 3:00 PM) shift CNA and [NAME] Clerk schedule; and the 3/11 (3:00 PM to 11:00 PM) and 11/7 (11:00 PM to 7:00 AM) schedule, had an x in some boxes, but the x did not have a number value to indicate the number of hours the x indicated. Some boxes on the RN and LPN schedule had numbers such as 7-3 (7:00 AM to 3:00 PM), 3-7 (3:00 PM to 7:00 PM), 4p-11p (4:00 PM to 11 PM), 3-11 (3:00 PM to 11:00 PM) and 7-11 (7:00 AM to 11:00 PM). The total actual…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-27 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 21 residents who received mechanical soft diets from 1 of 1 kitchen. The findings are: 1. The menu for lunch documented residents on pureed diets were to receive a #6 scoop (2/3) cup of pureed chicken and dumplings. a. On 02/24/2025 at 12:49 PM, Dietary [NAME] (DC) #3 was observed using a #8 scoop (1/2) cup to serve a single portion of chicken and dumplings to the residents who required pureed diets, instead of a #8 scoop (2/3) cup. b. On 02/24/2025 at 12:59 PM, DC #3 was interviewed and was asked what scoop she had used to serve pureed chicken and dumplings and how many servings she gave to each resident and if she had looked at the menu before serving. She stated she used a #8 scoop, gave one serving each, and did not look at the menu. 2. On 02/24/2025 at 12:51 PM, the kitchen ran out of cornbread and served…

    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 before2025-02-27 · 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 facility policy review, the facility failed to ensure dietary staff washed their hands and changed their gloves before handling food items; foods stored in the dry storage area, refrigerator, and freezer were covered and sealed; expired food items were promptly removed from stock; 1 of 2 ice machines was maintained in clean and sanitary condition; hot food items were maintained at or above 135 degrees Fahrenheit on the steam table. The findings are: 1. On 02/24/2025 at 8:11 AM, an ice scoop holder on the wall in the kitchen by the ice machine had a wet black and beige residue on it. The Dietary Manager was interviewed and was asked if she could wipe the area. The black and beige residue easily transferred to the tissue. She stated, It was black and beige residue. The surveyor asked the Dietary Manager who uses the ice from the ice machine and how often she cleans it. She stated she cleaned it every day and the kitchen used it to fill beverages served to the residents at mealtimes. 2. On 02/24/2025 at 8:41 AM, the following observations were made…

    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 · D2025-02-27 · tag F0917 — isolated
    Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and policy review, the facility failed to provide appropriate bedding for 1 (Resident #1) of 1 sampled resident observed for bedding. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/2024 revealed Resident #1 had short-term and long-term memory problems. A review of the plan of care for Resident #1 (revised on 09/08/2023) revealed Resident #1 required total assistance to turn and reposition in the bed and the resident could use rail with left hand to assist with turning and repositioning. On 02/24/2025 at 09:15 AM, this surveyor observed Resident #1 lying on [pronoun] back in bed without a pillow. Resident #1 was holding [pronoun] head up from the mattress. This surveyor did not see a pillow on or around the bed. On 02/24/2025 at 02:54 PM, this surveyor observed Resident #1 in bed lying on [pronoun] left side without a pillow. Resident #1's head was resting on the left hand folded into a fist. This surveyor did not see a pillow on or around the bed. On 02/25/2025…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-23 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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 operate under the direction of a licensed Administrator, which had the potential to affect all 45 residents who resided in the facility. The findings are: On 10/21/2024 at 1:50 PM, upon entering the facility and requesting to speak to the Administrator, this surveyor was informed by the Director of Nursing (DON), and the Acting Administrator (the Compliance Coordinator), no administrator was currently employed at the facility. During interview, the Acting Administrator stated the Administrator had been gone since 7/15/2024, and the position had been posted on employment websites. When asked if she held a nursing home administrator's license, the Acting Administrator confirmed she did not. On 10/22/2024 at 10:10 AM, during an interview the Acting Administrator was asked if she could provide any documentation assigning her as Acting Administrator. She produced an undated typed document stating she was Acting Administrator with no name or signature of who assigned this position. On 10/22/2024 at 3:30 PM, 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-01-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage areas were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; leftover foods were in a manner to maintain food quality; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; 1 of 2 ice scoop holders was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen; and the ceiling tiles were free of stains and walls were free of peeling paint. These failed practices had the potential to affect 35 residents who receive meals from the kitchen (total census: 39) as documented on a list provided by Dietary Supervisor. The findings are: 1. On 01/04/24…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a janitor closet on the 500 Hall containing chemicals remained locked to prevent accidents. This failed practice had the potential to affect 25 residents who were ambulatory or self-propel in a wheelchair as documented on a list provided by the Administrator on 01/05/2024 at 09:41 AM. The findings are: 1. On 01/02/2024 at 01:06 PM, a closet door labeled Janitor was noted with a key on a red key chain in the doorknob. 2. On 01/02/2024 at 01:09 PM, a closet door labeled Janitor was noted with a key on a red key chain in the doorknob. Upon observation of the room, the Surveyor noted 2 mop buckets with mops and a blue chemical dispenser with (disinfectant cleaner) in it on the wall on the right side of the room. 3. On 01/02/2024 at 01:13 PM, a closet door labeled Janitor was noted with a key on a red key chain in the doorknob. Upon observation of the room, the Surveyor noted 2 mop buckets with mops and a blue chemical dispenser with (disinfectant cleaner) in it on the wall on the right side of the room. 4.…

    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 before2024-01-05 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 4 residents who received pureed diets and 20 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 01/05/2024. The findings are: 1. On 01/04/2024, the menu for the lunch meal documented residents who received mechanical soft diets were to receive #8 scoop (4 ounces) of ground fried chicken. Residents who received pureed diets were to receive (4 ounces) of pureed fried chicken. a. On 01/04/2024 at 12:54 PM, the following observations were made during the lunch meal: b. The Dietary Supervisor used a 2 ounce (orange spoon) which is equivalent to 1/4 cup (2 ounces) to serve a single portion of pureed cut green beans, to the residents who required pureed diets, instead of #8 scoop as specified on the menu. c. The Dietary Supervisor used a 2 ounce spoon…

    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
Show the remaining 15 citations
  • Potential for harm · E2024-01-05 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The failed practice had the potential to affect 8 residents who received their meal trays in their rooms on the 500 Hall, 8 residents who received meals in their rooms on the 100 Hall, as documented on a list provided by the Dietary Supervisor on 01/05/2024 at 10:51 AM. The findings are: 1. On 01/02/24 at 10:40 AM, Resident #39 was asked if the hot food was hot, and cold food was cold when served? Resident #39 stated, The hot food is cold at times. 2. On 01/05/24 at 07:57 AM, an unheated food cart that contained 8 trays for the breakfast meal was delivered to the 500 Hall by Certified Nursing Assistant (CNA) #4. At 08:19 AM, immediately after the last resident received their tray in their room, the Surveyor asked the Dietary Supervisor to check the temperatures of the food items on the trays. She did and stated, a. Milk - 49 degrees…

    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 · E2024-01-05 · 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. This failed practice had the potential to affect 4 residents who received pureed diets, as documented on the Diet List provided by the Dietary Supervisor on 01/05/2024. The findings are: 1. On 01/04/24 at 11:59 PM, Dietary Employee (DE) #1 placed deboned pieces of fried chicken into a blender, added water, thickener and pureed. At 12:02 PM, DE #1 poured the pureed chicken into a pan and placed it on the steam table. The consistency of the pureed chicken was gritty, not smooth. On 01/04/24 at 12:14 PM, DE #1 used a 4 ounce spoon to place 4 servings of cut green beans into a blender, opened two packages of thickener, emptied them on the beans, and pureed. At 12:15 PM, DE #1 poured the pureed cut green beans into a pan and placed it on the steam table. The consistency of the cut green beans was runny. On 01/05/24 at 07:55 AM, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-05 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies to ensure residents with Mental Health Diagnosis received a Level II Pre-admission Screening and Resident Review (PASARR) before being admitted to the facility. The findings are: A Recertification survey was conducted on 10/13/22 at the facility. A review of the facility's Plan of Correction was conducted on 01/05/24. The Plan of Correction, with a completion date of 11/12/22 stated: F644 - To ensure the deficient practice does not recur, on 10/13/22 the MDS [Minimum Data Set] Coordinator was in-serviced on making sure all residents with mental illness diagnosis are screened for preadmission and a resident with a new mental illness diagnosis receives a PASARR. DON [Director of Nursing]/Designee will monitor new admissions and new diagnosis of current residents to ensure any resident with a mental illness diagnosis receives a PASARR 5X week for 8 weeks or…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-05 · 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, the facility failed to ensure a multi-resident use glucometer (a machine to check glucose levels) was properly disinfected after use to prevent potential spread of infection for 3 (Residents #10, #12 and #14) sampled residents who had physician orders for capillary blood glucose monitoring as documented on a list provided by the Administrator on 1/05/23 at 9:31 AM. The findings are: 1. On 1/03/23 at 11:30 AM, during Medication Administration Observation, Licensed Practical Nurse (LPN) #1 performed a fingerstick on Resident #10. LPN #1 took a (Brand Name) disinfectant bleach wipe and cleaned the glucometer for 4 seconds then placed the machine on the medication cart. At 11:37 AM, LPN #1 used the same glucometer and obtained a fingerstick on Resident #14. LPN #1 then cleaned the glucometer with a (Brand Name) disinfectant bleach wipe for 6 seconds. After the fingerstick on Resident #14, LPN #1 used the same glucometer and obtained a fingerstick on Resident #12, then cleaned the glucometer for 5 seconds with a (Brand Name)…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-05 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident records, care plans, and physician orders contained accurate documentation of a residents' Cardio-Pulmonary Resuscitation (CPR) status for 1 (Resident #39) of 1 sampled resident. The findings are: 1. On [DATE] at 11:11 AM, a review of Resident #39's electronic medical record (EMR) contained a Living Will Declaration provided by the Administrator which noted the resident does not want Cardiac Resuscitation (CPR), Artificially Administered Feeding (Feeding tubes), or Artificial Breathing Machine (Respirator/ventilator). This document was signed on [DATE], by the Power of Attorney and was witness by the Social Services Director (SSD). 2. The Physician Order dated [DATE] noted an order for Full Code. 3. The Face Sheet printed on [DATE] noted, Full Code. 4. The Care Plan dated [DATE] noted a care plan for Advanced Directives and noted Resident #39 was a Full Code. 5. On [DATE] at 04:11 PM, the SSD was asked, What is Resident #39's code…

    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 · D2024-01-05 · tag F0623 — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Ombudsman was notified of a transfer to the hospital for 1 (Resident #42) of 1 sampled resident. The findings are: 1. On 01/04/24 at 11:08 AM, during review of Resident #42's medical record, it was noted Resident #42 was admitted [DATE] with diagnoses of heart failure, diabetes mellitus, hypertension, Stage 3 kidney disease and chronic obstructive pulmonary disease (COPD); was a full code; was in the hospital from [DATE] to 10/06/23 for acute-chronic renal insufficiency, hyponatremia, and difficulty swallowing. 2. On 1/4/23 at 11:40 AM, there was no documentation in the medical record that the Ombudsman had been notified of Resident #42 transfer to the hospital. 3. On 1/5/23 at 08:53 AM, the Administrator provided a form titled, Emergency Transfer from Facility Resident #42 was not listed for the second admission to the hospital. 4. On 1/5/23 at 09:00 AM, the Administrator confirmed there was no proof the Ombudsman was notified. 5. On 1/5/23…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-05 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the State Agency for a Pre-admission Screening and Resident Review (PASARR) for a new mental illness diagnosis for 1 (Resident #19) sampled resident to ensure the resident received appropriate mental health services. The findings are: Resident #19 was admitted on [DATE] with a Medical Diagnosis of Unspecified Psychosis not due to a substance or known physiological condition. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/23 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). A Care Plan dated 11/14/23 documented, He is dependent on staff for meeting emotional, intellectual, physical, and social needs related to Cognitive deficits, Immobility, and Physical Limitations related to stroke. On 01/02/24 at 1:30 pm, per record review a PASARR could not be located. On 01/03/24 at 10:00 am, the Director of Nursing (DON) was asked for a PASARR for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to develop and implement a care plan to address cigarette smoking for 1 (Resident #33) of 6 (Residents # 5, #9, #18, #26, #33 and #35) sampled residents who smoke documented on a list provided by the Administrator on 01/02/2023. The findings are: Resident #33 had diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/2023 documented the resident used tobacco. 1. Review of Resident #33's Plan of Care did not address smoking. 2. On 01/04/2024 at 12:10 PM, the Director of Nurses (DON) was at the Nurses Station and was asked who was responsible for ensuring smoking was included in the care plan. The DON stated, The MDS Coordinator. 3. On 01/04/2024 at 12:15 PM, the MDS Coordinator was asked if tobacco use should be addressed on the resident's care plan. The MDS Coordinator confirmed that it should be. The MDS Coordinator was asked if Resident #33 had tobacco use addressed on the care plan. The MDS Coordinator…

    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 · D2024-01-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    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 observation, record review, and interview, the facility failed to ensure rehabilitative services were carried out according to the physician's orders for 1 (Resident #19) of 1 sampled resident who have a contracture. The findings are: Resident #19 was admitted on [DATE] with a diagnosis of Unspecified Psychosis not due to a substance or known physiological condition. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/23 documented the resident scored a 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). A Care Plan dated 11/14/23 documented, He is dependent on staff for meeting emotional, intellectual, physical, and social needs related to Cognitive deficits, Immobility, and Physical Limitations related to stroke. The Care Plan does not address the resident requiring a hand roll to the right hand. A Physician's Order dated 04/17/23 documented, Restorative: Apply hand roll to right hand daily. On 01/02/24 at 11:20am., 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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, record review and interview, the facility failed to follow a therapeutic diet by ensuring the nutritional interventions ordered by the physician were served and offered when the resident's weight continued to decline from week to week in order to minimize further weight loss and maintain nutritional status to the extent possible for 1 (Resident #36) of 1 sampled resident. The findings are: Review of Resident #36's medical record noted Resident #36 was admitted on [DATE] with a weight of 129.2 pounds. Resident #36 weighed 116.8 on 10/03/23. On 11/06/23 Resident #36 weighed 114.6. On 12/5/23 resident #36 weighed 113.8. On 11/30/23 the physician ordered pudding for every meal and to be an assist feeder. Speech Therapy did an evaluation and changed her diet to a mechanical soft and nectar thickened liquids. Resident #36 had an 11.9% weight loss since admission. A Care Plan dated 10/04/23 with a revision date of 10/20/23 documented Resident #36 had unplanned weight loss over the past 6-8…

    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 before2022-10-13 · tag F0644 — pattern
    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 interview and record review, the facility failed to notify the state agency for a Pre-admission Screening and Resident Review (PASRR) for a new mental illness diagnosis for 1 (Resident #34) sampled resident to ensure the resident received appropriate Mental Health Services. The findings are: Resident (R) #34 had diagnoses of, other Specified Depressive Episodes, Unspecified Psychosis not due to a substance or known Physiological Condition. The Resident's Face Sheet for 9/08/21 documented the diagnosis of Unspecified Psychosis not due to a substance or known physiological condition. 1.During the record review no PASRR screening documentation was in the Resident's Electronic Health Record. 2. On 10/12/22 at 10:45 AM, The Surveyor asked the Director of Nursing (DON), Should a resident with a diagnosis of Unspecified Psychosis not due to a substance or known physiological condition receive a PASSR screening? The DON stated, Yes. The Surveyor asked the DON, Who is responsible for ensuring PASRR's are completed on residents? The DON stated, The MDS Coordinator. 3. On 10/12/22 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-13 · tag F0657 — failed to keep the care plan current — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that the Person-Centered Comprehensive Care Plan was reviewed and revised by the interdisciplinary team who had knowledge of the resident and the resident's needs, for 1 (Resident #34) of 1 sampled resident that had a diagnosis of Unspecified Psychosis not due to substance or known psychological condition. The findings are: 1.Resident #34 had diagnoses of Unspecified Psychosis not due to Substance or Known Psychological Condition, Other Specified Depressive Disorder, Hypertensive Heart Disease without Heart Failure, Acquired Absence of the Right Leg Below the Knee, acquired Absence of the Left Leg Below the Knee, and Acute Kidney Failure Unspecified. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/13/22 documented a score of 10 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). The MDS documented resident required extensive assist of one person with toileting and limited assist of one…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and interview, the facility failed to ensure 1 resident (Resident #14) of 1 (Resident #14) case mix residents was not left unattended following a doctor's appointment, as evidenced by the resident having a fall outside the doctor's office. The resident was left alone outside of the doctor's office while the Transport Assistant (TA) went to get the van. While waiting on the van to arrive the resident unlocked her wheelchair and rolled down to the curb where the wheelchair tipped over with the resident in it. The failed practice had the potential to affect all residents who require transportation by the facility van to outside appointments. The findings are: Resident #14 had diagnoses of History of falling, Unspecified dementia, Hypertensive Heart Disease . The 5-day Medicare Minimum Data Set (MDS) with an Assessment Reference Date of 8/11/22 documented the resident scored 14 (12-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required limited assistance of one person for bed mobility and transfers, and used a walker for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-13 · tag F0838 — failed to assess facility resources and resident needs — pattern
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    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 a Facility-Wide Assessment was updated on an annual basis to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. This failed practice had the potential to affect all 44 residents according to the Census and Conditions provided by the Administrator on 10/10/22 at 2:38 pm. The findings are: a. On 10/12/22 at 11:01 am., the Facility Assessment was reviewed and documented the date of Assessment or Update was 11/13/18. The dates the Assessment was reviewed with the Quality Assurance Assessment (QAA)/Quality Assurance and Performance Improvement (QAPI) Committee documents a date of 11/13/18. b. On 10/12/22 at 12:55 pm., The Surveyor asked the Director of Nursing (DON), How often should the Facility Assessment be updated? The DON stated, I thought it was annually. The Surveyor asked, How do you have input into the Assessment? The DON stated, We do it as a team. We get together and talk about what needs to be updated and we talk about how many staff…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-13 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure a resident's rights for dignity were maintained as evidenced by 1 Resident (Resident #41) had a urinary catheter bag being in full view of others. The findings are: Resident #41 was admitted on [DATE] with medical diagnoses of Peripheral Vascular Disease, and Benign Prostatic Hyperplasia without lower urinary tract symptoms. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/22 documented, the resident is independent for bed mobility, transfer, requires supervision with eating, limited assistance with toileting and personal hygiene, and physical help with bathing. A Care Plan dated 04/06/22 documented, Resident #41 has a Suprapubic Catheter with no revisions. a. On 10/12/22 at 1:00 pm., The Surveyor asked Certified Nursing Assistant #1 (CNA) #1, Should a foley bag be in a privacy bag? CNA #1 stated, Yes. The Surveyor asked, How would a resident feel with his foley bag in full view of others? CNA #1…

    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

“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

$48,527 in federal fines across 3 penalties.

  • $24,662 — penalty dated 2026-07-08
  • $14,901 — penalty dated 2025-12-23
  • $8,964 — penalty dated 2024-10-23

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.

Who owns this facility

Owner / managerTypeRoleSince
CARBAGE, RALPHIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 11/01/2022
DILLARD, BETTYEIndividualCORPORATE DIRECTORsince 11/01/2022
JENKINS, ROSIEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/29/2025
BOATMAN, BARBARAIndividualCORPORATE OFFICERsince 01/23/2025
MARTIN, NAOMIIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/06/2017
RUSSELL, JOHNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/06/2017
SMITH, BARBARAIndividualCORPORATE OFFICERsince 05/20/2024
DERMOTT CITY NURSING HOMEOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/29/2025

CMS files one row per role, so the 14 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$4.9M
Net patient revenuemost recent cost report
-1.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 77%Medicare 9%Other / private 14%

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$307per resident / day
operating cost
$9,345per month
≈ monthly operating cost
$303per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in AR

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 045172. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-27, 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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