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The Springs Of El Dorado

1700 East Short Hillsboro, El Dorado, AR 71730 · For profit - Limited Liability company · 122 certified beds · (870) 862-5124 Medicare & Medicaid certified

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1 immediate-jeopardy citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 29% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
403 W Oak St · (870) 863-4996 · Call to confirm hours
Pharmacy
102 E Elm St · (870) 863-8111 · Call to confirm hours
Grocery
2416 Junction City Rd · (870) 314-2433 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1621 E Hillsboro St · (870) 862-1360

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 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 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.3%9.5%15.4%better
Long-stay residents who lose too much weight7.5%4.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%1.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.6%3.9%3.3%typical
Long-stay residents whose ability to walk worsened4.4%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication26.3%21.7%18.9%worse
Long-stay residents given the seasonal flu vaccine98.7%96.1%95.3%typical
Long-stay residents with pressure ulcers3.0%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control6.4%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table17.9%10.9%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine95.7%77.7%79.4%better
Short-stay residents rehospitalized after admission28.6%24.1%22.6%worse
Short-stay residents with an outpatient ER visit15.3%12.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.002.011.67better
Long-stay outpatient ER visits per 1,000 resident days1.482.131.80better

* 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.

9.8%U.S. median 10.7%
Went back to hospital
80.0%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 80.0% 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 25 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 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.6–16.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge80.0%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 discharge68.0%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 discharge60.0%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 worsened14.3%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 SNFs1.111.02Oct 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

0.46
RN hours/ resident / day
0.85
LPN hours/ resident / day
2.47
Aide hours/ resident / day
3.78
Total nurse hours/ resident / day
0.35
RN hoursweekends
54.5%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 122 beds and averages 74.5 residents a day — about 61% occupied, or roughly 48 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 4.01 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.50 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2025-05-01)
6
at the previous standard inspection (2024-03-01)

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.

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

  • Immediate jeopardy · Jcited before2022-12-30 · 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 record review and interview, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 (Resident #52) of 1 sampled resident who fell during transport in the facility van. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #52 who fell out of the wheelchair in the facility van during transport on 11/22/22. The failed practice had the potential to affect all 63 residents who resided in the facility as documented on the Daily Census Report provided by the Administrator on 12/27/22 at 10:27 a.m. The Administrator was notified of the Immediate Jeopardy on 12/27/22 at 3:50 PM. The findings are: 1. Resident #52 had diagnoses of Functional Quadriplegia, Pressure Ulcer Right Buttock Stage 4, Acquired Absence of Left Leg, and Acquired Absence of Right Leg. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/22 documented the resident scored 14 (13-15 indicates…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview, record review, and facility policy review, it was determined the facility failed to ensure provider orders were completed for one resident (Resident #2) of three residents reviewed for wound care. The findings include: Review of Resident #2's admission Record revealed the facility admitted Resident #2 on 01/07/2025 with diagnoses that included peripheral vascular disease, acquired absence of a right toe, and malnutrition. Review of Resident #2's Progress Notes from 03/31/2025 at 2:58 PM, revealed the resident was alert and oriented to person, place, and time. The Progress Note also revealed Resident #2 was cognitively intact and went to the Wound Care Clinic for wound care. Review of a Wound Care Clinic Order for Resident #2 dated 03/18/2025, revealed the following order for dressing wound #2 (right lower leg), wound #3 (left lower leg), and wound #4 (right lower leg): -Wound to be cleansed with normal saline every other day for 30 days. -Primary Dressing of transfer foam to be applied every other day for 30 days. -Secured with soft cloth surgical…

    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 · Dcited before2026-04-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and facility document review, the facility failed to provide a safe care environment by placing one (Resident #1) of five residents reviewed for Quality of Care, at risk. Specifically, Resident #1 consumed alcohol brought in by Certified Nursing Assistant (CNA) #3 and became intoxicated in the facility. The findings include: A review of Resident #1's admission Record revealed an admission date of 05/22/2024, with which included diagnoses of Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, mild protein-calorie malnutrition, and alcohol abuse (in remission). A review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/2026, revealed a Brief Interview of Mental Status score of 15, which indicated the resident was cognitively intact. Resident #1's MDS further revealed the resident's history of alcohol abuse (in remission), anxiety disorder, COPD, and malnutrition. A review of Resident #1's Care Plan did not reveal an allowance for consumption of alcohol. Resident #1's Care Plan indicated an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-01 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, it was determined the facility failed to notify the resident, and/or the resident's representative, in writing and provide written information regarding the facility's bed-hold policy when a resident was transferred to the hospital for three (Residents #40, #61, and #45) of four sampled residents, reviewed for hospitalization. 1. Review of Resident #40's Medicare-5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/2025, revealed a Brief Interview for Mental Status (BIMS) score of 10 (indicated the resident had moderate cognitive impairment). Resident #40 ' s MDS also revealed the resident had active medical diagnoses which included: diabetes mellitus, non-Alzheimer ' s dementia, and respiratory failure. a. Review of Resident #40 ' s Progress Notes on 04/30/2025 at 11:12 AM, revealed on 03/14/2025 at 10:43 PM, indicated Licensed Practical Nurse (LPN) #3 was doing rounds and noticed Resident #40 sounded very congested. LPN #3…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-01 · 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, record review, and facility policy review, the facility failed to ensure food items in the refrigerator, freezer and storage room were covered or sealed; one (1) of one (1) ice machine was maintained in clean and sanitary condition; dietary staff washed their hands before handling food or clean equipment; ceiling tiles, air vents, dish washer wall, kitchen door frames were free of, debris, dirt, rust, stains; baseboards were secured for one (1) of two (2) meals observed. The findings are: 1. During an observation on 04/28/2025 at 10:22 AM, an opened box of sausage patties was on a cart in the walk-in the refrigerator. The box was not covered or sealed. 2. During an observation on 04/28/2025 at 10:26 AM, an opened box of fish was observed on a shelf in the freezer. The box was not covered or sealed. 3. During an interview on 04/28/2025 at 10:29 AM, with the Dietary Manager, she was asked what the concerns of not storing food in the freezer or refrigerator properly were, and she stated it could lead to freezer burn. 4. During an observation 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-03-01 · 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 dented cans were discarded to prevent bacteria growth; food items had opened and/or received dates; shelves were clean of debris; and contaminated pan covers were not placed on food to be served. These practices had the potential to affect 80 (total census 81) residents who resided in the facility. The findings are: 1. On 2/26/2024 at 11:30 AM, one 50 ounce can of Tomato Soup did not have received date and had a dent near the seal. The Surveyor asked the Dietary Manager, why should dented cans not be used? The Dietary Manager confirmed dented cans bent at rim may not be safe, may be contaminated. 2. On 2/27/2024 at 12:00 PM, the following spices on the spice shelf were opened and did not have an open date: Parsley Flakes - 11 ounces; Chopped Onions 3 pounds; Ground Cumin Seed 15 ounces; Poppy Seeds 2.37 ounces; Mild Chili Powder 16 ounces; Ground Nutmeg 16 ounces; Taco Season 21 ounces; Italian Seasoning 7 ounces; [NAME] Leaf 6 ounces; Ground Mustard 14 ounces; Leaf Basil 5.5 ounces; Ground Mustard 14…

    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 · F2024-03-01 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that resident laundry was transported in a way to prevent the spread of infection. This failed practice had the potential to affect 81 residents residing in the facility. The findings are: 1. On 02/26/24 at 3:43 PM, Laundry Worker #1 was putting clothes away in room [ROOM NUMBER]. The laundry cart was sitting outside in the hall, uncovered, with clean clothing laying on it. 2. On 02/29/24 at 2:35 PM, the Housekeeping Supervisor [HS] was asked, How is clean laundry supposed to be transported back to a resident's room? The HS stated, The laundry is supposed to be on a cart and covered with a sheet. 3. On 02/29/24 at 3:06 PM, the Director of Nursing [DON] was asked, How is resident laundry supposed to be transported back to a resident's room? The DON stated, Residents clean laundry is supposed to be on a cart and covered. 4. Laundry Worker (LW) #1 was asked how resident's clean laundry is supposed to be transported back to the resident ' s room. LW…

    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 · E2024-03-01 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure physicians orders were followed to maintain a medication error rate of less than 5% to prevent potential complications for 1 (Residents #45) of 5 sampled residents. The findings are: 1.Resident # 45 had diagnoses of Allergic Rhinitis, Osteoarthritis and Hypertension. a. A Physician Order dated 12/08/21 documented, Aspirin EC [Enteric Coated] Tablet Delayed Release 81 MG [milligram] (Aspirin) Give 1 tablet by mouth one time a day . Do Not Crush . b. A Physician Order dated 02/08/22 documented, [Nasal Allergy Spray] Suspension 2 sprays in both nostrils one-time a day . c. The Medication Administration Record (MAR) documented, [Nasal Allergy Spray] Suspension . 2 spray in both nostrils one time a day . wait one minute between sprays in same nostril . c. On 2/27/24 at 09:10 AM, Licensed Practical Nurse (LPN) #1 gave medications to Resident # 45, then signed them off. LPN #1 failed to give the Aspirin EC Tablet. LPN #1 gave [Nasal Allergy Spray] 2 sprays to each nostril. LPN #1 failed to wait 1 minute…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-01 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure the refrigerated narcotic medications were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property. The findings are: 1. On 2/27/24 at 3:40 PM, the Medication room was inspected with the Licensed Practical Nurse (LPN) #3. Inside the refrigerator was a locked narcotic box containing narcotics, but it was not permanently affixed. 2. The narcotic box contained Lorazepam 30 milliliters. 3. On 02/27/24 At 03:43 PM, LPN #3 was asked what the process was for securing refrigerated narcotics. LPN # 3 stated, It must be locked up behind two locks. LPN # 3 was asked, Who has a key to the refrigerator? LPN #3 stated, I do. LPN #3 was asked, How should the box be kept, and can anyone take it currently? LPN #3 stated, It is usually attached to the inside of the refrigerator. Yes, they could take it. 4. On 03/01/24 at 11:57 AM, the Director of Nursing (DON) was asked what the process was for securing refrigerated narcotics. The DON stated, It's double locked in the refrigerator.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed ensure fingernails were cleaned, trimmed, smooth and free of jagged edges to promote good personal hygiene and grooming for 1 (Resident #15) of 1 sampled resident who was dependent for nail care. The findings are: 1. On 02/26/24 at 10:48 AM, Resident #15's left hand had long jagged fingernails. The right hand had long fingernails with a dark brown substance packed under the nails. 2. On 02/26/24 at 04:09 PM, Resident #15's fingernails had long jagged fingernails on both hands with a dark brown substance packed under the fingernails on the right hand. 3. On 02/27/24 at 08:57 AM, Resident #15 was sitting up in bed eating breakfast and was holding a piece of bread in his right hand. The fingernails on his right hand were long, jagged, and had a dark brown substance packed under them. The left had long jagged nails. 4. A Care Plan dated 1/18/23 documented, .I have an ADL [activities of daily living] self-care performance deficit r/t [related to] Dementia. Revision on: 01/18/2023 . I will be clean and well-groomed…

    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 · Dcited before2024-03-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure parameters were put in place to ensure the correct dosage of oxygen was administered to enable the Physician to determine the dosage needed for 1 (Resident #27) sampled resident. The findings are: 1.On 02/26/24 at 11:24 AM, Resident #27 was lying in bed with oxygen on via nasal cannula (NC) at 2 liters per minute (LPM). a. On 02/26/24 at 04:11 PM, Resident #27 was lying in bed with oxygen on via NC at 2 LPM. b. On 02/27/24 at 09:03 AM, Resident #27 was lying in bed receiving oxygen via nasal cannula at 2 LPM. c. A Physicians Order dated 6/30/23 documented, Oxygen on at 2 liters via NC to keep sats at 90% or above, every shift for shortness of breath . d. A Care Plan with an initiated date of 4/13/22 documented, [Resident #27] uses oxygen therapy r/t [related to] SOB [shortness of breath]. Revision date 09/29/2022 .Oxygen via NC @ 2 liters to keep sats [saturations (oxygen level)] above 90% - May self-remove for ADL's [activities of daily living] Date Initiated: 09/29/202 Revision on: 12/11/202 . e. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Ecited before2024-03-01 · 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, record review and interview, the facility failed to ensure residents on the secured unit were supervised while smoking to decrease the potential for injury for 2 (Residents #37 and #71) of 2 sampled residents who were smoking without supervision. The findings are: 1. Resident #37 had diagnoses of Alcohol-Induced Persisting Dementia. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/23 documented the resident scored 14 (13-15 cognitively intact) on a Brief Interview for Mental Status (BIMS). a. A Care Plan with a revision date of 12/13/23 documented, .I smoke cigarettes and am at risk for injury . Resident requires supervision with smoking . b. A Smoking Safety Screen dated 12/07/23 documented, .Category: safe to smoke with supervision . c. On 2/27/24 at 3:25 PM, Certified Nursing Assistant (CNA) #2 opened the door to the smoking area on the secured unit, gave Resident #37 and one male resident a cigarette, lit it with a lighter and allowed those two residents and another male resident who did not have cigarette, to go outside…

    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 before2022-12-30 · 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 and interview, the facility failed to ensure dietary staff washed their hands between clean and dirty tasks, foods were utilized prior to their use by dates, containers were sealed to prevent the potential for food borne illness for residents who received meals from 1 of 1 kitchen and the kitchen and equipment was cleaned to prevent cross contamination. These failed practices had the potential to affect 62 residents (Total Census: 63) who obtained their meals from 1 of 1 kitchen according to a list provided by the Administrator on 12/29/22 at 1:18 PM. The findings are: 1. On 12/27/22 at 10:32 AM, the following observations were made in the Dry Storage Area: a. On a shelf was a 25 pound box of graham cracker crumbs was on a shelf. Upon opening the box, the bag of graham cracker crumbs was opened to air and contaminants. b. Located in the same area was a one pound, 8 ounce bag of Fried Onions with a use by date of 12/13/21. c. In the same area was a five pound container of baking powder with a use by date 12/17/20. d. On a rolling cart, there was a clear plastic…

    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 · F2022-12-30 · tag F0885 — failed to notify residents/families about COVID-19 — widespread
    Report COVID19 data to residents and families.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to notify residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of a single confirmed infection of COVID-19 for 4 (Residents #1, #3, #36 and #52) sampled residents whose records were reviewed. The findings are: 1. The Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes dated 05/06/2020 documented, .COVID-19 Reporting. The facility must . (3) Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other . 2. The list of the most recent COVID positive residents and staff provided by the Administrator on 12/29/22 at 1:40 PM documented:…

    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 · E2022-12-30 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 label was placed on the formula bottle to identify the type of formula the resident was receiving for 1 (Resident #6) of 3 (Residents #6, #26 and #171) sampled residents who received continuous enteral feedings according to the list provided by the Administrator on 12/30/2022 at 10:24 AM. The findings are: 1. Resident #6 had diagnoses of Gastrostomy Status and Cerebrovascular Accident (CVA). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/22 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and received tube feedings. a. The Plan of Care dated 12/01/22 documented, .NPO [Nothing by mouth], She receives all nutrition/hydration via PEG [Percutaneous Endoscopic Gastrostomy] Tube . b. The Physician's Order dated 12/27/22 documented, .Enteral Feed Order every 24 hours *JEVITY 1.5 - Infuse 35 ml/hr [milliliters/hour] attempt to increase by 5mls q [every] 12h [hours] until reaches…

    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 before2022-12-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to administer oxygen at the correct flow rate for 1 (Resident #171) of 3 (Residents #6, #171 and #221) sampled residents who had physician orders for oxygen. This failed practice had the potential to affect 6 residents who had a physician's order for oxygen according to a list provided by the Administrator on 12/30/2022 at 10:24 AM. The findings are: 1. Resident #171 had diagnoses of Pneumonia and Cerebrovascular Accident. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/22 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview Mental Status (BIMS) and did not receive oxygen therapy. a. The Plan of Care dated 12/02/2022, did not address oxygen therapy. b. The Physician's Order dated 12/15/22 documented, .O2 [oxygen] at 2L [liters] via N/C [nasal cannula] . c. On 12/27/22 at 11:37 AM, Resident #171 was lying in bed, asleep, O2 in place at 3 LPM/NC (liters per minute). c. On 12/30/2022 at 11:20 AM, the Surveyor asked Licensed Practical Nurse…

    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 · E2022-12-30 · 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 the written menu was followed to ensure the nutritional needs of the residents were met. The failed practice had the ability to effect 3 sampled residents who had physician orders for a pureed diet as documented on a list provided by the Administrator on 12/29/22 at 1:20 PM. The findings are: 1. The [Facility] Menu Extension, provided by the Dietary Manager on 12/27/22 at 11:00 AM documented the residents with a physician's order for a pureed diet were to receive Pureed Lasagna, two #8 scoops, one 2 ounce extra sauce, 4 ounces of pureed [NAME] Beans and a #16 scoop of pureed Dinner Roll and Lemon Pudding. 2. On 12/27/22 at 12:10 PM, a pureed lunch tray being filled on the tray line contained pureed Lasagna and pureed [NAME] Beans. The Lemon Pudding was in a bowl. 3. On 12/28/22 at 11:30 AM, the Lunch Menu for the residents who had physician orders for a pureed diet documented they were to receive a #10 scoop of Roast Beef, a #8 scoop of Noodles Au Gratin, #8 scoop of pureed Cauliflower, #8 scoop of…

    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 · D2022-12-30 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a water pitcher was provided to ensure water was assessable at the bedside to prevent the potential for dehydration for 1 (Resident #170) of 3 (Residents #61, #170 and #171) sampled residents who were recently admitted to the facility according to the list provided by the Business Office Manager on 12/30/2022 at 10:34 AM, and 1 (Resident #170) of 1 sampled resident who had a Urinary Tract Infection (UTI) on admission according to the list provided by the Director of Nursing (DON) on 12/30/2022 at 11:10 AM. The findings are: 1. Resident #170 was admitted to the nursing facility on 11/10/2022 and had diagnoses of Urinary Tract Infection and Edema. The Medicare 5 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/22 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) a Brief Interview Mental Status (BIMS) and requires total assistance of one person with eating and drinking. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-30 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate to facilitate the ability to plan and provide necessary care and services for 1 (Resident #3) of 14 (Residents #1, #3, #6, #24, #26, #27, #29, #33, #49, #52, #55, #61, #67 and #171) sampled residents whose MDS were reviewed. The findings are: 1. The RAI (Resident Assessment Instrument) Manual documented, .Section 1 .The RAI process has multiple regulatory requirements . the assessment accurately reflects the resident status . (Resident Assessment Instrument Manual Minimum Data Set 3.0 Resident Assessment Instrument Manual V1.17.1 October 2019) 2. Resident #3 had a diagnosis of Schizoaffective Disorder, Bipolar Type, Bipolar Disorder, Current Episode Manic without Psychotic Features, Moderate, and Unspecified Convulsion. The Quarterly MDS with an Assessment Reference Date (ARD) of 10/14/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was totally dependent of two plus persons physical…

    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 · D2022-12-30 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the baseline care plan was completed within 48 hours of admission for 1 (Resident #61) of 1 sampled resident whose baseline care plan was reviewed. The failed practice had the potential to affect all 63 residents who resided in the facility according to the Census and Conditions of Residents provided by the Administrator on 12/27/22 at 1:00 PM. The findings are: 1. Resident #61 had diagnoses of Unspecified Dementia with other Behavioral Disturbance, and Early Onset Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision for bed mobility and transfers, limited physical assistance with dressing, toilet use, and personal hygiene and set up assistance only with eating. a. The Resident Assessment Instrument (RAI) §483.21(b)(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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a comprehensive care plan within 21 days of admission for 1 (Resident #61) of 1 sampled resident whose care plans was reviewed. The failed practice had the potential to affect all 63 residents who resided in the facility according to the Census and Conditions of Residents provided by the Administrator on 12/27/22 at 1:00 PM. The findings are: 1. Resident #61 had diagnoses of Unspecified Dementia with other Behavioral Disturbance, and Early Onset Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision for bed mobility and transfers, limited physical assistance with dressing, toilet use, and personal hygiene and set up assistance only with eating. a. Resident #61's Medical Record documented the resident was admitted on [DATE]. b. On 12/29/22 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 · D2022-12-30 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to review and revise the care plan to include oxygen and a recent diagnosis of Pneumonia for 1 (Resident #171) of 3 (Residents #6, #171 and #221) sampled residents who received oxygen. This failed practice had the potential to affect 6 residents in the facility who had physician orders for oxygen according to a list provided by the Administrator on 12/30/22 at 10:24 AM. The findings are 1. Resident #171 had diagnoses of Pneumonia and Cerebrovascular Accident. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/22 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview Mental Status (BIMS) and did not receive oxygen therapy. a. The Physician's Order dated 12/15/22 documented, .O2 [oxygen] at 2L [liters] via N/C [nasal cannula] . b. On 12/27/22 at 11:37 AM, Resident #171 was lying in bed, asleep, O2 in place at 3 LPM/NC (liters per minute). c. As of 12/29/22 at 3:10 PM, the Plan of Care dated 12/02/2022, had not been revised or updated to…

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

    Resident Assessment and Care Planning 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE SPRINGS ARKANSAS — 26 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.4-0.4 vs chain
Health inspection 3 of 53.2-0.2 vs chain
Staffing 4 of 53.0+1.0 vs chain
Quality measures 4 of 53.8+0.2 vs chain
The other 25 homes this chain runs (chain average 3.4★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
EL DORADO HEALTHCARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2021
COOPER, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/31/2022
ROSS, JULIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/07/2022
EL DORADO BUILDING LLCOrganizationADP OF THE SNFsince 07/01/2021
GUTMAN, ISAACIndividualADP OF THE SNFsince 03/31/2022
HERZBERG, CHAIMIndividualADP OF THE SNFsince 03/31/2022
HOFFMAN, ALEXANDERIndividualADP OF THE SNFsince 03/31/2022
TAUB, JACOBIndividualADP OF THE SNFsince 03/31/2022

CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$7.6M
Net patient revenuemost recent cost report
+4.3%
Operating marginrevenue minus expenses
$2.1M
Related-party expense29% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 8%Other / private 14%

About 78% 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. This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 29% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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

$281per resident / day
operating cost
$8,551per month
≈ monthly operating cost
$294per day
avg. revenue, all payers

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

What families pay in AR

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045275. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-01, 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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