Cavalier Healthcare Of England
400 Stuttgart Highway, England, AR 72046 · For profit - Limited Liability company · 70 certified beds · (501) 842-2771 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $18,356 in federal fines (most recent 2024-01-31)
- its independent health-inspection rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.4% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.8% | 4.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.6% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 1.1% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.2% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.3% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.3% | 21.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.3% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.8% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.1% | 10.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.7% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 85.3% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 49.3% | 24.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.6% | 12.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.54 | 2.01 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.02 | 2.13 | 1.80 | worse |
* 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.
47.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 44 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.4% 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 21 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 47.9%CMS range 34.5–64.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 6.9–15.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 71.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 76.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 71.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 6.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.7%CMS range 5.4–13.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.42 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 70 beds and averages 61.3 residents a day — about 88% occupied, or roughly 9 beds typically open. It runs fairly full. 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 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 is below 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 2.70 hrs/resident/day on weekends vs 3.34 on weekdays — 19% thinner on weekends. RN hours go from 0.46 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-01-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, staff interviews, record review and review of manufacturer's instructions, the facility failed to properly secure the seat belt for 1 Resident #1 of 2 (Resident #1, and #2) case mix residents who were transported in the facility's transport van. This failed practice resulted in a past immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1. These findings were determined to be a past Immediate Jeopardy. The Administrator was notified of the findings of Immediate Jeopardy on 01/31/2024 at 11:35 AM. The findings included: 1. During record review on 1/30/24 at 9:20 AM Resident #1 was admitted on [DATE] with a diagnosis of Orthopedic aftercare following and amputation and Dementia. Resident ' s Minimum Data Set, dated [DATE] assessed the resident cognitive ability as being severely impaired with a Brief Interview for mental Status (BIMS) score of 3. Resident #1 ' s Care Plan dated 10/07/23 Focus: I am at moderate risk for falls related to gait/balance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-03 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment or change in condition for four (Resident #10, #47, #35, and #43) of five sampled residents. The findings include: Resident #10 A review of Resident #10’s Medical Diagnosis record revealed diagnoses which included muscle wasting and atrophy, dementia with behavioral disturbance, anxiety disorder, cognitive communication deficit, schizophrenia, dementia with agitation, and schizoaffective disorder. A review of Resident #10’s annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. A review of Resident #10’s Care Plan, revised on 09/02/2024, the Care Plan identified the resident to be at high risk for falls, with the resident’s last fall documented on 03/11/2024. A review of Resident #10’s Progress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-03 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and facility policy review, it was determined that the dietary staff failed to ensure hand hygiene was completed for one of one meal service observed. The findings include: During an observation on 07/01/2025 at 11:20 AM, this surveyor observed Dietary [NAME] (DC) #4 open a box of rolls, without gloves on. DC #4 then reached into the box with their bare hands and took out a hand full of rolls to prepare, without washing their hands in between touching the outside of the box and the food. During an interview on 07/01/2025 at 11:42 AM, DC #4 stated, I touched the box and didn't wash my hands. I should have washed my hands after opening the box before touching the rolls because it is cross contamination. During an observation on 07/01/2025 at 12:33 PM, DC #4 opened the lid to the hot metal plate warmer container, retrieved a metal plate, and closed the lid with his bare hands. DC #4 then placed the metal plate on the base of the heat keeper combination. Then DC #4 opened the ceramic hot plate container with his bare hands, retrieved a ceramic plate,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-03 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 resident’s family member serving as Power of Attorney was invited to participate in a care plan meeting for one (Resident #13) of three residents reviewed for care plans. The findings include: A review of Resident #13’s admission Record indicated the facility admitted the resident on 10/20/2023, with diagnoses which included Alzheimer’s and dementia. The admission Record indicated the resident had a designated Power of Attorney (POA) when admitted . A review of Resident #13’s quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/28/2025 revealed the resident had a Brief Interview for Mental Status score of 04, which indicated severe cognitive impairment. A review of Resident #13's Care Plan, initiated on 11/27/2023, revealed the resident had impaired cognitive function, dementia or impaired thought processes. The Care Plan also revealed Resident #13 had impaired nutrition, with an intervention to include family in their nutritional evaluation. During an interview on 07/02/2025 at 3:23 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-03 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and observation, the facility failed to ensure one (Resident #15) of one resident reviewed had formulated an advanced directive that provided a clear understanding of the resident's wishes. Specifically, documentation regarding Resident #15’s code status containing conflicting information regarding life-sustaining treatments. The findings include: A review of Resident #15’s Code Status, on 06/30/2025 at 8:14 PM, revealed a signed Acknowledgement of Receipt of Advance Directive was signed by their family member on 08/08/2023. A second acknowledgment of Receipt of Advanced Directives/Medical Treatment Decisions was signed on 08/09/2023 and read, “I have chosen to formulate and issue the following Advance Directives,” with the Do Not Resuscitate box checked and an enacted date of 08/08/2023. Another checked box stated, I do not choose to formulate or issue any Advance Directives at this time. I want efforts made to prolong my life and I want life-sustaining treatment to be provided. The family member who signed these documents were not documented as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-03 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days after the facility determined there had been a significant change in a resident’s physical or mental condition for one (Resident #35) of one resident. The findings include: A review of Resident #35’s “admission Record indicated the facility initially admitted the resident on 01/06/2021, with diagnoses which included abnormal finding of blood chemistry and pneumonia. A review of Resident #35’s “Arkansas Department of Health and Human Services Evaluation of Medical Need Criteria” form indicated the resident was re-admitted from the hospital, on hospice services on 04/25/2025, with a diagnosis of acute kidney injury. The form indicated Resident #35 had multiple hospitalizations within the last month and had decided to transition to hospice care. A review of Resident #35’s Minimum Data Set (MDS) dashboard on the resident's electronic health record revealed the resident’s Significant Change MDS was started on 04/28/2025. A review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-03 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that the facility failed to ensure an entry Minimum Data Set (MDS) comprehensive assessment was encoded and transmitted in the allotted timeframe for one (Resident #35) of one resident reviewed for MDS requirements. The findings include: A review of Resident #35's admission Record indicated the facility initially admitted the resident on 01/06/2021, with diagnoses which included chronic obstructive pulmonary disease and pneumonia. A review on 07/03/2025 of Residents #35's electronic health record revealed a discharge MDS with an assessment review date (ARD) of 04/23/2025. Also present was an entry MDS, ARD date of 04/25/2025, with n export ready status, a significant change MDS with an ARD of 04/28/2025, with an in-progress status, and a quarterly MDS with an ARD of 06/20/2025, with an in-progress status. A review of Resident #35's Care Plan Report, last revised on 04/01/2024, did not reflect any of the resident's changes in care, such as the resident being admitted to hospice services. During an interview on 07/03/2025 at 8:39…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, interviews, facility document review, and facility policy review, the facility failed to ensure a resident was checked and changed every two hours for perineal care and repositioned to prevent the risk of infection and skin breakdown for one (Resident #39) of one resident reviewed. The findings include: During an observation on 07/01/2025 at 3:00 PM, this surveyor observed Certified Nursing Assistant (CNA) #1 and CNA #2 transfer Resident #39 from a wheelchair to their bed, using a gait belt. When the resident was assisted in placing their legs on the bed, this surveyor observed a large, dark wet spot on the back of both legs going from the groin to just above the knees, and a dark wet spot streaking across the front of Resident #39's jeans. CNA #1 described the resident's jeans as soaked and dirty. The resident's demeaner indicated embarrassment. This surveyor was granted permission to observe care by the resident nodding their head. During an observation on 07/01/2025 at 3:10 PM, this surveyor observed Resident #39 during perineal care and noted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-11 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and facility policy review, the facility failed to ensure meals were served in a method that conserved the nutritive value and maintained the appearance of cold and hot products and serving of food items at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The findings are: 1. The Grievance complaint form initiated 1/6/2025 provided by the Assistant Director of Nursing (ADON) on 3/10/2025, indicated meals on the evening shift were cold when served down the halls. 2. On 3/10/2025 at 12:20 pm, during an interview, Resident #14 stated to this surveyor that the food was sometimes cold when it was served. When asked if the food was cold in the dining room or bedroom, Resident #14 stated, both. 3. On 3/10/2025 at 12:39 PM, Dietary Aide (DA) #1 left the door to an unheated food cart open while loading the lunch meal trays inside the cart. After loading 9 lunch trays into the cart DA #1 closed the door at 12:48 PM and pushed the food cart outside the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-04-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility (1) failed to ensure food items stored in the refrigerator were covered and dated, (2) failed to ensure that the kitchen vents were cleaned to provide a sanitary environment for food preparation, (3) failed to ensure floors, dish washer the door frames, baseboard and ceiling tiles were free of chipped, holes, paint peeling, rust, stains, (4) failed to ensure dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen, dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and (5) failed to ensure hot food item was maintained at 135 degrees Fahrenheit or above on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; The failed practices had the potential to affect 57 residents who received meals from the kitchen (total census: 57). The findings are: 1. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-04 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure nails were clean and trimmed for 1 (Resident #2) of 1 sampled resident. The findings are: Resident #1 had a diagnosis of Type 2 Diabetes mellitus. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/09/2024 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). A care plan for Resident #2 documented, .Check nail length and trim and clean on bath day and as necessary. Report changes to the nurse . On 04/01/2024 at 10:41 AM, Resident #2 ' s fingernails were long with a black substance underneath. She stated, They clean them whenever they have enough help. On 04/01/2024 at 01:04 PM, Resident #2 ' s fingernails were long with a black substance underneath. On 04/04/2024 at 09:19 AM, Certified Nurse Aide (CNA) #3 was asked, Who's responsible for cutting and cleaning Resident #2 nails? She stated, The nurses, because the [Resident] is a diabetic. On 04/04/2024 at 09:22 AM, Licensed Practical Nurse (LPN) # 2 was asked,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · Ecited before2024-04-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and policy review, the facility failed to ensure a safe and hazard-free environment for 2 (Resident #43 and #50) sample mixed residents. The findings are: 1. Resident # 50 had diagnoses of Dementia without behavioral disturbance, Psychotic disturbance, Mood disturbance, and Anxiety. 1 a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/2024 showed a Brief Interview for Mental Status (BIMS) of 4 (a score of 0-7 suggests severe cognitive impairment.) The Resident required supervision or touch assistance with personal hygiene. 1 b. The care plan showed Resident #50 has a communication problem related to dementia. Staff are to ensure/provide a safe environment. 1 c. On 04/01/2024 at 10:54 AM, the Surveyor observed aftershave, shaving gel, shave cream, and body lotion sitting on the dresser by the door. 1 d. On 04/01/2024 at 12:34 PM, the Surveyor observed aftershave, shaving gel, shave cream, and body lotion sitting on the dresser by the door. 1 e. On 04/02/2024 at 09:23 AM, the Surveyor observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-04 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure the refrigerated narcotic medications in 1 of 1 medication storage room were stored in a permanently affixed compartment to prevent the potential misappropriation of resident property. The findings are: On 04/03/2024 at 11:47 AM, Licensed Practical Nurse (LPN) #1 pulled the medication narcotic box out of the refrigerator and placed it on the counter. The narcotic box was not affixed to the refrigerator. On 04/03/2024 at 11:48 AM, LPN #1 confirmed that the narcotic box hadn't been affixed to the refrigerator. On 04/03/2024 at 01:12 PM, the Director of Nurses (DON) was asked, Can you tell me why the narcotic box is not permanently affixed to the refrigerator? She stated, I'm not sure, but it should be. On 04/04/2024 at 09:22 AM, the Administrator provided a policy titled, Drug Acquisition, Storage and Inspection. It documented, .Medications shall be stored in a secure manner .
- Potential for harm · Ecited before2024-04-04 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure meals were served in a method that maintained the appearance of cold product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. This failed practice had the potential to affect 16 residents who receive meal trays in their rooms on the A Hall, 15 residents who receive meal trays on the B hall, 24 residents who receive meal trays in their room on the C hall. The findings are: 1. Resident #41 had diagnoses of Vitamin deficiency, Mood (affective disorder, Hypo-osmolality, and Hyponatremia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/05/2024 showed a Brief Interview for Mental Status (BIM) of 15 (13-15 indicates cognitively intact). Resident was independent for eating. a. A Physician's Order Summary for April 2024 documented, Regular diet Regular texture, Regular/Thin consistency. b. The care plan showed Resident #41 was able to feed themselves after the tray was set up.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-04 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure 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 6 residents who received pureed diets. The findings are: 1. On 04/03/2024 at 11:14 AM, Dietary Employee (DE) #3 used a #6 scoop to place 8 servings of lasagna into a blender, added tomato sauce and pureed. At 11:19 AM, DE # 3 poured the pureed lasagna into a pan and placed it in a pan of hot water on the stove. The consistency of the pureed lasagna was gritty and not smooth. 2. On 04/03/2024 at 11:21 AM, DE #3 placed 8 servings of garlic bread into a blender, added 3 cartons of 2% milk and pureed. At 11:22 AM, DE #3 poured the pureed garlic bread into a pan. The consistency was thick, lumpy, and not smooth. There were pieces of bread left in the mixture. 3. On 04/03/2024 at 11:44 AM, DE #3 used a #8 scoop to place 8 servings of vegetable blend into a blender and pureed. At 11:46 AM, DE…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-04 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to ensure the biohazard and oxygen rooms remained locked at all times. This failed practice had the potential to affect all 57 residents. The findings are: On 04/02/2024 at 03:09 PM, the Surveyor observed an unattended set of keys in the doorknob to the Biohazard Room on 300 Hall. The Surveyor knocked on the door with no answer. On 04/02/2024 at 03:19 PM, the Surveyor observed Maintenance walk up to the Biohazard room door and remove the keys. The Surveyor asked Maintenance to open the door and observed oxygen cylinders and biohazard boxes with full containers of syringes and needles inside. The Surveyor asked, Should the keys be left in the door? Maintenance stated, No, but I was only gone for a couple of minutes. The Surveyor asked, What time is it? Maintenance stated, It's 3:19. On 04/02/2024 at 03:33 PM, the Administrator confirmed the keys were left in the door unattended. On 04/03/2024 at 10:11 AM, the Surveyor observed a door on Hall 3 with a sign showing, .keep closed at all times . with a built-in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-04 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure that the residents had knowledge of the State Inspection Book, and it was made accessible to them if they chose to read it. The findings are: On 04/02/2023 at 09:30 AM, the Resident Council meeting was conducted. The Surveyor asked the Residents if they were familiar with the State Inspections Book and where it was located in the facility if they chose to read it. All 4 (Resident #1, #3, #26, and #34) residents stated that they were not aware of the State Inspections Book, or where it was located. On 04/02/2023 at 10:15 AM, this Surveyor looked around the facility for the survey results binder. The survey results binder was not located. On 04/02/2024 at 10:22 AM, the Activity Director was asked where the results of the state inspections were located. The state inspection results were located behind the nurse's station, in a location inaccessible to Residents and their Representatives. On 04/02/2024 at 10:24 AM, the Administrator stated, They didn't put the state inspection book back on the wall after they painted.
- Potential for harm · Fcited before2023-01-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment; the freezer temperature was maintained at 0 degrees Fahrenheit to prevent growth of bacteria; food in the refrigerator was covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; and leftover food items were used properly to maintain food quality for residents who received meal trays from 1 of 1 kitchen. The failed practices had the potential to affect 59 residents who received meals from the kitchen (total census:59 ), as documented on a list provided by Dietary Supervisor on 01/19/2023. The findings are: 1. On 01/18/23 at 7:27 AM Dietary Employee (DE) #1 turned on the hand washing sink and washed her hands, she removed tissue paper from the dispenser and used it to wipe her face, contaminating the tissue papers. She used the tissue paper to dry her hands. Without washing her hands, she removed clean plates from the plate warmer with her fingers touching the interior…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-01-19 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to review and revise the care plan to include that a resident had a wound on the right hip to ensure appropriate coordination of care for 1 (Resident #35) of 3 (Residents #35, #58 and #62) sampled residents who had wounds, and failed to ensure the care plan documented the correct code status for 1 (Resident #29) of 2 (Residents #29 and #56) sampled residents who had a change in code status in the past 120 days. These failed practices had the potential to affect 7 residents who had wounds according to a list provided by the Administrator on [DATE] at 3:25 PM, and 5 residents who had changed their code status in the past 120 days according to a list provided by the Administrator on [DATE] at 1:45 PM. The findings are: 1. Resident #35 had a diagnosis of Metabolic Encephalopathy, Seizure Disorder and End Stage Renal Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 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.
- Potential for harm · Ecited before2023-01-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident hazards by allowing residents to have over the counter medications in their room and not locked up for 1 (Resident #58) of 8 (Residents #7, #19, #29, #50, #56, #57, #58 and #59) sampled residents who resided on the 200 Hall. The failed practice had the potential to affect 21 residents with cognitive impairments and ambulated by any means and had access to the medications according to a list provided by the Administrator on 01/18/23. The findings are: 1. Resident #58 had diagnoses of Hypertension, Obstructive Sleep Apnea, and Pain in Left Leg. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two people with bed mobility, transfer, and toilet use. a. On 01/16/23 at 10:50 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.
- Potential for harm · E2023-01-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 1 (Resident #22) of 4 (Residents #7, #22, #58 and #82) sampled residents who received Oxygen. This failed practice had the potential to affect 5 residents that had physicians' orders for Oxygen as documented on a list provided by the Administrator on 01/18/22 at 3:25 PM. The findings are: 1. Resident #22 had diagnoses of Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Heart Failure. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received oxygen therapy. a. The Physician's Order dated 03/22/22 documented, .O2 [Oxygen] @ [at] 2L [Liters]/MIN [Minute] IF SPO2 [Oxygen Saturation] BELOW 90% [percent] VIA NASAL CANNULA as needed for DECREASED SPO2 . b. On 01/16/23 at 11:00 AM, Resident #22 was sitting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-01-19 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure food was prepared by methods that maintained appearance; failed to ensure meals were served at temperatures that were acceptable to the residents to maintain palatability and encourage good nutritional intake for 2 of 2 meals observed on A Hall and C Hall. The failed practice had the potential to affect 4 residents who received pureed diets, 44 residents who received regular diets, 11 residents who received mechanical soft diets, 18 residents who received meal trays in their rooms on A Hall, and 18 residents who received meal trays in their rooms on C Hall as documented on a list provided by the Dietary Supervisor on 01/19/2023 at 10:02 AM. The findings are: 1. Resident #14 had a diagnosis of Gastro-Esophageal Reflux Disease without Esophagitis. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/2022 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) was independent after set up for eating. a. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident and hazards for 1 (Resident #58) of 8 (Resident #7, #19, #29, #50, #56, #57, #58 and #59) sampled residents on the 200 Hall, as evidenced by allowing the resident to have over the counter medications in their room and not locked up. This failed practice had the potential to affect 21 residents who were cognitively impaired and ambulated by any means and had access to the medications according to a list provided by the Administrator on 01/18/23. The findings are: 1. Resident #58 had diagnoses of Hypertension, Obstructive Sleep Apnea, and Pain in Left Leg. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two people with bed mobility, transfer and toilet use. a. The Care Plan with an initiated date of 12/05/22 did not address self-administration 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$18,356 in federal fines across 2 penalties.
- $8,160 — penalty dated 2024-01-31
- $10,196 — penalty dated 2024-01-31
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CAVALIER HEALTHCARE — 4 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 2.5 | +0.5 vs chain |
The other 3 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CAVALIER HEALTHCARE OF ENGLAND, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/01/2014 |
| BETHEL INVESTMENTS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 06/01/2014 |
| LIMITED HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 06/01/2014 |
| CUNNINGHAM, JOANN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 06/01/2014 |
| CUNNINGHAM, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 06/01/2014 |
| HUBBARD, BRIEN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 06/01/2014 |
CMS files one row per role, so the 14 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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.
About 71% 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 $786K paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AR
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arkansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045442. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-03, 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.