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Fayetteville Health And Rehabilitation Center

3100 Old Missouri Rd, Fayetteville, AR 72703 · For profit - Limited Liability company · 140 certified beds · (479) 521-4353 Medicare & Medicaid certified

Call the home — (479) 521-4353 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 29 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3340 N College Ave · (479) 443-3536 · Call to confirm hours
Pharmacy
Infuse RX1.1 mi
375 E Millsap Rd Ste 3 · (479) 445-6833 · Call to confirm hours
Grocery
3014 N College Ave · (479) 571-4465 · Call to confirm hours
Park
3739 Steele Blvd · Typically dawn to dusk
Place of worship
1755 E Rolling Hills Dr · (479) 442-8164

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 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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 increased4.0%9.5%15.4%better
Long-stay residents who lose too much weight0.5%4.3%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.6%0.9%better
Long-stay residents with a urinary tract infection0.7%1.2%2.0%better
Long-stay residents with depressive symptoms0.7%1.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.2%3.9%3.3%worse
Long-stay residents whose ability to walk worsened5.0%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.2%21.7%18.9%worse
Long-stay residents given the seasonal flu vaccine94.3%96.1%95.3%typical
Long-stay residents with pressure ulcers4.3%4.2%4.7%typical
Long-stay residents with worsening bladder/bowel control3.9%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table11.9%10.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine93.2%77.7%79.4%better
Short-stay residents rehospitalized after admission18.1%24.1%22.6%better
Short-stay residents with an outpatient ER visit9.9%12.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.252.011.67worse
Long-stay outpatient ER visits per 1,000 resident days1.912.131.80typical

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

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

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

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

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

33.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

33.1%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
0.22U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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 SNF33.1%CMS range 22.9–47.751.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 7.3–16.210.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 3.3–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 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

0.13
RN hours/ resident / day
0.63
LPN hours/ resident / day
2.79
Aide hours/ resident / day
3.55
Total nurse hours/ resident / day
0.09
RN hoursweekends
40.0%
Total nursing turnover
83.3%
RN turnover

How full it usually is: this home is certified for 140 beds and averages 120.0 residents a day — about 86% occupied, or roughly 20 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 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.13 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.79 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 3.07 hrs/resident/day on weekends vs 3.74 on weekdays — 18% thinner on weekends. RN hours go from 0.14 to 0.09 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2025-11-21)
15
at the previous standard inspection (2024-06-27)

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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · D2025-11-21 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 record review and interview, the facility failed to ensure family was notified of a change in condition for one (Resident #132) of two sampled residents. The findings include: A review of Resident #132's quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE], revealed the resident had diagnoses which included Alzheimer's and Non-Alzheimer's dementia, heart disease, and type II diabetes mellitus. Resident #132's MDS also revealed a brief interview for mental status score of 06, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #132 was under Hospice care. A review of Resident #132's Care Plan revealed the resident was receiving services from Hospice ([DATE]). Resident #132's Hospice Care Plan records indicated Hospice and facility staff would assist family member in having an active role in care planning and the family member would be kept informed of Resident #132's care and changes in disease progression. A review of Resident #132'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, interview, and facility policy review, the facility failed to ensure interventions of the comprehensive care plan were implemented to prevent possible skin tears to one (Resident #22) of two residents sampled. The findings include: During an observation on 09/22/2025 at 2:07 PM, this surveyor observed Resident #22 ambulating in the hallway of the [gender specific] secure neighborhood. Resident #22 was observed wearing a short sleeve top and had a partially healed skin tear to the outer aspect of their right elbow that was actively bleeding, as well as a bandage to the area below the thumb of their right hand. The resident was not wearing protective sleeves of any type at this time. During subsequent observations on 09/23/2025 at 8:56 AM and 1:43 PM, and again on 09/24/2025 at 11:50 AM, this surveyor observed Resident #22 wearing clothing that did not have long sleeves, nor was the resident wearing any type of protective sleeve. A review of Resident #22's Face Sheet indicated the facility admitted the resident on 09/18/2023 with diagnoses, which…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · 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 policy review, the facility failed to ensure one (Resident #94) of one sampled resident received an ordered medication, and to ensure a physician's order was followed for one (Resident #4) of one sampled resident. The findings include: Resident #94 A review of Resident #94's Resident Face Sheet indicated the facility admitted the resident on 12/30/2019 with diagnoses which included unspecified intellectual disabilities, depression, and generalized anxiety disorder. A review of Resident #94's quarterly minimum data set with an assessment reference date of 07/14/2025, revealed a staff assessment for mental status score of 03, which indicated the resident was severely cognitively impaired and never/rarely made decisions A review of Resident #94's September Physician Orders documented, [Name Brand Contraceptive] administer 150mg intramuscularly every three months. Once a day on the 29th of every 3rd month, start date 03/31/2025. The medication was used to induce amenorrhea [the absence of monthly periods]. A review of Resident #94's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, interview, and facility policy review, the facility failed to ensure staff followed appropriate Enhanced Barrier Precautions (EBP) when providing care for one (Resident #14) of one sampled resident. The findings include: During an observation on 09/24/2025 at 9:50 AM, this surveyor observed an EBP sign outside Resident #14's door and the Treatment Nurse preparing to provide wound care. She put on gloves and walked into Resident #14's room, without putting on a gown. During an observation on 09/24/2025 at 9:52 AM, this surveyor observed the Treatment Nurse remove a bandage from Resident #14's right outer heel. The bandage was dated 09/22/2025 and had a yellowish drainage on it. She cleaned the resident's wound with wound cleanser and patted it dry. Resident #14 had a low bed and the Treatment Nurse was kneeled on the side of the bed. When she leaned over to provide treatment to Resident #14's wound, her shirt and pants touched the resident's bed. A review of Resident #14's Face Sheet indicated the facility admitted the resident on 03/11/2024, with…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-27 · 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, interview, and record review the facility failed to ensure food stored in the refrigerator, freezer, and storage room were labeled and dated and expired food items and left over foods were promptly removed from stock; and ensure employees avoided the use of alcohol-based hand rub (ABHR)/hand sanitizer gel in lieu of proper handwashing during food distribution, in 1 of 1 kitchen observed. These failed practices had the potential to affect 99 residents who received meals from the 1 of 1 kitchen. The findings are: 1. On 06/25/2024 at 11:16 AM, the following observations were made: a. Two clear plastic disposable containers of a smooth brown substance, covered with a clear lid, contained no description of contents or date. The Dietary Manager stated it was gravy and should have been labeled. The Dietary Manager removed the items from the refrigerator and placed them in trash can outside door of refrigerator. b. A clear plastic food storage container was not labeled or dated. Dietary Manger identified the contents as chocolate frosting. c. An individual container 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 · E2024-06-27 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure residents rights were acknowledged and treated in a manner to promote dignity for 6 (Resident #3, #39, #46, #55, #68, and #95) of 6 sample mix residents. The findings are: 1. A review of a Face Sheet indicated the facility admitted Resident #39 with diagnoses that included hemiplegia, hemiparesis, and dementia. a. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/2024 revealed Resident #39 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated the resident was moderately impaired for their daily decision making. Skin and ulcer treatments included a pressure relieving device for chair and bed. b. Review of Resident 39's Care Plan, dated 10/23/2017, revealed the resident was at risk for skin breakdown, with interventions that included utilizing pressure reducing cushion while up in chair. c. On 06/24/2024 at 1:13 PM, (Certified Nursing Assistant) CNA #35 assisted Resident #39 into a regular chair from a specialized chair in the dining room. The dining…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-27 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility failed to ensure care plans were revised for 2 of 2 sampled Residents (Resident #78 and #89). The findings are: 1. A review of the Face Sheet reveals that Resident #78 had diagnoses of severe intellectual disabilities and developmental disorders. a. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/06/2024 showed Resident #78 had a Staff Assessment of Mental Status (SAMS) completed that reveals memory problem for long-term and short-term memory. b. A review of the Care Plan revealed an intervention of resident door open at all times for easy visualization related to inability to utilize call light. No other interventions are in place for the recent removal of the call light. c. On 06/24/2024 at 11:36 AM, Surveyor observed Resident #78 sitting on bed crossed legged with the call light going off continuously and no call light located on Resident #78 ' s side of the room or plugged into the board on the wall. d. On 06/24/2024 at 12:00 PM, during an interview Certified Nursing…

    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 · E2024-06-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure a transfer lift was properly working to prevent the potential for harm for 2 (Resident #76 and Resident #79) of 2 sampled residents; and the facility failed to ensure chemicals were contained / stored when not in use to prevent the possible ingestion and injury for 1 (Resident #32) sampled resident. The findings are: 1. A review of a Face Sheet indicated the facility admitted Resident #32 with a diagnosis of dementia. a. A review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2024 revealed Resident #32 had scored a 12 on a Brief Interview for Mental Status, indicating moderate cognitive impairment. b. On 06/25/2024 at 5:27 PM Resident # 32 observed lying in bed. A canister of disinfecting wipes was observed on resident nightstand. c. On 06/25/2024 at 5:30 PM, Licensed Practical Nurse (LPN) #19 was asked about the disinfecting wipes and revealed it was possible the resident's family brought them in, and it was a hazard and dangerous to leave those items in the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-27 · 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, interview, and record review the facility failed to ensure expired bubble pack medications were removed from the medication cart once the expiration date has been reached for 3 of 5 medications carts checked for review, the facility failed to ensure controlled substances were properly removed once the seal to the medication had been broke to prevent the possible misappropriation of medication for 1 of 3 medication carts checked for review, the facility failed to ensure that medications were stored and labeled out of resident reach for 1 (Resident #32) of 1 residents. The findings are: 1. On 06/27/2024 at 09:51 AM Surveyor checked E Hall Cart for compliance with Licensed Practical Nurse (LPN) #33. The findings are: (1) bubble pack card of Ibuprofen 600 mg (milligram)tablets with an expiration date of 10/17/2023 with 13 pills remaining (1) bubble pack card of Ibuprofen 600 mg tablets with an expiration date of 10/17/2023 with 12 pills remaining (1) bubble pack card of Hyoscyamine 0.125 mg sublingual tablets with an expiration date of 05/10/2024 with 30 pills…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-27 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. The failed practices had the potential to affect 7 residents who received pureed diets, 1 resident who received pureed meat only, 60 residents who received regular diets and 30 residents who received mechanical soft diets from 1 of 1 kitchen. The findings are: 1. The 06/25/2024 supper menu documented the residents who received pureed diets were to receive 3-ounce of chicken salad and 4-ounce (1/2 cup) of pureed country macaroni salad and for the residents on regular diets were to receive 3/4 cup of toss salad with dressing. 2. On 06/25/2024 at 5:26 PM, the following observations were made during the supper meal service. a. Dietary Aide #7 used a tong to serve a small portion of toss salad to the residents on regular diets. b. Dietary [NAME] (DC) #6 served mashed potatoes to the residents on pureed diets, instead of pureed country macaroni salad. At 06:05 PM, the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Ecited before2024-06-27 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility failed to ensure food was prepared by methods that maintained appearance; hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed on the B Hall and C Hall. The failed practice had the potential to affect 14 residents who received meal trays in their room on B Hall and 18 residents who received meal trays in their rooms on A-Hall. The findings are: 1. On 06/24/2024 at 2:53 PM, Resident #29 stated the food is always cold when asked if the hot food is hot when received to the room on a tray. 2. On 06/25/2024 at 1:42 PM, an unheated cart that contained trays for lunch was delivered to the B Hall by Certified Nursing Assistant (CNA) #14. 06/26/24 2:02 PM, immediately after the last resident received their tray in their room on B-Hall (Unit), the temperatures of the food items on a test tray from the food cart were checked by the Dietary Manager and read by Certified Nursing Assistant #13. The results were as follows: a. Ground ham…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-27 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 7 residents who received pureed diet, and one resident who received pureed meat only. The findings are: 1. On 06/25/2024 at 4:53 AM, the following observations were made on the steam table: a. A pan of pureed cut green beans, the consistency was runny. b. A pan of pureed chicken, the consistency was gritty, not smooth, and had water in the mixture. c. A pan of pureed beef sauce, the consistency was running. 2. On 06/25/2024 at 6:28 PM, the surveyor asked the Dietary Manager to describe the consistency of the pureed food items served to the residents on pureed diets at supper meal. She stated, Pureed cut green beans look like nectar. Pureed chicken was gritty and pureed beef sauce was watery. 3. On 06/26/2024 at 7:14 AM, the following observations were made on the steam table: a. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview the facility failed to ensure staff implemented hand hygiene to prevent the spread of disease and infection for 3 (Residents #39, #20, and #12) of 3 sampled residents, and failed to ensure a resident was not exposed to pests while in their room for 1 resident (Resident #73). The findings are: 1. A review of a Face Sheet indicated the facility admitted Resident #39 with diagnoses that included hemiplegia, hemiparesis, and dementia. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/2024 revealed Resident #39 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated the resident moderately impaired for their daily decision making. Skin and ulcer treatments included, pressure relieving device for chair and bed. On 06/25/2024 at 12:57 PM, Certified Nursing Assistant (CNA) #17 touched the top of Resident #20 ' s head with her right bare hand and patted her head. CNA #17 did not perform hand hygiene. On 06/25/2024 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-27 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to provide residents with a safe, functional, sanitary, and comfortable environment to promote dignity and safety. The findings are: On 06/24/2024 at 3:02 PM, the top of bedside table in room [ROOM NUMBER] observed with hard, thick, vinyl ripped and torn, and edges pointed and sharp. On 06/26/2024 at 11:21 AM, a bedside table in room [ROOM NUMBER] was observed placed over the resident ' s bed. The vinyl is torn and ripped, exposing pointed and sharp edges. The Maintenance Director revealed during an interview the bedside table had not been reported. The table could not be fixed, and they are usually thrown away. Maintenance verbally described the table as peeling vinyl and pointed, guaranteed to cause injury, and should have been reported. On 06/27/24 8:30 AM, Certified Nursing Assistant (CNA) #12 revealed during an interview that if something needed to be fixed in the facility, they have a book they write in that goes to maintenance, but…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-27 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 maintain an effective pest control program to ensure the kitchen service areas the main dining room were free of pests. This failed practice had the potential to affect all residents who resided in the facility. The findings are: 1. The following Pest Elimination Invoice dated 4/19/2024 documented, . Inspected and treated selected areas. Performed Exterior Rodent Service, Performed Interior Rodent Service and re set traps. Target Pests Mice, Cockroaches, flies' location kitchen. 2. An Invoice dated 5/30/2024 documented, .large fly serviced .Performed Interior spot treatment, for large flies. Performed Exterior fly treatment .Target Pests .Flies. large Equip. Location. Kitchen. Application Method. Stop Location applied. Dining interior, Exterior Area, kitchen area interior, near entry. 3. On 06/26/2024 8:25 AM, there were 5 flies in the storage room. The Dietary Manager closes the door between the storage room and the kitchen. 4. On 06/26/2024 at 11:58 AM, a fly was at the edge of a plate on the plate warmer.…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure walls in residents' rooms were maintained in good repair to provide a clean and homelike environment for residents who resided on 2 (B Hall and D Hall) of 2 halls observed. Findings include: During an observation of room [ROOM NUMBER] on 06/24/2024 at 12:28 PM, the golden colored wall next to the bed was damaged exposing the gypsum compound which is used to patch and fix drywall and was exposed from under the paint in white irregular shaped areas visible above the edge of the side of the bed. The edge of the door to the resident ' s bathroom had chipped paint and rough cracked areas with brown debris in the cracks on the edge of the door, above and below the handle and on the door jam. There was a gouged area in the middle of the door exposing raw wood. The toilet seat on the toilet in the resident ' s bathroom was peeling and had yellow, brown and black staining covering the top where resident would sit on the toilet. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-27 · 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 observations, record review, and interview the facility failed to ensure a Minimum Data Set (MDS) was accurately coded for 1 (Resident #89) sampled resident. The findings are: A review of the Face Sheet revealed that Resident #89 had a diagnosis of amyotrophic lateral sclerosis (ALS) A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/321/2024 revealed that Resident #89 had a Staff Assessment of Mental Status (SAMS) completed that revealed had a memory problem for long-term and short-term memory. A review of Section GG revealed that it was coded for one upper extremity with limited range of motion. A review of the Care Plan for Resident #89 revealed no interventions for limited range of motion. On 06/24/2024 at 11:58 AM, the Surveyor observed both of Resident #89 ' s hands contracted with the fingers touching the forearms, no interventions are in place. On 06/25/2024 at 9:40 AM, Surveyor observed no interventions in place for the contractures. On 06/25/2024 at 2:37 PM, during an interview with Certified Nursing Assistant (CNA) #24,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-27 · 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, observation, and interview, the facility failed to ensure interventions to prevent pressure ulcers to prevent skin breakdown or worsening of skin issues, were utilized for 1 (Resident #39) of 1 sampled resident. The findings are: 1. A review of a Face Sheet indicated the facility admitted Resident #39 with diagnoses that included hemiplegia, hemiparesis, and dementia. a. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/2024 revealed Resident #39 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated the resident moderately impaired for their daily decision making. Skin and ulcer treatments included a pressure relieving device for chair and bed. b. Review of Resident 39's Care Plan, dated 10/23/2017, revealed the resident was at risk for skin breakdown, with interventions that included utilizing a pressure reducing cushion while up in chair. c. On 06/24/2024 at 1:10 PM, Resident #39 observed sitting in a specialized chair in the dining room. There was no cushion in Resident #39 ' s specialized chair. d. On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-27 · 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 that physicians orders were followed for oxygen therapy for 1of 1 Resident #89 sampled resident. These are our findings: A review of the Face Sheet revealed that Resident #89 had diagnosis of amyotrophic lateral sclerosis (ALS). A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/321/2024 reveals that Resident #89 had a Staff Assessment of Mental Status (SAMS) completed that revealed had a memory problem for long term and short-term memory. A review of the Care Plan states that the care plan goal is Resident #89 Will exhibit no shortness of breath, and interventions include administer oxygen therapy as ordered. A review of the Physicians Order List revealed Resident #89 had a physician's order for oxygen 2 liters per minute via nasal cannula for shortness of breath. On 06/24/2024 at 11:58 AM, Surveyor observed Resident #89 had uneven labored respirations, the oral cavity is red and cracked from mouth breathing. Surveyor observed Resident #89's oxygen…

    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 before2023-05-26 · 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 the kitchen was clean, sanitary and maintained; floor tiles and baseboard were replaced; a loose baseboard was secured; storage areas and kitchen vents were cleaned to provide a sanitary environment for food preparation, failed to ensure food items stored in the refrigerator and freezer were sealed or covered and were stored in accordance with the manufacturer's instructions; failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean dishes or food items; failed to ensure the ice machine and ice scoop holder were maintained in clean and sanitary condition; failed to ensure hot foods were maintained at or above 135 degrees Fahrenheit (F.) while awaiting to be served to prevent potential food borne illness, and failed to ensure leftover food items were not used for residents who received meals from 1 of 1 kitchen to maintain food quality and prevent the growth of bacteria. These failed practices had the potential to affect 92 residents who received meals…

    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 · E2023-05-26 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: [NAME], [NAME] Based on observation, interview, and record review, the facility failed to provide nail care to promote good hygiene, reduce risk of injury and infection for 2 (Residents #22 and #40) of 17 (Residents #1, #2, #9, #12, #15, #16, #22, #25, #28, #39, #40, #44, #45, #57, #82, #84 and #87) sampled residents who required assistance with nail care as documented on a list provided by the Unit Manager on 05/26/23 at 11:17 AM. The finding are: 1. Resident #22 had diagnoses of Parkinson's, Anxiety, and Depression. The Quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 03/22/23 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required limited physical assistance of one person for personal hygiene and bathing. a. The Care Plan with a start date of 05/08/23 documented, .Requires assistance to complete daily activities of care safely . Assist with hair . Assist with brushing teeth/oral care . Bath…

    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 before2023-05-26 · 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, record review, and interview, the facility failed to ensure the refrigerated narcotic medications in the medication storage room were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property; failed to ensure expired medications were not stored with other medications in the medication storage room and failed to ensure medications were not left in resident rooms for 3 (Resident #12, #15 and #82) sampled residents. This failed practice had the potential to affect all 92 residents residing in the facility according to the Resident Census and Conditions of Residents provided by the Director of Nursing (DON) on 05/22/23 at 12:20 PM. The findings are: 1. On 05/22/23 at 12:21 PM, Resident #12 was sitting in his wheelchair. The Surveyor observed a medicine cup with a white creamy substance behind his TV. Resident #12 said, I had a yeast infection, but it's been cleared up. That was the medicine they put on me. 2. On 05/22/23 at 12:46 PM, Resident #15 was sitting at the bedside with a medication cup containing two…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-26 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure food was prepared by methods that maintained appearance; hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed on the B Hall and C Hall. The failed practice had the potential to affect 13 residents who received meal trays in their room on B Hall and 16 residents who received meal trays in their rooms on C Hall as documented on a list provided by Dietary Supervisor on 05/25/23 at 9:40 AM. The findings are: 1. On 05/24/23 at 7:52 AM, an unheated cart that contained 13 trays for breakfast was delivered to the B Hall by Certified Nursing Assistant (CNA) #3. At 8:02 AM, immediately after the last resident received their tray in their room, the temperatures of the food items on a test tray from the food cart were checked and read by the Dietary Supervisor. The results were: a. Milk - 45 degrees Fahrenheit. b. Scrambled eggs - 100 degrees Fahrenheit. c. Ground sausage with gravy - 90 degrees Fahrenheit. 2. 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 · Ecited before2023-05-26 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 7 residents who received pureed diets as documented on a list provided by the Dietary Supervisor on 05/25/23. The findings are: 1. On 05/22/23 at 4:11 PM, Dietary Employee (DE) #2 used a number 6 scoop (2/3cup) to place 10 servings of lasagna into a blender and pureed. At 4:16 PM, she poured the pureed lasagna into a pan. She covered the pan with foil and placed it in the oven. The consistency of the pureed lasagna was thick, sticky, and lumpy. There were pieces of noodles visible in the mixture. 2. On 05/22/23 at 4:42 PM, DE #2 placed 8 servings of bread sticks into a blender, added butter and broth and pureed. At 4:47 PM, she poured the pureed bread into a pan and placed it on the steam table. The consistency of the pureed bread was gritty and thick. 3. On 05/22/23 at 5:12 PM, the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-26 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the rooms were free of damage for 4 (Rooms 3, 8, 52 and 57) of 72 Resident Rooms in the facility. The findings are: 1. On 05/22/23 at 3:16 PM, in Resident room [ROOM NUMBER], paint was peeling off the wall next to Bed A. a. On 05/26/23 at 8:30 AM, the Surveyor asked the Resident in Bed A if she liked having the paint peeling off the wall by her bed. The Resident answered, No, I know that paint can be poisonous. I don't like it. 2. On 05/22/23 at 3:55 PM, paint was peeling, and a hole was observed in the wall in Resident room [ROOM NUMBER]. a. On 5/25/23 at 4:10 PM, the Surveyors asked the Resident, How do you feel about the hole in the wall and the paint peeling? She stated, I don't like it. 3. On 05/22/23 at 4:40 PM, in Resident room [ROOM NUMBER]B the paint was peeling off the walls in the room and in the bathroom. a. On 05/26/23 at 8:28 AM, the Surveyor asked the Resident if he liked having the paint peeling off the walls in his room and in the…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-26 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and interview, the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and the PASARR evaluation report into a resident's Care Plan to facilitate needed care for 1 (Resident #12) of 1 sampled resident who had a Level II PASARR. The findings are: Resident #12 had diagnoses of Bipolar Disorder, Anxiety Disorder, Altered Mental Status and Depression. a. On 05/25/23 at 2:40 PM, a review of the Comprehensive Care Plan did not document Resident #12's Level II PASARR determination, evaluation, and recommendations. b. On 05/25/23 at 2:50 PM, the Surveyor asked the Minimum Data Set (MDS) Coordinator if Resident #12 had a Level II PASARR. The MDS Coordinator said, Yes, he is a Level II. The Surveyor asked if the Level II PASARR evaluation and recommendations were incorporated into Resident #12's Care Plan. The MDS Coordinator said, I am sure it is. The Surveyor asked if there was a Care Plan specifically for the Level II PASARR evaluation and determination. The MDS Coordinator said, No,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-26 · tag F0728 — failed to protect against nurse-aide misconduct — isolated
    Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure full time Nurse Aides (NA) were certified within 4 months of the Nurse Aide Training. The findings are: 1. On 05/26/23 at 9:05 AM, the Director of Nursing, (DON) provided a list of the Nurse Aides on staff, that Nurse Aide (NA) #2 was hired on 09/27/22. 2. On 05/26/23 at 9:06 AM, the Surveyor asked the DON, Can you tell me why NA #2 has not received her nurse aide certification? She stated, I don't know, staff development is in charge of that. 3. On 05/26/23 at 10:00 AM, the Surveyor asked the Staff Development Coordinator, How long can a NA work at this facility without being certified? She stated, Ninety days. The Surveyor asked, Can you tell me why [NA #2] has not received her nurse aide certification? She stated, I believe they were supposed to take their test yesterday. The Surveyor asked, Has she been working at this facility longer than 120 days? She stated, Yes. 4. On 05/26/23 at 10:29 AM, the Staff Coordinator stated, NA #2's last day of class was 12/07/22. 5. On 05/26/23 at 10:30 AM, the DON provided 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-26 · tag F0803 — failed to meet residents' dietary needs — isolated
    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, an interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 27 residents who received mechanical soft diets, 7 residents who received pureed diets and 3 residents who received pureed meat only from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 05/25/23 at 9:40 AM. The findings are: 1. The menu for the 05/22/23 supper meal showed residents who received pureed diets were to receive 6 ounces of pureed lasagna (2/3 cup) and residents on mechanical soft diets were to receive 1/2 cup of broccoli. 2. On 05/22/23 at 5:09 PM, the following observations were made during the supper meal service. a. Dietary Employee (DE) #4 used 2-ounce spoon which is equivalent to ¼ cup to serve a single portion of Broccoli to the residents on mechanical soft diets. The menu specified for each resident on mechanical soft diets to receive ½ cup of broccoli. b. DE #4 used 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2023-05-26 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a level II Preadmission Screening and Resident Review (PASARR) evaluation with recommendations to facilitate the ability to plan, coordinate and provide necessary care for 1 (Resident #12) of 1 sampled resident who had a level II PASARR. The findings are: Resident #12 had diagnoses of Bipolar Disorder, Anxiety Disorder, Altered Mental Status and Depression. The Significant Change Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/23 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was not evaluated by PASSAR. a. On 05/25/23 at 9:12 AM, the Regional Sales Director provided a Level II PASARR evaluation and recommendations, completed on 03/23/22 for Resident #12. b. On 05/25/23 at 2:50 PM, the Surveyor asked the MDS Coordinator if she could review the significant change MDS dated [DATE] for Resident #12…

    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 NHS MANAGEMENT — 43 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 52.9+0.1 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 3 of 53.7-0.7 vs chain
Quality measures 4 of 53.5+0.5 vs chain
The other 42 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Aspire Physical Recovery Center At Cahaba RiverVestavia, AL 1 of 5Aspire Physical Recovery Center At Hoover, LLCHoover, AL 1 of 5Cordova Health And Rehabilitation, LLCCordova, AL 1 of 5Glen Haven Health And Rehabilitation, LLCNorthport, AL 1 of 5Huntsville Health & Rehabilitation, LLCHuntsville, AL 1 of 5Legacy Health And Rehabilitation Of Pleasant GrovePleasant Grove, AL 1 of 5Prattville Health And Rehabilitation, LLCPrattville, AL 1 of 5St Augustine Health And Rehabilitation CenterSaint Augustine, FL 1 of 5Wetumpka Health And Rehabilitation, LLCWetumpka, AL 2 of 5Civic Center Health And Rehabilitation, LLCBirmingham, AL 2 of 5Gulf Coast Health And Rehabilitation, LLCMobile, AL 2 of 5Legacy Health And Rehabilitation CenterFort Smith, AR 2 of 5South Health And Rehabilitation, LLCBirmingham, AL 2 of 5Springdale Health And Rehabilitation CenterSpringdale, AR 2 of 5Tallassee Health And Rehabilitation, LLCTallassee, AL 2 of 5West Melbourne Health & Rehabilitation CenterWest Melbourne, FL 3 of 5Ashland Place Health And Rehabilitation, LLCMobile, AL 3 of 5Florala Health And Rehabilitation LLCFlorala, AL 3 of 5Hunter Creek Health And Rehabilitation, LLCNorthport, AL 3 of 5Jacksonville Health And Rehabilitation, LLCJacksonville, AL 3 of 5Northway Health And Rehabilitation, LLCBirmingham, AL 3 of 5Oak Knoll Health And Rehabilitation, LLCBirmingham, AL 3 of 5Opp Health And Rehabilitation, LLCOpp, AL 3 of 5Ozark Health And Rehabilitation, LLCOzark, AL 3 of 5Park Manor Health And Rehabilitation, LLCNorthport, AL 3 of 5South Haven Health And Rehabilitation, LLCBirmingham, AL 3 of 5Sumter Health And Rehabilitation, L L CYork, AL 4 of 5Aspire Physical Recovery Center Of West AlabamaNorthport, AL 4 of 5Columbiana Health And Rehabilitation, LLCColumbiana, AL 4 of 5Covington Court Health And Rehabilitation CenterFort Smith, AR 4 of 5Crystal River Health And Rehabilitation CenterCrystal River, FL 4 of 5Georgiana Health And Rehabilitation, LLCGeorgiana, AL 4 of 5Luverne Health And Rehabilitation, LLCLuverne, AL 4 of 5Moundville Health And Rehabilitation, LLCMoundville, AL 4 of 5Ocala Health And Rehabilitation CenterOcala, FL 4 of 5Paris Health And Rehabilitation CenterParis, AR 4 of 5Valley View Health And Rehabilitation, LLCMadison, AL 5 of 5Athens Health And Rehabilitation LLCAthens, AL 5 of 5Crossville Health And Rehabilitation, LLCCrossville, AL 5 of 5Daytona Beach Health And Rehabilitation CenterDaytona Beach, FL

Showing 40 of 42; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
JAMES NORMAN ESTES JR TROrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2006
JENNIFER LEE ESTES TR 031093Organization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2006
ESTES, JAMESIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER92%since 09/29/1997
REGIONS BANKOrganization5% OR GREATER SECURITY INTERESTsince 08/27/2013
MOORE, MARCIAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 08/05/2024
GALLAGHER, BEVERLYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 08/21/2023
RASCO, LYNNIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2022
WHITE, HOLLYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 03/04/2022
LONG, PHILLIPIndividualCORPORATE OFFICERsince 10/01/2019
WHITE, JESSEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2023

CMS files one row per role, so the 16 rows in the source record cover these 10 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.

$11.5M
Net patient revenuemost recent cost report
+10.4%
Operating marginrevenue minus expenses
$1.5M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 3%Other / private 14%

About 83% 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 $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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

$295per resident / day
operating cost
$8,971per month
≈ monthly operating cost
$329per 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 045220. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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