No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Katherine's Place at Wedington

4405 West Persimmon Street, Fayetteville, AR 72704 · For profit - Limited Liability company · 119 certified beds · (479) 444-6108 Medicare & Medicaid certified

Call the home — (479) 444-6108 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 2025
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 24% of its spending goes to commonly-owned related companies

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

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

4/5
CMS overall
4 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 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
995 N Shiloh Dr · (479) 430-2323 · Call to confirm hours
Pharmacy
4015 W Wedington Dr · (479) 442-2561 · Call to confirm hours
Grocery
3980 W Wedington Dr Ste 8 · (479) 444-6935 · Call to confirm hours
Park
15 S Broyles Ave · (501) 315-9009 · Typically dawn to dusk
Place of worship
560 N Rupple Rd · (479) 527-6424

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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

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

Overall rating4★
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 increased6.3%9.5%15.4%better
Long-stay residents who lose too much weight1.0%4.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%1.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.8%3.9%3.3%better
Long-stay residents whose ability to walk worsened7.1%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.5%21.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers1.2%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control4.3%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table0.4%10.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%77.7%79.4%better
Short-stay residents rehospitalized after admission12.0%24.1%22.6%better
Short-stay residents with an outpatient ER visit7.8%12.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.292.011.67better
Long-stay outpatient ER visits per 1,000 resident days1.612.131.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

47.4% 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 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.4%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
66.7%U.S. median 56.6%
Met the expected recovery
0.19U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 66.7% 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 63 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 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.4%CMS range 39.2–56.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.9–15.410.7%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 discharge66.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge38.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge57.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.9%CMS range 3.2–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 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

0.30
RN hours/ resident / day
1.02
LPN hours/ resident / day
2.81
Aide hours/ resident / day
4.13
Total nurse hours/ resident / day
0.28
RN hoursweekends
50.0%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 119 beds and averages 103.6 residents a day — about 87% occupied, or roughly 15 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 4.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.81 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 3.48 hrs/resident/day on weekends vs 4.40 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.31 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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

2
deficiencies at the latest standard inspection (2025-09-05)
10
at the previous standard inspection (2024-05-16)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · D2025-09-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, document review the facility failed to provide incontinent care during an eight-hour shift for one resident (Resident #30) of four residents reviewed for neglect. The findings include: Review of a quarterly Minimum Data Set (MDS) with assessment reference date of 08/08/2025, revealed that Resident #30 had a Brief Interview of Mental Status score of 14, which indicated that Resident #30 was cognitively intact. The MDS also revealed that Resident #30 required substantial to maximal assistance with toileting hygiene. A review of Care Plan for Resident #30 with initiation date of 02/26/2025 indicated that staff should anticipate and meet the resident's needs. The Care Plan included an intervention with an initiation date of 02/08/2025, for staff to keep Resident #30's skin clean and dry. During an interview with Resident #30 on 09/03/2025 at 2:52 PM, it was revealed that Resident #30's brief was not checked or changed during a night shift back in July. Resident #30 stated that The day shift Certified Nursing Assistants (CNAs) came in and found me 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2025-09-05 · 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 record review, observation, interview and facility policy review the facility failed to ensure good hand hygiene was maintained for 1(Resident #54) of 2 sampled (Resident #54 and Resident #101) residents observed during perineal care and reviewed for bowel and bladder. The findings include: Review of a Medical Diagnosis report revealed Resident #54 had diagnoses which included inflammation and swelling of the kidney, urinary tract infection, and inability to voluntarily move the upper and lower body. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 08/19/25 revealed a Brief Interview for Mental Status score of 3, which indicated Resident #54 had severe cognitive impairment. The MDS also indicated Resident #54 was always incontinent with bowel and stool. Review of a Care Plan revealed Resident #54 had bowel incontinence related to advanced disease process and decreased mobility with interventions in place to check the resident every two hours and assist with toileting needs. The Care Plan also indicated to provide perineal care after each…

    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 · D2025-04-18 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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, interview, and facility policy review, the facility failed to report to the State Licensing Agency an incident of resident allegation of verbal abuse for one (Resident #5) resident of five residents reviewed for abuse. The findings are: A review of facility policy Abuse Investigations and Reporting revealed that all allegations would be reported immediately, but not later than two hours of allegation of abuse to the State Licensing/Certification Agency. A review of admission Record revealed Resident #5 was admitted on [DATE], with medical diagnoses which included: acute congested heart failure, high blood pressure, muscle wasting and atrophy, and difficulty walking. A review of Resident #5 ' s annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/13/25, revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The MDS revealed Resident #5 had adequate hearing, used a mobility device (wheelchair), required…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-05-16 · 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 dietary staff washed their hands and changed their gloves before handling food items to prevent the potential for cross contamination for the residents who received meals from 1 of 1 kitchen, the failed practice had the potential to affect 103 residents who received meals from the Kitchen (Total Census: 104). The findings are: 1. On 05/14/2024 at 04:50 PM, the following meat items stored on a shelf in the freezer were not covered or sealed: a. Box of steak finger patties. b. A box of pork rib patties. 2. On 05/14/2024 at 05:16 PM, there was an opened cup from a restaurant that contained chocolate shake in the freezer with a received date of 05/14/2024, exposing it to air and or potential for cross contamination. 3. On 05/15/2024 at 08:07 AM, DE #2, who was on the tray line assisting with breakfast meal, was observed to pick up condiments and place them on the trays. Without washing his hands, he picked plates and placed them on the trays to be used in portioning food items to be served to the residents…

    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 before2024-05-16 · tag F0656 — failed to write and follow a full care plan — pattern
    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 observations, interviews, record review, and facility policy review, it was determined that the facility failed to initiate care areas and interventions on the resident care plan for oxygen usage and physician's orders for high risk medications for 3 (Resident #13, Resident #15, and Resident #99) of 3 sampled residents reviewed for care plans and interventions. Findings include: 1. A review of an Order Summary indicated the facility admitted Resident #13 with diagnoses that included atherosclerotic heart disease and type 2 diabetes mellitus. A. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/2024 revealed Resident #13 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. This MDS indicated that Resident #13 had received insulin injections for the past 7 days and was taking an anticoagulant. B. A review of Resident #13's Care Plan on 05/15/24 at 10:22 AM revealed that this resident's care plan did not address anticoagulant use and insulin use. C. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-16 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to revise the resident care plan to reflect current physician orders for 3 (Resident #13, Resident #15, and Resident #46) of 3 residents reviewed for care plan revision. Findings include: 1. A review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/2024 revealed Resident #13 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively Intact. This MDS indicated that Resident #13 is prescribed opioids. B. A review of Resident #13's Care Plan revised, revealed the resident was on pain medication therapy (Tramadol) the interventions included ask physician to review medication if side effects persist. Dated 01/24/2024. C. A review of Resident #13's Order Summary revealed Resident #13 had a Physician's order for, Hydrocodone-Acetaminophen Oral Tablet 5-325 milligram, give 1 tablet by mouth every 6 hours as needed for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure that the physicians order for wound care was following during a scheduled dressing change for 2 (Resident #4 and Resident #32) of 2 residents reviewed for wound care management. Findings include: 1. A review of Resident #4's Order Summary Report indicated Resident #4 did not have a medical diagnosis for the wound care received. a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/2024, revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated the resident was moderately cognitively impaired. The MDS did not indicate the presence of a current pressure ulcer. b. A review of Resident #4's Care Plan revealed the resident had a pressure ulcer of the left heel related to immobility. Interventions included wound/dressing changes as ordered on Treatment Administration Record (TAR). c. A review of Resident #4's Order Summary Report revealed Resident #4 had an order for L [left] heel ST3 [Stage…

    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 · E2024-05-16 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure meals were served 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 1 of 1 meal observed. This failed practice had the potential to affect 11 residents who receive meal trays in their rooms on the 100 Hall, 8 residents who receive meal trays on the 200 Hall, 13 residents who receive meal trays in their room on the 300 Hall, 5 residents who receive meal trays in their room on 400 Hall, 25 residents who receive meal trays in their room on the 500 Hall, and 6 residents who receive meal trays in their room on the 600 Hall. The findings are: 1. On 05/15/2024 at 12:17 PM, an unheated food cart that contained 11 trays for lunch was delivered to the 100 Hall by Certified Nursing Assistant (CNA) #2. At 12:39 PM, immediately after the last resident was served in their room on the 100 Hall, the temperature of the food items on the tray used as a test tray was taken and read by…

    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 · E2024-05-16 · 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 that 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 9 residents who received pureed diets. The findings are: 1. On 05/14/2024 at 04:47 PM, Dietary Employee (DE) #1 placed 11 dinner rolls into a blender, added whole milk and pureed. DE #1 poured the pureed bread into a pan and placed it in the oven. The consistency of the pureed bread was lumpy and not smooth. 2. On 05/14/2024 at 04:59 PM, the following observations were made on the steam table before meal service: a. A pan of pureed vegetables. The consistency of the pureed vegetables was not formed and was running. b. A pan of pureed beef steak fingers. The consistency of the meat was lumpy and not smooth. There were pieces of meat visible in the mixture. 3. On 05/14/2024 at 05:34 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food…

    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 before2024-05-16 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper hand hygiene was performed before and during wound care to maintain aseptic technique throughout wound care, ensure no cross contamination of Personal Protective Equipment (PPE) and during wound bed cleansing for 2 (Resident #4 and Resident #32) of 2 residents reviewed for wound care. Findings include: 1. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/2024 revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated the resident was moderately cognitively impaired. a. A review of Resident #4's Care Plan revealed the resident had a pressure ulcer of the left heel related to immobility. Interventions included wound/dressing changes as ordered on the on Treatment Administration Record (TAR). b. A review of Resident #4's Order Summary Report revealed Resident #4 had an order for a left heel stage 3 pressure ulcer to be cleaned and dressed every Monday, Wednesday, and Friday. c. During an…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2024-05-16 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and record review, the facility failed to ensure a bed hold notification was sent to a resident and/or resident representative following a hospital transfer and admission for 1 (Resident #13) of 1 resident reviewed for hospitalizations. Findings include: A review of an eInteract Transfer Form V5 revealed Resident #13 had an unplanned transfer to the local hospital on [DATE] at 05:30 PM for a change of condition. A review of Business Office Manager (BOM) Facility Initiated Transfer-V4, revealed Resident #13 had a form completed on 02/02/2024 for a previous hospital transfer but there was no form located for the transfer on 03/03/2024. During an interview on 05/16/2024 at 12:17 PM, the Business Office Manager (BOM) confirmed that there was not a bed hold notification letter created or sent to the resident and/or resident representative for Resident #13 hospital transfer on 03/03/2024. The Surveyor asked, What is the process for ensuring that residents and/or 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-16 · 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 observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the physicians orders were followed on changing oxygen tubing and humidifier bottle for 1 (Resident #99) of 1 resident reviewed for oxygen usage. Findings include: The 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/08/2024, revealed Resident #99 had a Brief Interview of Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. This MDS indicated the resident was on oxygen at admission and while a resident. A review of Resident #99's Care Plan revealed the resident did not have an initiation of oxygen usage on the care plan. A review of the Order Summary revealed Resident #99 had an order for oxygen as needed for shortness of breath 2-4 liters/minute per nasal cannula as needed was ordered on 02/23/2024 and to change and date the O2 (oxygen) tubing and water bottle every week on day shift every 7 days was ordered on 02/23/2024. A review of the Medication…

    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 · D2024-05-16 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility policy review, the facility failed to ensure a medication regimen review was completed monthly for 1 (Resident #91) of 1 resident reviewed for unnecessary medication review. Findings include: A review of Resident #91's Order Summary Report indicated the facility admitted Resident #91 on October 13, 2023. A review of Resident #91's electronic medical record on 05/15/2024 at 11:09 AM, indicated there was not a medication regimen review for the month of January 2024. On 05/16/2024, the Director of Nursing (DON) was asked to review Resident #91's electronic medical record and locate a medication regimen review for the month of January 2024 completed by the consultant pharmacist. During an interview on 05/16/2024 at 12:50 PM, the DON stated there was not a medication review completed for Resident #91 during January 2024 by the consultant pharmacist. The Surveyor asked what the importance of a medication regimen review was. The DON replied to make sure that no medication changes need to be fixed to avoid side effects or accidents. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-05-18 · 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 food items stored in the refrigerator were dated, kitchen appliances (deep fryer shelf below the deep fryer) were clean and free of stains and spills; and staff washed their hands between dirty and clean tasks and before handling clean dishes or food items to prevent potential for cross contamination. These failed practices had the potential to affect all 94 residents who received meals from the kitchen (total census: 94), as documented on a list provided by the Dietary Supervisor on 05/16/23.The findings are: 1. On 05/15/23 at 10:19 AM, the bottom shelf of the deep fryer had an accumulation of grease and caked-on food crumbs across the entire surface, 4 pallets next to the shelf of the deep fryer were covered in grease. The Surveyor asked the Dietary Supervisor, How often do you clean it? She stated, We clean it once a week. 2. On 05/15/23 at 10:42 AM, in the Utility Room on the 200 Hall, the following were in the refrigerator: a. One box (Fast Food Establishment) contained one chicken nugget. There…

    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 · E2023-05-18 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    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 residents' confidential and personal information was not overheard by family members of 16 residents on the 400 Hall during shift change as documented on the Census by Hall provided by the Administrator on 05/15/23 at 10:34 AM. The findings are: 1. On 05/17/23 at 3:10 PM, the Surveyor observed Certified Nursing Assistants (CNAs) #3, #4, #5, #6 and #7 walking together on the 400 Hall speaking loudly, using resident names and room numbers, discussing residents' doctor's appointments, behaviors, peri care, and care needs still to be performed. The Surveyor observed Resident #245's son standing on the 400 Hall 3 to 5 feet from the group of CNAs. a. On 05/17/23 at 3:11 PM, the Surveyor asked the Charge Nurse, Licensed Practical Nurse (LPN) #1 if resident information should be discussed in front of other residents' family members. LPN #1 stated, No, and walked with another nurse to the group of CNAs. The group moved away from Resident #245 ' s son and began to speak quieter. 2. On 05/18/23 at 8:12 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-18 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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

    Based on observation, and interview, the facility failed to ensure residents were allowed to have personal property within reach creating a homelike environment and maximizing the resident's independence for 1 (Resident #19) of 58 (Residents #1, #2, #3, #7, #8, #11, #13, #14, #15, #16, #19, #23, #25, #26, #30, #31, #32, #33, #36, #38, #39, #41, #45, #47, #48, #51, #52, #53, #54, #56, #57, #59, #61, #62, #63, #66, #69, #71, #72, #73, #74, #79, #80, #82, #84, #85, #86, #87, #98, #145, #205, #245, #246, #346, #347, #348 and #349) sampled residents. The failed practice had the potential to affect 94 residents as documented on the Matrix provided by the Assistant Director of Nursing (ADON) on 05/15/23 at 11:05 AM. The findings are: 1. Resident #19 had diagnoses Unspecified Fracture of Left Pubis, Subsequent Encounter for Fracture with Routine Healing, Fracture of Unspecified Metatarsal Bone(s), Right Foot, Initial Encounter for Closed Fracture. The admission Minimum Data Set (MDS) with an Assessment Reference Data (ARD) of 02/04/23 documented the resident scored 11 (8-12 indicates…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-18 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Care Plans were implemented and accessible for staff who were responsible for the interventions for 1 (Resident #245) of 1 sampled resident with diet and nutritional interventions for Gastro-Esophageal Reflux Disease (GERD) as documented on a list provided by the Administrator on 05/18/23 at 8:48 AM. The findings are: 1. Resident #245 was admitted on [DATE] and readmitted on [DATE] and had diagnoses of GERD, Anemia, Dementia, Malignant Neoplasm of Colon, and Type 2 Diabetes Mellitus. The admission Minimum Data Set (MDS) with an Assessment Reference Date of 02/13/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview of Mental Status (BIMS) was on a mechanically altered and therapeutic diet and weighed 217 pounds. a. A Comprehensive Care Plan with an initiated date of 05/10/23 documented, .Provide small frequent meals rather than 3 large ones . b. A Hospital Discharge Record dated…

    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 · E2023-05-18 · 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

    Based on observation, record review, and interview, the facility failed to ensure residents fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 2 (Residents #53 and #346) of 53 (Residents #1, #2, #3, #5, #7, #8, #11, #13, #14, #15, #16, #19, #20, #23, #25, #26, #32, #33, #36, #37, #38, #39, #41, #45, #47, #48, #51, #52, #53, #56, #57, #61, #62, #63, #66, #69, #70, #71, #72, #73, #74, #80, #82, #84, #85, #86, #87, #245, #246, #346, #347, #348 and #349) sampled residents who were dependent for nail care and failed to ensure shaving and beard trimming services were regularly provided to maintain good hygiene for 2 (Residents #36 and #53) of 25 (Residents #2, #11, #13, #16, #20, #25, #26, #32, #36, #37, #39, #41, #45, #53, #57, #62, #69, #70, #72, #82, #87, #245, #346, #347 and #349) sample residents who were dependent on staff for shaving. The failed practices had the potential to affect 90 residents who were dependent for nail care and 39 residents who were dependent on staff for shaving and beard trimming as documented on lists provided by 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 before2023-05-18 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by properly storing toothbrushes for 2 (Residents #36, and #87) of 54 (Residents #1, #2, #3, #5, #7, #11, #13, #14, #15, #16, #19, #20, #23, #25, #26, #32, #33, #35, #36, #37, #39, #41, #45, #47, #48, #51, #52, #53, #56, #57, #59, #61, #62, #63, #66, #69, #70, #71, #72, #74, #80, #82, #84, #85, #86, #87, #88, #145, #245, #246, #346, #347, #348 and #349) sampled residents who utilize a toothbrush for oral care. This failed practice had the potential to affect 88 residents who required a toothbrush for dental hygiene as documented on a list provided by the Director of Nursing (DON) on 05/18/23 at 9:30 AM. The findings are: 1. Resident #36 had diagnoses of Cerebral Infarction, Unspecified, Type 2 Diabetes Mellitus without Complications and Dysphagia following Cerebral Infarction. The Annual Minimum Data Set (MDS) with an Assessment Reference Data (ARD) of 03/21/23…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-18 · 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, interview, the facility failed to ensure the kitchen was free of pests to prevent the potential of cross contamination or bacteria growth. The failed practice had the potential to affect 101 residents who received food from 1 of 1 kitchen according to the list provided by the Assistant Administrator on 05/16/23 at 12: PM. The findings are: 1. On 05/15/23 at 12:20 PM, there were serving spoons and a tong on the pan liners on the food preparation counter opposite the microwave oven, where Dietary Employee (DE) #1 was about to puree food items to be served to the residents on pureed diets. Three roaches were crawling between the serving spoons and the tongs. The Surveyor showed the roaches to DE #1 and the Dietary Supervisor. Two of the roaches crawled under the microwave and the Dietary Supervisor killed the roach that crawled under the pan liners. At 12:27 PM, the Surveyor asked DE #1, How long have you had this problem? She stated, I have not seen one recently. Maybe they came out because the bug man came last week and sprayed. 2. A (Company)…

    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 · D2023-05-18 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure call lights were within reach to enable residents to call for assistance to meet their needs for 1 (Resident #145) of 43 (Residents #1, #2, #3, #5, #7, #13, #15, #16, #19, #23, #25, #26, #32, #33, #35, #36, #37, #39, #41, #45, #47, #48, #51, #52, #53, #56, #59, #62, #63, #66, #70, #73, #74, #82, #84, #85, #88, #145, #245, #246, #346, #348 and #349) sampled residents who were able to use a call light. This failed practice had the potential to affect 77 residents who were able to use a call light as documented on a list provided by the Director of Nursing (DON) on 05/18/23 at 8:10 AM. The findings are: 1. The Grievance Log provided by the Administrator on 05/15/23 at 12:01 PM documented .incident date 3/11/23 .received 3/13/23 . [discharged Resident] .call light out of reach . 2. Resident #145 had diagnoses of Congestive Heart Failure, Type 2 Diabetes Mellitus, Macular Degeneration, and Muscle Weakness. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/23 documented…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-05-18 · tag F0888 — widespread
    Ensure staff are vaccinated for COVID-19
    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 all staff received complete primary vaccinations, had an approved or pending medical or religious exemption, or a temporary delay per the Center for Disease Control (CDC) and the Centers for Medicare and Medicaid Services (CMS) COVID-19 Health Care Staff Vaccination regulations; failed to ensure staff COVID-19 vaccinations were accurately tracked, documented, and updated timely and failed to submit data weekly to the National Healthcare Safety Network (NHSN). The findings are: 1. The Administrator provided a Staff COVID-19 event list on 05/16/23 at 11:35 AM which documented 3 partially vaccinated staff with one dose of either a Pfizer or Moderna vaccination. 2. The Administrator provided a COVID card for Nurse Assistant #1 that documented two Moderna doses, and COVID cards for Housekeeping/Laundry Aide #1 and #2 that documented one Pfizer dose. 3. The NHSN on 05/16/23 at 12:26 PM documented, N [no] for Data submitted for week ending 4/30/23 and was blank under the column of Passed Quality Assurance Check. 4. 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.

    Infection Control 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 ANTHONY & BRYAN ADAMS — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.8+0.2 vs chain
Health inspection 3 of 53.5-0.5 vs chain
Staffing 3 of 53.0≈ chain avg
Quality measures 5 of 54.3+0.7 vs chain
The other 37 homes this chain runs (chain average 3.8★, per CMS)
1 of 5Ridgecrest Health And RehabilitationJonesboro, AR 2 of 5Bailey Creek Health And RehabTexarkana, AR 2 of 5Magnolia Square Nursing And RehabSpringfield, MO 2 of 5St. Elizabeth's PlaceJonesboro, AR 2 of 5Twin Lakes Therapy And LivingFlippin, AR 2 of 5Westwood Health And Rehab, INCSpringdale, AR 3 of 5Alcoa Pines Health And RehabilitationBenton, AR 3 of 5Birch Pointe Health And RehabilitationSpringfield, MO 3 of 5James River Nursing And RehabilitationSpringfield, MO 3 of 5The Lakes At Maumelle Health And RehabilitationMaumelle, AR 3 of 5Timberlane Health & RehabilitationEl Dorado, AR 3 of 5Windcrest Health And Rehab INCSpringdale, AR 4 of 5Beebe Retirement Center, Inc.Beebe, AR 4 of 5Chapel Woods Health And RehabilitationWarren, AR 4 of 5Evergreen Living Center At StagecoachBryant, AR 4 of 5Gassville Therapy And LivingGassville, AR 4 of 5Heritage Living CenterConway, AR 4 of 5Hiram Shaddox Health And RehabMountain Home, AR 4 of 5Maples Health And Rehabilitation, TheSpringfield, MO 4 of 5Mountain Meadows Health And RehabilitationBatesville, AR 4 of 5Oak Ridge Health And RehabilitationEl Dorado, AR 4 of 5Silver Oaks Health And RehabilitationCamden, AR 4 of 5Southridge Village Nursing And RehabHeber Springs, AR 5 of 5Amberwood Health And RehabilitationBenton, AR 5 of 5Care Manor Nursing And RehabMountain Home, AR 5 of 5Chambers Health And RehabilitationCarlisle, AR 5 of 5Corning Therapy And Living CenterCorning, AR 5 of 5Eaglecrest Nursing And RehabAsh Flat, AR 5 of 5Edgewood Health And RehabSpringdale, AR 5 of 5North Hills Life Care and RehabFayetteville, AR 5 of 5Pioneer Therapy And LivingMelbourne, AR 5 of 5Rector Nursing And RehabRector, AR 5 of 5Southfork River Therapy And LivingSalem, AR 5 of 5Spring Creek Health & RehabCabot, AR 5 of 5The Crossing At Riverside Health And RehabilitatioSearcy, AR 5 of 5The Maples At Har-Ber MeadowsSpringdale, ARNot ratedQuail Run Health And RehabTrumann, AR

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
3B HOLDINGS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF76%since 04/01/2025
ADAMS, ANTHONYIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNFsince 10/16/2008
CENTENNIAL BANKOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 04/01/2025
HOME BANCSHARESOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 04/01/2025
ANGEL, TAMMYIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 10/16/2008
SOUZA, KELLYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/02/2022
THOMAS, DARRYLIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 10/16/2008
ADAMS, BRYANIndividualCORPORATE OFFICER; ADP OF THE SNFsince 10/16/2008
RELIANCE HEALTH CARE, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/02/2025
LTC SYSTEMS/RX, LLCOrganizationADP OF THE SNFsince 08/01/2010
PHARMACY CONSULTS, LLCOrganizationADP OF THE SNFsince 08/01/2010
RHC REAL ESTATE, LLCOrganizationADP OF THE SNFsince 08/01/2010
ELLIS, JOHNIndividualADP OF THE SNFsince 10/16/2008
KOEHLER, TOBEYIndividualADP OF THE SNFsince 10/16/2008
MCGINNIS, LARRYIndividualADP OF THE SNFsince 10/16/2008

CMS files one row per role, so the 26 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

$11.3M
Net patient revenuemost recent cost report
+4.4%
Operating marginrevenue minus expenses
$2.6M
Related-party expense24% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 8%Other / private 32%

This home reported $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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

$303per resident / day
operating cost
$9,203per month
≈ monthly operating cost
$317per 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 045434. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, 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.

What to do next