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Heather Manor Nursing And Rehabilitation Center

400 West 23rd Street, Hope, AR 71801 · For profit - Corporation · 128 certified beds · (870) 777-3448 Medicare & Medicaid certified

Call the home — (870) 777-3448 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
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
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
Worth asking about
  • 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

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) 4 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

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
100 E 20th St · (870) 777-2100 · Call to confirm hours
Pharmacy
1523 S Main St · (870) 777-5555 · Call to confirm hours
Grocery
Hwy 67 & Hwy 4 · (870) 777-8831 · Call to confirm hours
Park
121 Legion Ln · Typically dawn to dusk
Place of worship
2300 S Main St · (870) 777-8816

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 increased0.8%9.5%15.4%better
Long-stay residents who lose too much weight6.2%4.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms1.5%1.4%6.5%typical for the 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 injury0.7%3.9%3.3%better
Long-stay residents whose ability to walk worsened0.7%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.2%21.7%18.9%better
Long-stay residents given the seasonal flu vaccine96.2%96.1%95.3%typical
Long-stay residents with pressure ulcers3.7%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control9.7%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table15.5%10.9%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine33.9%77.7%79.4%worse
Short-stay residents rehospitalized after admission12.6%24.1%22.6%better
Short-stay residents with an outpatient ER visit14.7%12.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.302.011.67worse
Long-stay outpatient ER visits per 1,000 resident days2.452.131.80worse

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

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

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

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

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

44.7% 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 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.7%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
54.3%U.S. median 56.6%
Met the expected recovery
0.12U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 54.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 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 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF44.7%CMS range 35.1–56.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 7.2–14.710.7%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 discharge54.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.4%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 discharge48.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified94.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.3%CMS range 5.1–15.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.221.02Oct 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

0.53
RN hours/ resident / day
1.22
LPN hours/ resident / day
2.76
Aide hours/ resident / day
4.51
Total nurse hours/ resident / day
0.25
RN hoursweekends
29.5%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 128 beds and averages 76.3 residents a day — about 60% occupied, or roughly 52 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.76 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 3.79 hrs/resident/day on weekends vs 4.80 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.64 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% is below 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

6
deficiencies at the latest standard inspection (2025-02-06)
7
at the previous standard inspection (2024-04-04)

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 · E2025-02-06 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility document review, it was determined the facility failed to ensure written notification provided to the resident and/or the resident's representative of transfer/discharge to the hospital included all the required information for 3 (Resident #69, Resident #76, and Resident #49) out of 3 sampled residents reviewed for hospitalizations. The findings include: The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/2024, revealed Resident #69 had a Brief Interview for Mental Status (BIMS) of 15 (indicating the resident was cognitively intact), and diagnoses that included end-stage renal disease (Kidney Failure), seizure disorder, and diabetes (abnormal blood sugar). A review of the facility document titled Emergency Transfers from Facility indicated Resident #69 was transferred to the hospital on 4 occasions: a. 10/29/2024 to 11/04/2025 b. 12/18/2024 to 12/21/2024 c. 12/28/2024 to 12/30/2024 d. 01/08/2025 to 01/11/2025 On the morning 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-06 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, interview and policy review the facility failed to ensure staff used infection control measures while providing care to 1 (Resident #70) of 1 sampled resident observed for incontinence care, and staff donned the proper Personal Protective Equipment (PPE) prior to providing high contact care to 2 (Resident #11, #64) of 2 sampled residents on Enhanced Barrier Precautions (EBP), and proper hand hygiene was followed during wound care for 1 resident (Resident #53) of 3 sampled residents reviewed for pressure ulcer care. The findings include: 1. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/2024, revealed Resident #11 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. a. Review of a Plan of Care for Resident #11 with a revision date of 01/10/2025, revealed Resident #11 had an indwelling catheter due to a terminal condition and was on enhanced barrier precautions related to the indwelling catheter. b. On 02/03/2025 at 11:35 AM, this surveyor observed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and facility policy review, the facility failed to ensure privacy was protected, and dignity was maintained for 1 (Resident #70) of 1 sample resident observed for incontinence care. The findings include: A review of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/2024, revealed Resident #70 had a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #70 was occasionally incontinent of bowel and bladder. A review of the Plan of Care for Resident #70, revision date 07/05/2024, revealed Resident #70 had occasional incontinent episodes of bladder. On 02/04/25 at 2:24 PM, Surveyor observed Certified Nursing Assistant (CNA) #4 provide incontinence care to Resident #70 with the blinds raised halfway and open at the top. The window was facing the parking lot to the front of the building, where the facility entrance was located. The surveyor observed several cars in the lot outside the window. CNA #4 removed the resident ' s brief while 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 · D2025-02-06 · 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 interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure a written bed hold notification was provided prior to hospital transfer for 1 (Resident #76) of 7 sample residents reviewed for hospitalization. The findings include: 1. A review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/2024, indicated Resident #76 had diagnoses of Dementia with other behavior disturbances, encephalopathy, presence of right artificial knee joint and a Brief Interview for Mental Status (BIMS) score of 14 (13-15 indicates cognitively intact). a. A facility letter dated 12/18/2024, indicated Resident #76 was transferred to [named Hospital] for behavior symptoms. b. A review of Resident #76 ' s medical record revealed no documentation of bed hold notification was provided to resident or the resident representative at time of Resident #76 ' s transfer to the hospital on [DATE]. c. On 02/06/2025 at 11:35 AM, a bed hold…

    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 · D2025-02-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 gradual psychotropic (antipsychotic) dose reductions were addressed and (anti-anxiety) dose reductions (GDR) were attempted in the absence of a physician's documented evaluation of the specific risks versus benefits of continuing the as needed (PRN) medication past 14 days and a documented explanation as to why a dose reduction attempt would be contraindicated, in order to ascertain the smallest effective dose and minimize the potential for adverse drug effects for 1 (Resident # 11) of 5 residents reviewed for unnecessary medications. The findings include: A review of the admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/31/24, revealed Resident #11 had a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of a Plan of Care for Resident #11 with a revision date of 01/09/2025, revealed Resident #11 used the psychotropic medication [A brand name antipsychotic medication used to treat major depressive disorder,…

    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 · Dcited before2025-02-06 · tag F0761 — failed to label and store drugs safely — isolated
    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 observations, and facility policy review, the facility failed to ensure medication was properly stored to prevent unauthorized individuals from having access. The findings include: On 2/04/25 at 9:05 AM, this surveyor observed Licensed Practical Nurse (LPN) #3 walk down the hall and enter a resident's room. This surveyor noted there was a vial of insulin, a tube of wound gel, and a plastic cup which contained a clear liquid on top of the medication cart left unattended in the hallway. On 02/04/25 at 9:08 AM, this surveyor observed LPN #3 walk down the hall and enter a resident's room. This surveyor noted there was a vial of insulin, a tube of wound gel, and an unlabeled plastic cup with a clear liquid inside on top of the unattended medication cart. On 02/04/25 at 9:44 AM, this surveyor observed LPN #3 administer the contents in the plastic cup to a resident. LPN #3 stated he had pre-prepared a resident ' s [laxative solution mediation name] which was in the plastic cup. LPN #3 stated it was not standard practice to pre-prepare medications, but the [laxative solution…

    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 before2024-04-04 · 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, investigation, and record review, the facility failed to ensure that hand sanitation was performed while preparing food, that kitchen equipment was clean and properly maintained, that food was in useable condition, that food was stored at least 6 off the floor, and that dirty dishes were properly placed in the dishwasher. The findings are as follows: 1. On 04/03/2024 at 12:08 PM, Dietary Aide #1 placed her hands under her apron, retrieved her glasses, and without washing her hands continued to set food up for serving. 2. On 04/03/2024 at 12:30 PM, the seal on the Ice Machine on the right, between the vent and ice container, was held in place by tape. 3. On 04/03/2024 at 12:38 PM, the following observations were made: a) The walk-in freezer contained 12 wheat sub rolls and 60 white sub rolls on the top shelf with ice particles inside the bag and surrounding the rolls. b) Ice was frozen to the side of the freezer door. The Dietary Manager (DM) confirmed she should scrap the ice off because it interferes with the seal of the freezer. 4. On 04/03/2024 at 12:39 PM,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-04 · 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 observation, interview, and record review, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promoted the maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 (Residents #25 and #50) sampled residents with the potential to affect 8 Residents dependent on staff for meal assistance. The findings are: 1. Resident #25 had diagnoses of Paraplegia and Major depression disorder. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/2024 documented Resident #25 scored an 11 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS), and required limited assistance with eating. a. On 04/01/2024 at 12:50 PM, Certified Nursing Assistant (CNA) #2 placed a clothing protector around Resident #25's neck and voiced to the resident, Don't try to feed yourself, you are a feeder. b. On 04/01/2024 at 12:55 PM, CNA #1 set Resident 25's meal, one of the first trays to come out the kitchen, on 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 · Ecited before2024-04-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure combustible equipment was safely locked away from residents who wonder and/or self-propel throughout the facility. This failed practice had the potential to affect 8 (Residents #30, #68, #4, #50, #23, #28, #81, and #19) sampled residents of 38 residents who could self-propel in a wheelchair. The findings are: On 04/01/2024 at 09:05 AM, the Surveyor opened a door labeled Oxygen at the end of 200 Hall and found portable oxygen tanks, supplies, and other equipment inside. A second Surveyor arrived and observed the Surveyor standing with the door open. On 04/01/2024 at 09:14 AM, the Surveyor opened a door labeled Oxygen at the end of 600 Hall and found portable oxygen tanks, supplies, and other equipment inside. On 04/01/2024 at 09:07 AM, the Surveyor asked the admission Coordinator if the door should be locked, referring to the door labeled Oxygen at the end of 200 Hall. The admission Coordinator stated, Yes ma'am, it should be locked. On 04/01/2024 at 09:15 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3, if…

    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 before2024-04-04 · 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 the storage container used to store controlled medications requiring refrigeration was permanently affixed. The findings are: On 04/01/2024 at 10:15 AM, during observation of medication room with Licensed Practical Nurse (LPN) #1, LPN #1 removed the storage box used to store refrigerated controlled medications and placed the storage box on the counter. The Surveyor instructed LPN #1 to open the storage box for an inventory of what was contained inside. The Surveyor noted that the storage box contained 3 syringes of Lorazepam 2 mg/ml (milligram/milliliter) for emergency use and prescribed Lorazepam 0.25ml syringes. On 04/01/2024 at 10:20 AM, the Surveyor asked LPN #1 if the storage box was used to store refrigerated controlled medication permanently affixed. LPN #1 voiced that it was not attached and to his knowledge it was only required to be under 2 locks. On 04/02/2024 at 12:38 PM, the Surveyor asked the Director of Nursing (DON), what halls does the front medication room store medications for? 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
Show the remaining 12 citations
  • Potential for harm · D2024-04-04 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 2 (Residents #12 and #23) were not served dislikes in the dining area to prevent weight loss or nutritional deficits. This failed practice had the potential to affect 79 residents that eat meals from the kitchen. The findings are: 1. Resident #12 had diagnoses of Congestive heart failure, Acute respiratory failure with hypoxia, and Anemia. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/18/2024 documented a Brief Interview for Mental Status (BIMS) score of 9 (8-12 suggest mildly impaired). Resident #12 required supervision or touch assistance for meals. a. A Care Plan for Resident #12 (Revision on: 12/07/2021) documented, .Offer substitutes for foods not eaten . b. On 04/01/2024 at 01:09 PM, Resident #12 was complaining loudly to the Dietary Manager (DM) that the resident does not eat this stuff, while pointing to chicken alfredo on Resident #12's plate. Resident #12's meal slip documented Resident #12 disliked chicken spaghetti. c. On 04/01/2024 at 01:11 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · 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, interview, and record review, the facility failed to ensure humidifier bottles and nasal cannula tubing were dated and stored in a safe and sanitary manner to prevent infection for 2 (Resident #50 and #78) of 3 sampled residents with the potential to affect 5 residents on the 200 Hall and 2 on the 400 hall. The findings are: 1. Resident #78 had diagnoses of Abnormal findings of lung field and Cerebral infarction. Resident #78 had a Physicians Order dated 03/31/24 for oxygen therapy at 1 liter via nasal cannula and was changed to 3 liters on 04/03/2024. a. On 04/01/2024 at 11:15 AM, Resident #78 was lying in bed receiving humified oxygen via nasal cannula at 1 liter per minute. The Surveyor noted the humidifier bottle was not dated. b. On 04/01/2024 at 11:20 AM, the Surveyor asked Registered Nurse (RN) #1 while at Resident #78's bedside, Does that (humidifier) water bottle have a date? RN#1 stated, It is not dated. The Surveyor asked, Is the tubing dated? RN #1 stated, No it is not dated either. c. On 04/02/2024 at 12:38 PM, the Surveyor asked the Director 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · 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, interview and record review, the facility failed to ensure intravenous medications were administered in a safe and non-contaminated manner for 1 (Resident #68) sampled resident. This failed practice had the potential to cause further infection directly into blood stream. The findings are: Resident #68 had diagnoses of Osteomyelitis and Pressure ulcer to sacral region. Resident #68 was receiving Vancomycin (an antibiotic) 1250mg (milligram) every 8 hours intravenous, Ceftriaxone (an antibiotic) 2g (gram) twice a day intravenous and was on contact isolation due to Methicillin-resistant Staphylococcus Aureus in wound. According to a Quarterly Minimum Data Set with Assessment Reference Date of 03/11/2024, Resident #68 had Intravenous (IV) Access while a Resident. On 04/03/2024 at 01:09 PM, the Surveyor observed Licensed Practical Nurse (LPN) #2 putting on a gown and gloves prior to entering Resident #68's room. LPN #2 uncapped the Peripherally Inserted Central Catheter (PICC) lumen, uncapped a 10cc (cubic centimeter) normal saline flush and tossed the caps for 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-03-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure food items stored in the refrigerator were covered, sealed, and dated to prevent the potential food borne illnesses, expired food items were promptly removed/discarded by the expiration or use by dates. The facility failed to ensure beverages were dated when opened to prevent the potential for food borne illness, dietary staff washed their hands before handling clean equipment or food items; and cold food was maintained at or above 41 degrees Fahrenheit on the counter while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 86 residents who received meals from the kitchen (total census: 88), as documented on a list provided by the Dietary Supervisor on 3/3/2023 At 8:43 AM. The findings are: 1. On 3/01/2023 at 8:45 AM, a bag of nacho cheese stored on a shelf in the storage room had an expiration date of 02/26/23. 2. On 3/01/2023 at 9:13 AM, the following observations were made in the Medication Room on the 400…

    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 · E2023-03-03 · 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 Based on observation, record review, and interview, the facility failed to ensure showers/bathes were consistently given to promote health, good personal hygiene and grooming for 2 (Residents #69 and #334) of 38 (Resident #3, R #5, R #7, R #8, R #10, R #17, R #21, R #24, R #25, R #27, R #31, R #34, R #35, R #36, R #38, R #39, R #40, R #41, R #43, R #45, R #46, R #47, R #49, R #51, R #57, R #59, R #60, R #62, R #63, R #67, R #68, R #69, R #70, R #71, R #72, R #73, R #76, R #334, and R #385) sampled residents who were dependent for bathing/showering. The findings are: 1. Resident #69 had diagnoses of Myopathy and Morbid Obesity. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 01/04/23 documented a Brief Interview of Mental Status [BIMS] of 15 (13-15 indicates conatively intact), was totally dependent on two-persons for transfers and required one-person physical assistance with bathing and had Moisture Associated Skin Damage [MASD]. a. On 02/27/23 at 10:25 AM, Resident #69 stated, I…

    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 before2023-03-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure that medications were not left in (Resident #5, and R #67) who were not assessed for Self-Administration of Medication. This failed practice had the potential to affect all 88 residents residing in the facility according to the census and conditions provided by the Minimum Data Set (MDS) Coordinator on 2/27/2023 at 1:30 PM The findings are: 1. Resident #5 had diagnoses of Hemiplegia and Hemiparesis following Cerebral infarction affecting left dominant side. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 01/19/23 documented a Brief interview for Mental Status [BIMS] of 15 (13-15 indicates cognitively intact), was totally dependent on one person for toileting, was always incontinent of bowel and bladder and had Moisture Associated Skin Damage (MASD). a. On 02/27/23 at 10:55 AM, Resident #5 laid in bed with her eyes closed. A 15-ounce tub of zinc oxide cream sat on top of the bed side table to the right side of the resident. The tub was open and had a wooden tongue blade…

    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 before2023-03-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interview, the facility failed to ensure oxygen tubing was changed for 1 (Resident #31) of 14 residents who were receiving oxygen. This failed practice had the potential to affect 14 residents who had a Physician's Order for oxygen tubing to be changed every week according to a list provided by the Director of Nursing on 3/02/23 at 3:00 PM. The findings are: Resident #31 had diagnoses of CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED CHRONIC RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA A Quarterly Minimum Data Set with an Assessment Reference Date of 12/13/2022, that is in progress, documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. Resident required limited assistance bed mobility, transfers, bathing, and personal hygiene, is independent with eating, and required oxygen therapy. 1. A Physician Order dated 9/8/19 showed , Change O2 [oxygen] tubing, clean filter, date all tubing every Sunday night on 11-7 shift. 2. The Care Plan dated 9/19/19 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-03 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, and inventory review of the two medication rooms and two medication carts on 03/02/23, the facility failed to ensure medications in 2 of 3 medication carts were labeled and stored in accordance with State law and accepted standards of pharmacy practice. The facility failed to ensure discontinued or expired medications were removed and placed into an area for destruction to prevent potential administration to residents. These failed practices had the potential to affect all 88 residents who resided in the facility and would receive any physician-ordered medications from the medications room, or the medication carts. The findings are: 1. On 03/02/23 at 8:03 AM, the Director of Nursing (DON) unlocked the Medication Room at Station 1. The refrigerator contained an open vial of tuberculin testing solution which did not contain the date it was opened. The bottom drawer of the refrigerator contained a box containing 11 hemorrhoidal suppositories with an expiration date of July 2022. The storage cabinet contained two bottles of Aspirin 81 mg [milligrams] with 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-03 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 2 residents who received pureed diets, from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 3/01/2023. The findings are: 1. The 3/01/2023 menu for breakfast documented residents who received enhanced diets were to receive ¾ ounce cup of super cereal, one biscuit, one cup of milk, one sausage/bacon, margarine spread, jelly, and coffee/tea. a. Resident 22's Tray Card documented, Mechanical soft Regular Diet, Enhanced food. b. The Physician's Order dated 9/7/2022 documented, .Regular enhanced diet, mechanical soft texture, regular consistency. c. On 03/01/2023 at 9:29 AM, Resident #22 was served one toast, ground sausage with gravy, scrambled eggs, a carton of cranberry juice, salt, jelly, butter, and pepper packet, instead of biscuit, milk, and super cereal. 2. The 03/02/2023 menu 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-03 · 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 meal trays were not left to sit out in a medication room while residents were sleeping and a new meal tray was provided instead of serving the food tray left sitting out to the residents to prevent the potential for food borne illness for 2 (Resident #22 and R #70 ) of 2 residents who received their meal trays in the unit dining room and/or in their room and who required assistance for eating, and failed to ensure meals were served at temperatures that were acceptable to the residents, to improve palatability and encourage good nutritional intake during 2 of 2 meals observed on the 400 hall (unit). The failed practice had the potential to affect 12 residents who received meal trays in the unit dining room, as documented on a list provided by Dietary Supervisor on 3/2/2023. The findings are: 1. Resident #22 had diagnosis of TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA of Depression, Diabetes Mellitus, Renal Failure (Dialysis) Congestive Heart Failure and Chronic Obstructive, HYPOKALEMIA,…

    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 · E2023-03-03 · 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 — the official record, unedited, 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 2 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 3/2/23. The findings are: a. On 3/01/23 at 10:25 AM, Dietary Employee #1 placed four servings of diced fried potatoes into a blender, added milk and pureed. She poured the pureed fried potatoes into a pan, covered the pan with foil, and placed in a pan of hot water on the stove. The consistency was thick and not smooth. b. On 3/01/23 at 12:35 PM, a pan of pureed cornbread was on the steam table. The consistency of the pureed cornbread was thick and not smooth. At 12:59 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, they were stiff.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-03 · 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 adhere to hygienic practices during the noon meal service on 2/27/23 at 12:30 pm by staff not sanitizing their hands between resident's when setting up meal trays for the 20 residents that chose to eat in the main dining room. This failed practice had the potential to effect 26 residents who eat in the main dining room according to a list provided by the Assistant Director of Nursing (ADON) on 3/2/23 at 10:43 am. The findings are: a. On 2/27/23 at 12:30 PM, during a dining observation, staff transported resident meal trays from the kitchen window to the residents who were eating in the Main Dining Room and setting up meals for the residents without performing hand hygiene between residents. One staff member coughed into her hand and participated in meal service for residents without performing hand hygiene. b. On 2/27/23 at 1:35 PM, the Surveyor asked the Admissions Director, when should you perform hand hygiene during meal service? The Admissions Director stated, between each resident when passing trays. 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.

    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 CENTRAL ARKANSAS NURSING CENTERS — 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 53.6+0.4 vs chain
Health inspection 3 of 53.2-0.2 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 5 of 54.2+0.8 vs chain
The other 37 homes this chain runs (chain average 3.6★, per CMS)
1 of 5Alma Nursing and RehabAlma, AR 1 of 5Jamestown Nursing And Rehab, LLCRogers, AR 2 of 5Apple Creek Health And Rehab, LLCCenterton, AR 2 of 5Belvedere Nursing And Rehabilitation Center, LLCHot Springs, AR 2 of 5Colonel Glenn Health And Rehab, LLCLittle Rock, AR 2 of 5Highlands Of Bella Vista Health & Rehab, LLCBella Vista, AR 2 of 5Innisfree Health And Rehab, LLCRogers, AR 2 of 5Robinson Nursing And Rehabilitation Center LLCNorth Little Rock, AR 3 of 5Aspen Health and RehabBroken Arrow, OK 3 of 5Bradford House Nursing and Rehab, LLCBentonville, AR 3 of 5Briarwood Nursing And Rehabilitation Center, INCLittle Rock, AR 3 of 5Brooken Hill Health And Rehab, LlcFort Smith, AR 3 of 5Eufaula Manor Nursing And Rehabilitation CenterEufaula, OK 3 of 5Hickory Heights Health And Rehab, LlcLittle Rock, AR 3 of 5Lake Hamilton Health And RehabHot Springs, AR 3 of 5Quapaw Care And Rehabilitation Center LLCHot Springs, AR 3 of 5Russellville Nursing And Rehabilitation CenterRussellville, AR 3 of 5Sherwood Nursing & Rehabilitation Center, IncSherwood, AR 4 of 5Ashton Place Health And Rehab, LLCBarling, AR 4 of 5Cabot Health And Rehab, LLCCabot, AR 4 of 5Chapel Ridge Health And RehabFort Smith, AR 4 of 5Cherokee County Nursing CenterTahlequah, OK 4 of 5Dardanelle Nursing And Rehabilitation Center,incDardanelle, AR 4 of 5Johnson County Health And Rehab, LLCClarksville, AR 4 of 5Lakewood Health And Rehab, LLCNorth Little Rock, AR 5 of 5Atkins Nursing And Rehabilitation CenterAtkins, AR 5 of 5Greenbrier Nursing And Rehabilitation CenterGreenbrier, AR 5 of 5Greystone Nursing And Rehab, LLCCabot, AR 5 of 5Hampton Place Healthcare, LLCRogers, AR 5 of 5Legacy Heights Nursing And Rehab, LLCRussellville, AR 5 of 5Lonoke Health And Rehab Center, LLCLonoke, AR 5 of 5Nursing And Rehabilitation Center At Good ShepherdLittle Rock, AR 5 of 5Oak Manor Nursing And Rehabilitation Center INCBooneville, AR 5 of 5Perry County Nursing And Rehabilitation CenterPerryville, AR 5 of 5Salem Place Nursing And Rehabilitation Center, INCConway, AR 5 of 5Shiloh Nursing And Rehab, LLCSpringdale, AR 5 of 5Superior Health & Rehab, LLCConway, 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 / managerTypeRoleSince
MORTON, MICHAELIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 11/09/2004
GOINS, DALEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/10/2024
CENTRAL ARKANSAS NURSING CENTERS INCOrganizationADP OF THE SNFsince 01/01/2025
HEATHER MANOR CARE CENTER INCOrganizationADP OF THE SNFsince 12/12/2024
NURSING CONSULTANTS INCOrganizationADP OF THE SNFsince 01/01/2025
CLAY, STACYIndividualADP OF THE SNFsince 12/10/2024

CMS files one row per role, so the 9 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$10.4M
Net patient revenuemost recent cost report
+17.3%
Operating marginrevenue minus expenses
$1.2M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 82%Medicare 7%Other / private 10%

About 82% 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 $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$275per resident / day
operating cost
$8,365per month
≈ monthly operating cost
$333per 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 045337. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-06, 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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