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The Springs Of Park Ave

1401 Park Avenue, Hot Springs, AR 71901 · For profit - Limited Liability company · 95 certified beds · (501) 623-3781 Medicare & Medicaid certified

Call the home — (501) 623-3781 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Dec 2024
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 30% of its spending goes to commonly-owned related companies

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

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

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
238 Woodbine St · (501) 321-1899 · Call to confirm hours
Pharmacy
159 E Grand Ave · (501) 624-5598 · Call to confirm hours
Grocery
231 Central Ave Ste B · (501) 545-8316 · Call to confirm hours
Park
1316 Park Ave · (214) 528-5234 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.1%9.5%15.4%better
Long-stay residents who lose too much weight9.1%4.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%1.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.8%3.9%3.3%worse
Long-stay residents whose ability to walk worsened2.8%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.9%21.7%18.9%worse
Long-stay residents given the seasonal flu vaccine97.1%96.1%95.3%typical
Long-stay residents with pressure ulcers8.2%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control19.6%13.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table7.3%10.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine84.8%77.7%79.4%typical
Short-stay residents rehospitalized after admission22.4%24.1%22.6%typical
Short-stay residents with an outpatient ER visit6.0%12.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.762.011.67worse
Long-stay outpatient ER visits per 1,000 resident days1.582.131.80better

* 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.

54.8% 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 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.8%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
44.8%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 44.8% 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 29 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% 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 SNF54.8%CMS range 38.5–72.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.5–15.910.7%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 discharge44.8%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 discharge41.4%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 discharge44.8%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 identified95.5%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 setting88.9%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 discharge75.0%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 stay2.3%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 hospitalization8.0%CMS range 4.5–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.331.02Oct 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

0.41
RN hours/ resident / day
1.04
LPN hours/ resident / day
2.38
Aide hours/ resident / day
3.83
Total nurse hours/ resident / day
0.46
RN hoursweekends
47.0%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 95 beds and averages 73.2 residents a day — about 77% occupied, or roughly 22 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.83 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.50 hrs/resident/day on weekends vs 3.96 on weekdays — 12% thinner on weekends. RN hours go from 0.39 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2025-08-06)
8
at the previous standard inspection (2024-05-08)

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · E2025-08-06 · 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, interview, record review, and facility policy review, it was determined the facility did not ensure incontinence care was provided in a manner that was timely and promoted cleanliness, good hygiene, and/or prevented infection for two (Resident #27 and Resident #54) of two sampled residents. The findings include: Resident #27 During an observation on 08/03/2025 at 11:59 AM, this surveyor observed Certified Nursing Assistant (CNA) #1 provide incontinence care to Resident #27. CNA #1 had the resident roll to their left side. This surveyor noted Resident #27's incontinence brief was saturated with urine, there were two wet incontinence pads, and the resident's fitted sheet was wet. CNA #1 wiped the resident's buttocks towards their genitals. The direction in which CNA #1 cleaned the resident's genital area could introduce bacteria into the body and cause an infection. This surveyor noted when Resident #27 was rolled to the right side, their gown was wet from just below the waist to above the left knee. CNA #1 did not clean Resident #27's left side, which also…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-06 · 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, interview, and facility document review, 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 one of one meal observed. The findings include: During an observation on 08/03/2025 at 12:43 PM, this surveyor observed Dietary [NAME] (DC) #7 use a #20 scoop, which was equal to 1.5 ounces, to serve a single portion of ground roast turkey to the residents who received mechanical soft diets instead of 3 ounces, per the menu. During an observation and interview on 08/03/2025 at 12:48 PM, this surveyor observed DC #7 using a #12 scoop, which was equal to 1/3 cup, to serve a single portion of pureed baked sweet potato, instead of 1/2 cup per the menu. DC #7 also used the #12 scoop (1/3 cup) to serve a single portion of pureed cut green beans, instead of a 3/8 cup per the menu. This surveyor also observed DC #7 use a #16 scoop, which was equal to 1/4 cup, to serve a single portion of pureed ham, instead of a 1/3 cup as per the menu. In addition, this surveyor observed 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 · Ecited before2025-08-06 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, the facility failed to ensure that food items stored in the freezer were covered or sealed, that dietary staff washed their hands between handling dirty and clean equipment, and hot food items were maintained at the required temperatures for one of one meal observed. The findings include: During a concurrent observation and interview on 08/03/2025 at 10:29 AM, this surveyor observed an open box of fish on a shelf in the freezer. The box was not covered or sealed, which exposed it to freezer burn and cross contamination. Dietary [NAME] (DC) #4 stated leaving the box open would cause the food to have freezer burn or could cause potential cross contamination. During a concurrent observation and interview on 08/03/2025 at 11:08 AM, DC #4 pushed the blender motor to the edge of the counter, contaminating her hands. Without washing her hands, she used her bare hand to pick up a clean blade and attached it to the base of the blender to puree food items for the residents who received pureed diets. This surveyor asked DC #4 what…

    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 before2024-12-31 · 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 facility policy review, the facility failed to ensure that staff followed Enhanced Barrier Precautions (EBP) by wearing required Personal Protection Equipment (PPE), and staff failed to change their gloves during perineal care for a resident on EBP before touching resident ' s lift pad, clean brief, clothing, and linens to prevent cross contamination and the risk for infection for 1 of 1 sampled (Resident #6) resident. Findings include: 1. A review of Medical Diagnoses, revealed Resident #6 had diagnoses of chronic obstructive pulmonary disease, kidney disease, bipolar, and heart failure. 2. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/2024, indicated a Brief Interview for Mental Status score of 11 (8-12 suggest moderate cognitive impairment). Section H0300 and H0400 indicated Resident #6 was incontinent of bowel and bladder. 3. On 12/30/2024 at 11:20 AM, the surveyor observed an Enhanced Barrier Precaution (EBP) sign outside Resident #6's door, and Certified Nursing Assistant (CNA) #1 and…

    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 · D2024-12-31 · 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

    Based on observation, interview, and record review the facility failed to report to the state survey agency when a resident, that was care planned not to leave the facility without supervision, left the facility without staff knowledge for 1 (Resident #8) of 1 sampled resident identified as an elopement risk. 1. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/2024 indicated Resident #8 had a diagnosis of non-Alzheimer's dementia, coronary artery disease, malnutrition and scored 12 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). a. Resident #8 ' s Care Plan with an initiation date of 05/30/2024, indicated, Focus; Risk for elopement/wandering identified, Goal: The resident will not leave the facility unattended b. An Elopement Assessment dated 10/20/24, for Resident #8 indicated, 6. Resistant to nursing home placement a) Yes 7. Expresses desire to go home a) Yes 8. Exit Seeking a) Yes 9. Evidence Sundowning behavior [increase in behaviors at the close of day] a) Yes; scored 9 [7-14 indicates moderate risk];…

    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 before2024-05-08 · 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

    Through observation, record review, and interviews, the facility failed to ensure open food packages were properly closed, ensure walls and floors were in sanitary condition, canned goods were dent free, dietary staff washed their hands between dirty and clean tasks, chemicals were kept away from serving items, food on the steam table was properly covered, and proper serving sizes were provided. The findings are as follows: 1) On 05/05/24 at 10:45 AM, two trash cans were not covered by the hand washing sink and the reach in refrigerator in the main kitchen prep area. The Registered Dietician stated trash cans should not be opened if not being used to prevent cross-contamination. 2) On 05/05/24 at 10:46 AM, a coffee filter containing coffee and one pitcher container were uncovered and sat next to the hand washing sink. The Dietary Supervisor confirmed the coffee in the coffee filter and pitcher not being covered could cause cross-contamination because something could land on them. 3) On 05/05/24 at 10:47 AM a plate warmer contained plates with serving side face up and uncovered. The…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-08 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5%. An observation of a medication pass performed on 08/16/23 at 7:53 AM resulted in the identification of 3 errors in 25 opportunities, resulting in a medication error rate of 12.00 %. The findings are: 1. Resident #176 had a physician's order for Aspirin Oral Capsule 81 MG (milligram) Give 1 tablet by mouth one time a day for blood thinner. a. On 05/06/24 at 08:10 AM, Licensed Practical Nurse (LPN) #3 gave Aspirin enteric coated 81 MG (Enteric-coated aspirin is designed to resist dissolving and being absorbed in the stomach. the purpose of taking low-dose aspirin is to help prevent the development of harmful artery-blocking blood clots. However, with enteric-coated aspirin, research indicates that bloodstream absorption may be delayed and reduced, compared to regular aspirin absorption). 2. Resident #176 had a physician's order for B Complex-C Oral Tablet (B Complex w/ C) Give 1 tablet by mouth one-time a day for supplement (Vitamin B with vitamin C added). a.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, it was determined that the facility failed to store controlled medications in a permanently affixed container, and to ensure medications were not left at the bedside. Findings include: 1. On [DATE] at 01:30 PM, the surveyor asked Licensed Practical Nurse (LPN) #1 what the procedure was to dispose of medications if a resident discharges or passes away in the facility. She stated the take the narcotics and the narcotic book to the Director of Nursing's (DON) office, count the medications, and then sign them over for her to send them out of facility. a. On [DATE] at 01:50 PM, LPN #2 was asked what the procedure was to dispose of medications if a resident discharges or passes away in the facility. She stated they take the narcotics and the narcotic book to the DON's office, count, and sign them over for her to send them out of facility. A b. On [DATE] at 01:50 PM, the surveyor observed the container used to store controlled medications in the medication room on Hall C…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-08 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an advanced directive was readily accessible in the electronic health record for 1 (Resident #24) of 1 sampled resident whose electronic health record (EHR) was reviewed for an advanced directive. The findings are: 1. Resident #24 had diagnoses of dementia and type 2 diabetes mellitus as documented on an order summary. a. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented a Brief Interview of Mental Status (BIMS) score of 03 (00-07 indicates severely impaired) b. A Care Plan dated [DATE] documented the residents did not want cardiopulmonary resuscitation (CPR) and to follow the do not resuscitate (DNR) instructions as detailed inside the Advance Directive and/or Living Will. c. On [DATE] at 11:03 AM, Resident #24's electronic health record (EHR) was reviewed and a resuscitation designation order dated [DATE] documented the resident had an advance directive but this surveyor did not locate it in the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-08 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a baseline care was completed within 48 hours of a residents admission to address activities of daily living, to promote continuity of care and communication among nursing home staff for 1 (Resident #123) of 1 sampled resident whose electronic health record (EHR) was reviewed for a 48 hour baseline care plan. The findings are: 1. Resident #123 had diagnoses of full incontinence of feces (unable to control bowel movements) and adult failure to thrive, as documented on an Order Summary. a. An entry Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/03/2024 documented Resident #123's most recent admission/entry or reentry to the facility was 05/03/2024. b. A care plan dated 05/05/2024 did not address Resident #123's activities of daily living (ADLs) for bathing, personal hygiene, oral hygiene, mobility, dressing, grooming or toileting for bowel incontinence. c. An admission assessment dated [DATE] on pages 20 through…

    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
Show the remaining 13 citations
  • Potential for harm · D2024-05-08 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plans were reviewed and revised at least annually, or when the residents care needs changed, as evidenced by failure to revise the plan of care to address the use of insulin, a high risk medication, to ensure staff were made aware of the necessary care, assessments and services required for insulin for 1 (Resident #39) of 1 sampled residents who were reviewed for care plan revisions for insulin. The findings are: 1. Resident #39 had a diagnosis of type 2 diabetes mellitus with hyperglycemia as documented on the medical diagnosis section of the electronic health record (EHR). a. An order summary documented a physician's order for insulin glargine .Inject 30 unit subcutaneously two times a day for diabetes which was ordered 03/26/2024. b. An annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/2024 documented Resident #39 had a Brief Interview for Mental Status (BIMS) score of received 7 (0-7 indicates severe…

    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 · D2024-05-08 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure enteral feeding and flush bags were properly labeled with the necessary information to promote continuity of care and decrease the potential for complications for 1 (Resident #123) of 1 sampled resident who had a percutaneous endoscopic gastrostomy (PEG) tube (tube that goes through the skin into the stomach). The findings are: 1. Resident #123 had a diagnosis of gastrostomy status as documented on an order summary. a. An order summary documented a physician's order of, .[named a 2.0 Cal/ml formula] continuous feed- 80 cc/hr (cubic centimeters per hour). b. An electronic Medication Administration Record (eMAR) documented, .[named a 2.0 Cal/ml formula] continuous feed- 80 cc/hr with flush 100 cc/2 hr (2 hours) every shift -Start Date 05/03/2024 2300 (11:00 PM) . There were initials in the boxes on 05/03/24 for night, 05/04/24-05/06/24 had initials in boxes for day, evening, and night and 05/07/24 initials in the box for day. That order was stopped on 05/05/24 at 9:47 AM and a new order to decrease 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 · Dcited before2024-05-08 · 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 a linen cart was covered while on a resident hall, failed to ensure hand hygiene was performed and proper protective equipment (PPE) was used when caring for 1 (Resident #44) of 1 sampled resident with Clostridium Difficile (C-Diff) and failed to ensure Enhanced Barrier Precautions were consistently implemented for 1 (Resident #39) of 1 sampled resident who was reviewed for EBP. The findings are: 1. On 05/05/24 at 10:35 AM, the clean linen cart was uncovered and unsupervised by staff. a) 05/07/24 at 11:19 AM, Laundry Personnel #1 confirmed clean laundry is to be distributed through the facility by placing the clean linen on the linen cart. Linen that hangs is placed on the metal rack in front of the wall with a sign that says Hall B. A brown cover is then placed on the linen cart then it goes out. The cover is only removed to take items from the cart that need to be taken to residents' room. 2. Resident #44 was n transmission based precaution for C-diff. a. On 05/05/24 at 12:59 PM, a 3 drawer cart was…

    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 · E2023-05-12 · 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, record review, and interview, the facility failed to ensure the laptop with the Medication Administration Record (MAR) was closed or covered when out of the Nurse's line of vision to maintain resident privacy of personal health information. This failed practice had the potential to affect 27 residents who resided on the A Hall as documented on a list provided by the Administrator on 05/10/23 at 11:30 AM. The findings are: 1. On 05/10/23 at 7:15 AM, during observation of the 8:00 am medication pass, Registered Nurse (RN) #1 prepared medications for Resident #168. After preparing the medications RN #1 sanitized her hands and donned gloves. Without locking the Medication Cart or closing the laptop with the MAR on the screen, RN #1 left the medication cart at the Nurses' Station and walked with Resident #168 ' s medications down the hall, around a corner and disappearing down a short hallway leaving the Medication Cart unattended and out of her field of vision. 2. On 05/10/23 at 7:33 AM, RN #1 returned to the Medication Cart to retrieve another cup of water. She…

    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 · E2023-05-12 · 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 the Medication Cart was locked when out of the Nurse's line of vision to prevent potential accident hazards. This failed practice had the potential to affect 21 residents on the A Hall who were independent or supervised with locomotion, as documented on a list provided by the Administrator on 10/11/23 at 8:29 AM. The findings are: 1. On 05/10/23 at 7:15 AM, during observation of the 8:00 am medication pass, Registered Nurse (RN) #1 prepared medications for Resident #168. After preparing the medications RN #1 sanitized her hands and donned gloves. Without locking the medication cart or closing the laptop with the Medication Administration Record (MAR) on the screen, RN #1 left the Medication Cart at the Nurses' Station and walked with Resident #168's medications down the hall, around a corner and disappearing down a short hallway leaving the Medication Cart out of her field of vision. 2. On 05/10/23 at 7:33 AM, RN #1 returned to the Medication Cart to retrieve another cup of water. She locked 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 · E2023-05-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 an indwelling catheter tubing was secured with a stabilization device to prevent potential pulling of the catheter, pain, and injury for 1 (Resident #168) of 3 (Residents #9, #42 and #168) sampled residents who had an indwelling catheter as documented on a list provided by the Administrator on 05/10/23 at 12:43 PM. The findings are: 1. Resident #168 was admitted on [DATE] with a diagnosis of Chronic Kidney Disease, Other Disorders of the Male Genital Organs and Hematuria. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/23 was In Progress. a. A Physician's Order dated 05/07/23 documented, Foley Catheter 16 FR [French] with 30 CC [cubic centimeters] balloon record output every shift for follow up with urologist on 05/09/2023 . b. A Care Plan with initiation date of 5/8/23 documented, I have an indwelling Foley catheter . Catheter: The resident has 16 French 30cc bulb Foley catheter. Position…

    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 · E2023-05-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: Rather, [NAME] Based on observation, record review, and interview, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for 2 (Residents #16 and #35) of 3 (Residents #12, #16 and #35) sampled residents who had a Physician's Order for a CPAP (Continuous Positive Airway Pressure) Machine, and for 3 (Residents #16, #35 and #50) of 6 (Residents #16, #30, #35, #50, #167 and #168) sampled residents who had a Physician's Order for Oxygen as documented on lists provided by the Administrator on 05/11/23 at 10:50 AM, and the facility failed to ensure emergency tracheostomy supplies were readily available in the resident's room for 1 (Resident #167) of 2 (Residents #39 and #167) sampled residents who had a tracheostomy as documented on a list provided by the Administrator on 05/10/23 at 12:00 PM. The findings are:1. Resident #16 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation and Acute and Chronic…

    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 before2023-05-12 · 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, and interview, the facility failed to ensure an indwelling catheter drainage bag was not on the floor to prevent the risk of infection for 1 (Resident #42) of 3 (Residents #9, #42 and #168) sampled residents who had a Physicians Order for an indwelling catheter as documented on a list provided by the Administrator on 05/10/23 at 12:43 PM. The findings are: 1. Resident #42 had diagnoses of Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Other Obstructive and Reflux Uropathy. The resident required extensive assistance from two people for toilet use. The resident had an indwelling catheter during the lookback period. a. A Physicians Order dated 06/29/22 documented, Suprapubic Catheter 16 FR [French] with 30 CC [cubic centimeters] balloon record output every shift . b. A Care Plan with a revision date of 02/20/23 documented, I have a Suprapubic Catheter r/t [related to] Neurogenic bladder . CATHETER: .Position catheter bag and tubing below the level of the bladder, secure catheter tubing to leg with applicable device. c. A…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-12 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission to ensure the resident received the needed care and services in the most integrated setting appropriate to their needs for 1 (Resident #13) of 1 sampled resident who required a PASARR. This failed practice had the potential to affect 6 residents as documented on a list provided by the Administrator on 05/09/23 at 3:50 PM. The findings are: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses of Other Specified Depressive Episodes, Posttraumatic Stress Disorder Unspecified and Multiple Sclerosis. The Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/06/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received antipsychotic and antidepressant medications 7 of the last 7 days. a. On 05/09/23 at 10:49 AM, the Surveyor reviewed 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 · D2023-05-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to develop and implement a Comprehensive Care Plan that included a measurable focus, goals/outcomes, and interventions for 1 (Resident #47) of 8 (Residents #1, #3, #9, #47, #59, #62 and #168) sampled residents who had physician orders to receive an anticoagulant. The findings are: 1. Resident #47 had diagnoses of Pathological Fracture, Hip, Gastro-Esophageal Reflux Disease Without Esophagitis and Essential Hypertension. The Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/21/23 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received an anticoagulant medication 4 of the last 7 days. a. A Physicians Order dated 04/18/23 documented, .Enoxaparin Sodium Injection Prefilled Syringe Kit 40 MG/0.4ML [40 milligrams per 0.4 milliliters] (Enoxaparin Sodium) Inject 1 application subcutaneously one time a day for blood thinner for 29 Days . b. The Care Plan with a revision date of 05/08/23 did not contain…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-12 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 implement interventions in a timely manner to prevent injury from falls for 1 (Resident #10) of 10 (Residents #1, #3, #10, #34, #35, #42, #43, #47, #51, and #54) sampled residents who had a fall in the last 30 days as documented on a list provided by the Administrator on 05/10/23 at 3:48 PM. The findings are: 1. Resident #10 had diagnosis of Morbid (Severe) Obesity due to Excess Calories, and Difficulty in Walking, not elsewhere classified. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/14/23 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person for locomotion on and off the unit, had not had any falls since prior assessment and had not had a Urinary Tract Infection (UTI) in the last 30 days. a. A Care Plan with an initiated date of 04/12/23 documented, The resident is at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-12 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 ongoing communication and collaboration with the dialysis facility for 1 (Resident #62) of 1 sampled resident reviewed for End Stage Renal Disease/Dialysis services. The findings are: 1. Resident #62 had diagnoses of End Stage Renal Disease and Muscle Wasting and Atrophy. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/21/23 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received dialysis. a. A Physicians Order dated 04/19/23 documented, .Dialysis at [Dialysis Center] on MWF [Monday, Wednesday, Friday] at [Address] . b. On 05/08/23 at 3:00 PM, a review of the Electronic Health Record (EHR) failed to reveal dialysis communication forms, or dialysis treatment run sheets to provide communication between the nursing facility and the dialysis facility. c. On 05/09/23 at 11:00 AM, the Surveyor reviewed the Nurses Progress Notes, and miscellaneous information in the EHR for coordination and/or…

    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 · D2023-05-12 · tag F0772 — isolated
    Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
    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 laboratory specimen collection supplies were readily available to collect a lab specimen for 1 (Resident #10) of 3 (Residents #9, #10 and #47) sampled residents who had a Physicians Order for a Urinalysis in the last 30 days as documented on a list provided by the Administrator on 05/10/23 at 3:48 PM. The findings are: 1. A Laboratory Services Agreement dated 07/14/22 provided by the Administrator on 05/10/23 at 3:47 PM documented, This agreement is made . between [Facility] . and [Dialysis Center] (Contractor) . 1. CONTRACTOR SERVICES AND OBLIGATIONS a.Contractor shall provide all materials and supplies necessary for such collection . b.Specimens for testing will be collected by appropriate facility staff and either (1) transported by Contractor's courier from facility within 24 hours of verbal notification from Facility that a specimen pickup is required or (2) shipped overnight with shipping materials . furnished by Contractor .…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

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

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

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

Who owns this facility

Owner / managerTypeRoleSince
BLACK RIVER HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/31/2022
RODA, FERDINANDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/31/2022
TRULOVE, AMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/27/2023
CANYON SPRINGS REALITY HOLDINGS LLCOrganizationADP OF THE SNFsince 03/31/2022

CMS files one row per role, so the 7 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$9.4M
Net patient revenuemost recent cost report
+10.8%
Operating marginrevenue minus expenses
$2.5M
Related-party expense30% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 16%Other / private 33%

This home reported $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 30% 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 2024. 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

$329per resident / day
operating cost
$9,991per month
≈ monthly operating cost
$369per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 045142. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-06, 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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