St. Elizabeth's Place
3010 Middlefield Drive, Jonesboro, AR 72401 · For profit - Limited Liability company · 110 certified beds · (870) 802-0090 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $9,350 in federal fines (most recent 2026-04-02)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (57%) runs well above the national median (45%)
- about 25% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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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 | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.7% | 9.5% | 15.4% | typical |
| Long-stay residents who lose too much weight | 7.2% | 4.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.3% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.3% | 10.1% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 11.8% | 21.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.5% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.6% | 4.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 12.6% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.6% | 10.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.3% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 41.6% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 34.4% | 24.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.2% | 12.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.01 | 2.01 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.81 | 2.13 | 1.80 | typical |
* 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.
40.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 112 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 51 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 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.2%CMS range 32.9–47.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.6%CMS range 9.7–18.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 64.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 64.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 4.0–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.10 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 110 beds and averages 69.8 residents a day — about 63% occupied, or roughly 40 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.06 hrs/resident/day on weekends vs 3.56 on weekdays — 14% thinner on weekends. RN hours go from 0.33 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · J2026-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, video surveillance review, facility document review, interview, and facility policy review, it was determined that the facility failed to ensure the facility provided an environment that was free from avoidable accidents and hazards for one (Resident #1) of six residents reviewed. Specifically, the facility staff failed to address a sounding alarm on an exit door that directly opened to an unsecured area and allowed Resident #1, who had an altered mental status, to leave the facility premises and travel to an establishment located 0.1 miles behind the facility without the facility's knowledge.It was determined the facility's past non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to the resident. The Immediate Jeopardy (IJ) was related to the Stated Operations Manual, Appendix PP, 483.25 (Quality of Care) for elopement at a scope and severity level of J. The IJ was identified at 04/01/2026 at 4:45 PM.The Director of Operations and the Registered Nurse Consultant (RNC)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and facility policy review, it was determined that the facility failed to ensure staff performed hand hygiene and utilized necessary personal protective equipment (PPE) for 1 (Resident #27) of 1 resident reviewed for isolation precautions. The findings are: 1. A review of the admission Record noted Resident #27 was initially admitted to the facility on [DATE], with diagnoses which included severe intellectual disability and autistic disorder. 2. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #27 was unable to complete a Brief Interview for Mental Status (BIMS), with a score of 00. 3. A review of the Physician Order Summary revealed Resident #27 was on enhanced barrier precautions (EBP), due to the wound to their left knee. 4. During an observation on 05/20/2025 at 5:30 AM, CNA #2 and CNA #3 were observed transferring Resident #27 using a mechanical lift and changing Resident #27's clothing.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-03-07 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility to ensure food preparation equipment was free of debris to prevent potential for cross contamination; spices stored in the cabinet or on a shelf in the storage room were dated for first-in-first out spice rotation; 1 of 2 ice machines and 1 of 2 ice scoop holders were maintained in clean and sanitary condition; and dietary staff washed their hands before handling clean equipment to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. The failed practice had the potential to affect 89 residents who received meals from the kitchen (total census 89). The findings are. 1. On 03/04/24 at 10:51 AM, the deep fryer had an accumulation of crumbs floating on the top of the oil. The Surveyor asked the Dietary Supervisor (DS) when they last used the deep fryer and how often they cleaned it. The DS stated, They used it on Friday, and we clean it once a week. The surveyor asked the DS if the crumbs should still be on the oil. The DS stated, They should have been strained on Friday. 2. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-07 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility to ensure a call light was within reach for 2 (Resident #6 and R#387) of 17 sample mix residents who could use a call light. The findings are: 1. Resident #6 had diagnoses of Dementia, Muscle wasting and atrophy, Epilepsy, Difficulty in walking, and Abnormalities of gait and mobility. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/25/24 showed a Brief Interview for Mental Status (BIMS) of 13 (13 to 15 indicates cognitive intactness). 1a. The care plan showed .staff are to encourage the resident to .utilize the call light for assistance, if needed . 1b. On 03/04/24 at 01:25 PM, the Surveyor observed Resident # 6 call light lying on the floor. 1c. On 03/04/24 at 03:09 PM, the Surveyor observed the resident's call light lying on the floor. 1d. On 03/04/24 at 03:13 PM, the Surveyor asked Certified Nursing Assistant (CNA) #6, Where should a call light be placed while a resident is in bed? CNA #6 stated, Within reach. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-07 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview the facility failed to ensure residents meals were removed from the serving trays in the dining room to de-emphasize the institutional character of the setting to promote dignity and respect. This failed practice had the potential to affect 3 (Residents #20, #30, and #73) sampled residents who eat in the dining room. The findings are: On 03/04/24 at 12:54 PM, the Surveyor observed the Director of Nursing (DON) delivering meals to 3 separate residents, leaving the plate of food and drinks on the serving tray. On 03/04/24 at 01:02 PM, the DON confirmed leaving the meals on a serving tray was not homelike. A document titled Resident Rights provided by the Nurse Consultant on 3/5/24 at 2:45 pm showed, .Federal and state laws guarantee certain basic rights to all residents .The rights include .be treated with respect, kindness, and dignity .
- Potential for harm · E2024-03-07 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure call lights were answered in a timely manner. This failed practice had the potential to affect 2 (Resident #43 and #82) of 17 sample mix residents who can use a call light. The findings are: 1. On 03/04/24 at 02:24 PM, the Surveyor observed Resident #43 push the call light after indicating to the Surveyor they were wet. The call light sounded and then stopped. No light came on outside of the door. 1a. On 03/04/24 at 02:36 PM, a Certified Nursing Assistant (CNA) answered the call light then left the room. 1b. On 03/04/24 at 02:39 PM, the CNA returned to the room with Nursing Assistant (NA) #2. 1c. On 03/04/24 at 02:44 PM, the Surveyor asked NA #2, Do the lights come on outside the door when a resident presses their call light? CNA #7 stated, The lights do not turn on outside the door or make an alarm. The room number and time shows up on the hall clock and on the screen at the nurse's desk. The Surveyor asked, Why did it take so long to answer Resident #43's call light? NA #2 stated, There are 2 NA's and 1 CNA. We each…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-07 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets. The findings are: 1. On 03/04/24 at 11:35 AM, Dietary Employee (DE) #1 placed 6 servings of sliced ham into a blender, added juice from the cooked ham, used #10 scoop to add a serving of thickener and pureed. At 11:37 AM, DE #1 poured the pureed ham into a pan to be served to the residents on pureed diets for lunch. The mixture did not have a smooth consistency and had particles of thickener that were not completely pureed, and there were pieces of intact ham visible in the mixture. 2. On 03/04/24 11:44 AM, DE #1 placed 6 servings of cornbread into a blender, added 2 cartons of warm whole milk and pureed. At 11:47 AM, DE #1 poured the pureed cornbread into a pan and placed it in the oven. The consistency of the pureed cornbread was lumpy and 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.
- Potential for harm · E2024-03-07 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure Dementia in-service training was provided in the past year. The findings are: On 03/07/24 at 11:20 AM, The Surveyor reviewed in-services and competency training for the past year and did not locate a Dementia in-service. The Surveyor requested the Dementia In-Service. On 03/07/24 at 11:29 AM, the Administrator stated, We looked through all the in-services and could not find one for Dementia. The Surveyor asked, Do you have a Dementia in-service for the past year? The Administrator confirmed there has been no Dementia in-service training for the last year.
- Potential for harm · D2024-03-07 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 assure that 1 (Resident #56) of 1 sampled got to go to their smoke breaks. The findings are: On 3/04/24 at 1:47 pm, Resident (R) #56 reported not having gotten to go out to smoke for 3 days, and that when a certified nursing assistant (CNA) was asked they say they don't have time or enough staff to take resident to smoke. On 3/05/24 at 10:45 am, the Director of Nurses (DON) was asked, Does [R #56] smoke? The DON confirmed, Yes, this resident does go out sometimes to smoke. The DON was asked, If a resident asks to be gotten up to smoke what should the staff do, and stated, The staff should get the resident up and take them. The DON was asked, If a resident refuses to get up to go smoke after asking staff to come and get them, up what should the staff do? The DON confirmed, Document that they didn't want to get up. On 3/05/24 at 10:45 am, the Nurse Consultant (NC) was asked, Should [R #56] be on the smoking list if a resident smokes, and is care planned for smoking? The NC confirmed, Yes, we will get them added…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure fingernails were regularly trimmed and cleaned to promote good personal hygiene and grooming. This failed practice had the potential to affect 2 (Resident #31 and R#44) residents of 21 sampled residents; and the facility failed to ensure 1 (Resident #72) of 11 sampled residents received a shave. The findings are: 1. Resident (R) #44 diagnoses included Alzheimer's disease, Dementia with agitation, and Bell's palsy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/24 showed a Brief Interview for Mental Status (BIMS) of 01 (0 to 7 points indicates severe cognitive impairment). R #44 required maximum/substantial assistance with personal hygiene. 1a. The care plan for R #44 showed the resident required assistance with activities of daily living (ADL) related to weakness and cognitive loss. Staff are to provide assistance to the extent necessary with ADL (hygiene, etc.) and the resident requires minimal assistance x1 with ADL tasks. 1b. On 03/04/24 at 01:46 PM, R #44 ' s fingernails…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that 1 (Resident #32) of 1 sampled resident received a thorough head to toe skin assessment. This had the ability to affect 89 residents. The findings are: On 3/4/24 at 11:29 am, Resident (R) #32 reported they had a sore on the top of the head that was draining. The Surveyor observed a sore with a scab and open area with drainage on the top of the resident's head. The Surveyor asked if the Resident had informed anyone. R #32 stated, I have been telling my nurse on every shift for 2 or 3 weeks that I need to see my doctor, and no one has done anything. I really need to see my doctor. On 3/5/24 at 11:30 am, Skin assessments documenting no sore to R #32 had been completed for the past two weeks. On 3/7/24 at 8:20 am, Licensed Practical Nurse (LPN) #3 was asked, When a skin audit is performed how should this be done? LPN #3 stated, Start with the head and move down over the entire body. LPN #3 was asked, If a Resident complains to the nurse that they have a draining sore what should the nurse do? LPN #3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2024-03-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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
Based on observation, interview, and record review, the facility failed to ensure catheter securement devices were utilized for 1 (Resident #69) of 3 sampled residents (#27, #69, #82) who had an indwelling catheter in place. The findings are: On 03/04/24 at 1:32 pm, Resident #69 did not have any securement device in place to hold catheter tubing in place to avoid trauma to the urethra by preventing pulling and tension. On 3/5/24 at 10:05 am, Resident #69 did not have a securement device to hold catheter tubing in place. On 3/5/24 at 3:25 pm, Certified Nursing Assistant (CNA) #5 was asked, How should a foley catheter be secured? CNA #5 stated, By a leg strap or [named brand of catheter securement device]. CNA #5 was asked, Who is responsible for making sure an indwelling foley security device is on the resident? CNA #5 stated, The nurse usually puts them on. On 3/5/24 at 3:33 pm, the Director of Nurses (DON) was asked, How should a foley catheter be secured? The DON stated, By using a [named brand of catheter securement device]. The DON was asked, Who is responsible for making sure 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.
- Potential for harm · Ecited before2024-03-07 · tag F0880 — failed to prevent and control infections — patternProvide 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 and interview, the facility failed to ensure that staff were wearing PPE (Personal Protection Equipment) correctly in the facility when residents had been diagnosed with Covid-19. The failed practice had the ability to affect 89 residents in the facility. The findings are: 1. On 3/4/2024 at 12:08 PM, Certified Nursing Assistant (CNA) #1 was passing trays in the main dining area with mask pulled down under their nose. 2. On 3/5/24 at 08:36 AM, CNA #2 was in the weight room where residents were present with their mask pulled down under their chin. 3. On 3/4/24 at 12:11 PM, CNA #1 was asked how a mask is intended be worn. CNA#1 stated, Over my nose and mouth. CNA #1 was asked, Why should you wear it over your nose and mouth? CNA #1 stated, To protect ourselves and the residents. 4. On 3/5/24 at 08:37 AM, CNA #2 was asked, Should staff be wearing a mask when they are around residents? CNA #2 confirmed, Yes, we should be. CNA #2 was asked, How is the proper way to wear your mask? CNA #2 stated, Over my nose and mouth. 5. On 3/6/24 at 10:47 AM, the Director of Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 interview, observation, and record review, the facility failed to preform nail care on two (Resident #2 and #3) of six (Resident #2, #3, #4, #5, #6 and #7) sampled residents who were dependent on the staff for nailcare according to a list supplied by the Nursing Consultant on 08/22/2023 at 3:59 PM. The findings included: On 08/21/2023 at 11:39 AM Resident #2 was observed sitting in a Geri Chair with contractures to both hands. The nails on both hands were long and jagged. On 08/22/2023 at 9:40 AM Resident #2 observed in room sitting in a Geri Chair. Fingernails on both hands and toenails on both feet were ¼ inch past the tips of the fingers and toes. Review of Resident #2's Care Plan with a revision date of 04/26/2021 showed, Provide assistance to extent necessary with ADLs (bathing, dressing, grooming, toileting, hygiene, etc.) Requires extensive assistance with ADL tasks. Review of Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident required extensive assistance of 2 people…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure humidity bottles and storage bags were changed weekly as ordered by the physician to prevent the potential for cross contamination that could result in a respiratory infection for 2 (Residents #74 and #134); failed to ensure there was a physician order for oxygen therapy for 1 (Resident #34) and failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complicationsfor 1 (Resident #74) of 3 (Residents #34, #74, and #134) sampled residents who had physician orders for oxygen therapy. The findings are: 1. Resident #74 had diagnoses of Acute and Chronic Respiratory Failure, Shortness of Breath (SOB) and Heart Failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/6/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received oxygen therapy. a. The Physicians Order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-15 · tag F0885 — failed to notify residents/families about COVID-19 — patternReport COVID19 data to residents and families.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the Resident, Resident Representatives and Families were notified by 5:00 PM the next calendar day following the occurrence/s of a confirmed positive COVID 19. The failed practice had the potential to affect 86 residents according to the Resident Census and Conditions of Residents provided by the Administrator on 12/13/22. The findings are: 1. The Staff and Resident COVID-19 Positive Log for the last four weeks provided by the Administrator documented: Four residents tested positive for COVID-19 on 11/14/22, one resident tested positive on 11/16/22 and 11/19/22, one staff member and four residents tested positive on 11/21/22, five staff members tested positive on 11/23/22, one staff member on 11/25/22 and a resident tested positive for on 12/1/22. 2. The facility's [Communication Software] messages for Residents #42, #57 and #76 was completed on 12/14/22, there were no messages sent out of confirmed cases of COVID-19 on 11/14/22, 11/16/22, 11/19/22, 11/23/22, 11/25/22 and 12/1/22. 3. Resident #134 tested positive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the call light was accessible to allow residents to summon for assistance to accommodate their individual needs for 1 (Resident #57) of 15 (Residents #9, #10, #21, #22, #43, #45, #57, #60, #63, #72, #74, #78, #79, #134, and #136) sampled residents who used call light system to summon for assistance. The failed practice had the potential to affect 70 residents who required and used a call light according to the list provided by the Director of Nursing (DON) on 12/15/22. The findings are: Resident #57 had diagnoses of Dementia and History of Falling. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person for bed mobility and transfers, was not steady with moving from seated to standing position, walking and surface to surface transfer, and utilized a wheeled walker and a wheelchair. a. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure information regarding a residents' code status was accurately documented to enable staff to quickly ascertain the residents' wishes in the event of a decline in condition for 1 (Resident #134) of 23 (Residents #9, #10, #21, #22, #29, #34, #43, #45, #46, #55, #60, #61, #63, #70, #72, #74, #78, #79, #80, #81, #82, #134 and#136) sampled residents whose code status were reviewed. The findings are: Resident #134 had a diagnosis of Dementia. The Modified admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) [DATE] documented the resident scored 3 (0 -7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. The Face Sheet documented, .CPR [Cardiopulmonary Resuscitation] FULL CODE - Please see misc.[miscellaneous] documentation . b. The Code Status dated and signed by the resident representative on [DATE] documented, .I want a DNR Code Status (DO NOT RESUSCITATE) . c. The Physician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure an injury of unknown source was reported to the Administration of the facility, the attending physician, and the state survey agency (SSA) within the required timeframe for 1 (Resident #29) of 2 sampled resident reviewed for abuse. Findings included: A review of a facility policy titled, Abuse Prevention, revised 11/28/2017, revealed, It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, volunteers, etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of resident property to the administrator or his/her designee. Further review of the policy revealed 3. When an alleged or suspected case of abuse, neglect, injuries of an unknown source, or misappropriation of resident property is reported, the facility administrator, or his/her designee, will notify the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 observations, interviews, record review, and facility policy review, the facility failed to ensure a resident who required assistance with personal hygiene received assistance to maintain good grooming related to nail care for 1 (Resident #60) of 1 sampled resident reviewed for activities of daily living (ADLs). Findings included: A review of a facility policy titled, Fingernails/Toenails, Care of, revised 02/2018, revealed, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection. The General Guidelines included daily cleaning and trimming of resident's nails, which could aid in the prevention of skin problems, and could also prevent injury to the resident's skin. A review of an admission Record revealed Resident #60 had diagnoses which included muscle wasting and atrophy and hemiplegia (paralysis of one side of the body) and hemiparesis. A review of a significant change Minimum Data Set (MDS), dated [DATE], revealed Resident #60 scored 11 on a Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure, skin audits were completed weekly for 1 (Resident #55) of 1 sampled residents whose records were reviewed for skin audits. The findings are: 1. Resident #55 had diagnoses of Dementia and Anemia. The Annual (MDS)with an (ARD) of 10/26/22 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was totally dependent with one-person assist for transfer, required extensive two-person physical assist for bed mobility, toileting and bathing, extensive one-person assist with personal hygiene, was always incontinent of bladder and bowel, at risk for pressure ulcers and had no open lesion/s, rashes, cuts . a. The Care Plan with a revision date of 04/26/22 documented, The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] limited mobility, generalized weakness . SKIN INSPECTION: The resident requires SKIN inspection weekly and as needed. Observe for redness, open areas, scratches,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 record review, interviews, and facility policy review, it was determined the facility failed to ensure residents were not prescribed antibiotics unnecessarily for 1 (Resident #9) of 6 sampled residents reviewed for unnecessary medications. Specifically, the facility failed to ensure there was an appropriate indication for antibiotic use for Resident #9. Findings included: A review of the facility policy titled, Antibiotic Stewardship, revised [DATE], revealed, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. The policy further indicated Antibiotics will be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. The policy revealed, Appropriate indications for use of antibiotics…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 observations, record reviews, interviews, and facility policy review, the facility failed to ensure its medication error rate was not 5% or greater. There were 2 errors out of 31 opportunities observed for two (Resident #84 and Resident #9) of three residents, which resulted in a medication error rate of 6.45%. Findings included: A review of the facility's policy titled, Administering Medications, revised 04/2019, revealed, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. During a medication administration observation on 12/14/2022 at 8:01 AM, Licensed Practical Nurse (LPN) #4 prepared medication for Resident #84 to administer orally. The following medications were prepared and given to the resident: - Vitamin B12 1000 micrograms (mcg), one tablet - Folic acid 400 mcg, one tablet - Aspirin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$9,350 in federal fines across 1 penalty.
- $9,350 — penalty dated 2026-04-02
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ANTHONY & BRYAN ADAMS — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.8 | -1.8 vs chain |
| Health inspection | 2 of 5 | 3.5 | -1.5 vs chain |
| Staffing | 2 of 5 | 3.0 | -1.0 vs chain |
| Quality measures | 2 of 5 | 4.3 | -2.3 vs chain |
The other 37 homes this chain runs (chain average 3.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CARAWAY NURSING CENTER, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2004 |
| EXTENDI-CARE, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2004 |
| RHC OPERATIONS INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2004 |
| CENTENNIAL BANK | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 04/01/2025 |
| HOME BANCSHARES | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 04/01/2025 |
| CAHOONE, PATRICIA | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 04/01/2025 |
| DOTY, SHARI | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/24/2026 |
| TALBOT, LAUREN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; ADP OF THE SNF | — | since 04/01/2025 |
| ADAMS, ANTHONY | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 02/20/2002 |
| ADAMS, BRYAN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2008 |
| ELLIS, JOHN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2008 |
| KOEHLER, TOBEY | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2008 |
| 3B HOLDINGS, LLC | Organization | ADP OF THE SNF | — | since 04/30/2025 |
| CRAIGHEAD CARE, LLC | Organization | ADP OF THE SNF | — | since 01/01/2004 |
| LTC SYSTEMS/RX, LLC | Organization | ADP OF THE SNF | — | since 01/01/2008 |
| PHARMACY CONSULTS, LLC | Organization | ADP OF THE SNF | — | since 01/01/2008 |
| RELIANCE HEALTH CARE, INC. | Organization | ADP OF THE SNF | — | since 01/01/2008 |
| HAHN, MARK | Individual | ADP OF THE SNF | — | since 08/28/2024 |
| MCGINNIS, LARRY | Individual | ADP OF THE SNF | — | since 01/01/2008 |
CMS files one row per role, so the 30 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 73% 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 $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 25% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AR
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arkansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045380. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-23, 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 →
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