Colonel Glenn Health And Rehab, LLC
13700 David O Dodd Road, Little Rock, AR 72210 · For profit - Limited Liability company · 120 certified beds · (501) 907-8200 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $50,700 in federal fines (most recent 2025-12-04)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
- about 24% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 2.4% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 4.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 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 | 4.5% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 4.4% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.9% | 21.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 2.5% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.9% | 10.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 11.2% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 17.9% | 24.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 3.1% | 12.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.13 | 2.01 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.95 | 2.13 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 101 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.7% 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 31 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 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 47.4%CMS range 37.6–56.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 7.8–15.1 | 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 | 67.7% | 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 | 54.8% | 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 | 67.7% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 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 | 0.0% | 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 | 7.3%CMS range 4.5–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.35 | 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 120 beds and averages 113.9 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.45 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.00 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.94 hrs/resident/day on weekends vs 4.66 on weekdays — 16% thinner on weekends. RN hours go from 0.45 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above 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
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Hcited before2025-12-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interviews, facility documentation review, and facility policy review, it was determined that the facility failed to prevent a rash from spreading between residents in different rooms, on two different halls and two separate floors when reviewed for infection control and prevention for one of one infection control plan The findings include: Resident #1Review of an admission Record, indicated the facility admitted Resident #1 on 11/01/2024, with diagnoses which included Alzheimer's disease and stroke. Resident #1 resided on the first floor of the facility. Review of a Medical Diagnosis report indicated Resident #1 was diagnosed with rash and other nonspecific skin eruptions on 11/10/2025, scabies on 11/15/2025, and unspecified skin changes on 11/22/2025. Review of an Orders Summary, indicated Resident #1 had orders for the following: -An antihistamine to be started on 08/05/2025, - An antibiotic due to elevated white blood cells ordered on 10/31/2024, -An oral antifungal…
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 before2025-04-24 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure minimum data set (MDS) assessments were transmitted after completion for 8 (Residents #4, #32, #47, #49, #55, #58, #76, #88) of 8 sampled residents reviewed for resident assessments. The findings are: On 04/23/25, the following issues were identified: 1. A review of Resident #4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/2025, status indicated Export Ready but had not been sent. The Completed MDS was dated 03/24/2025, and the Batch Accepted date was 04/24/2025. 2. A review of Resident #32 ' s record revealed that Resident #32 ' s quarterly MDS assessment completed on 03/10/2025 status indicated ready to export. 4. A review of Resident #47 ' s record revealed that Resident #47 ' s quarterly MDS assessment completed on 03/17/2025 status indicated ready to export. 5. On 04/24/2025 a review of Resident #49's MDS assessment history screen revealed a quarterly assessment dated [DATE], status was Export Ready,…
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 · E2025-04-24 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, policy review, and the review of the menu, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents during 1 of 2 meals observed being prepared in the kitchen. The findings are: 1. A review of the 4/22/2025 Breakfast Meal Menu indicated the residents on a regular diet and the residents on a mechanically soft diet were to receive 3/4 cup of cereal, residents on pureed diets were to receive a #8 scoop (1/2 cup) of cereal, and residents on enhanced diets were to receive 1 cup of cereal. a. During an observation of the breakfast meal in the kitchen on 4/22/25 at 7:35 AM, the Dietary [NAME] (DC) #1 used a 4-ounce (oz.) ladle spoon (1/2 cup) to serve a single portion of regular oatmeal to the residents on regular diets and residents on mechanical soft diets, instead of 3/4 cup as specified on the menu. b. During an interview on 4/22/25 at 8:00 AM, DC #1 stated she looked at the menu but did not know why she had used a 4 oz. ladle spoon (1/2 cup) to serve…
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 before2025-04-24 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and facility policy review, the facility failed to ensure expired food items were promptly removed / discarded on or before the expiration or use by date; Dietary staff washed their hands between dirty and clean tasks and before handling clean equipment; Cold food items were at 41 degrees Fahrenheit or below on ice while awaiting service for 2 of 2 meals observed; ensure meals were served at a safe and appetizing temperature to prevent possible food born illnesses for 1 (Resident #84) of 1 sampled resident. The findings include: 1.On 4/21/25 at 9:28 AM, the following observation was made in the walk-in refrigerator: A carton of half and half was on a shelf with an expiration date of 4/20/2025. 2. On 4/21/25 at 9:50 AM, the following observations were made in the first storage room: A box of cheese peanut butter crackers that contained 80 counts of crackers were on a shelf with an expiration date of 02/01/2025. A box of saltine crackers on a shelf had an expiration date of 02/01/2025. 3. On 4/21/25 at 10:25 AM, the following…
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 before2025-04-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 facility record review and interview, it was determined that the facility failed to update resident care plans to reveal an accurate code status (Full Code status changed to a Do Not Resuscitate (DNR) status) for 1 (Resident #5) of 2 residents sampled for revisions or updates to the care plan. The findings are: Review of Resident #5 ' s admission Record face sheet revealed Resident #5 ' s admission date was [DATE], and that Resident #5 ' s code status was Full Code. Review of Resident #5 ' s Hospice admission Record, completed on [DATE] revealed Resident #5 ' s code status had been changed to Universal Do Not Resuscitate (DNR), instructing providers not to do CPR (cardiopulmonary resuscitation) if a patient's breathing stops or if the patient's heart stops beating. Review of Resident #5 ' s Care Plan, initiated on [DATE], revealed Resident #5 ' s code status was Full Code (Full code indicates cardiopulmonary resuscitation (CPR) is requested if the resident has no heartbeat and is not breathing).…
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 before2025-04-24 · 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, record review, and facility document review, the facility failed to implement fall prevention interventions for 1 resident (Resident #58) of 3 residents reviewed for fall prevention. The findings include: A review of the admission Record, indicated the facility admitted Resident #58 with diagnoses that included spastic diplegic cerebral palsy which primarily affects the legs with stiffness and difficulty with walking, abnormality of gait and mobility, communication deficit, anxiety disorder, and muscle wasting and atrophy (muscle shrinking). The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 03/08/2025, revealed Resident #58 had a Brief Interview of Mental Status (BIMS) of 5 which indicated the resident had severe cognitive impairment. The MDS revealed the resident had two or more falls since the prior assessment and required moderate assistance with toileting hygiene, sit to stand, and toilet transfer. An intervention for transfer indicated the resident required extensive assistance by one staff to move…
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 before2025-04-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to ensure a urinary catheter drainage bag was not directly touching the floor for 1 (Resident #216) of 1 sampled resident reviewed for urinary catheter care. The findings are: Review of the admission Record revealed Resident #216 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood properly). Review of the Order Summary Report revealed [brand name] catheter: 16 French (FR) with 10 cubic centimeters (cc) balloon every night shift starting on the 15th and ending every month with an order date of 04/19/2025. Review of a Nursing Baseline Care Plan with a signed date of 04/18/2025, revealed for bowel and bladder, Resident #216 had an indwelling catheter. On 04/21/2025 at 2:13 PM, Resident #216 was observed lying in bed with eyes closed. On the right side of the bed, there was a urinary catheter drainage bag observed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-16 · 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 and interview, the facility failed to ensure food items stored in the refrigerator and storage area were covered or sealed to maintain freshness and prevent potential cross contamination of food and beverages, that expired food items were promptly remove/discarded by the expiration or use by dates, that kitchen vents and ceiling tiles were cleaned to provide a sanitary environment for food preparation, and that baseboards were not missing and were free of chips, debris, rust, and dirt, that 1 of 2 ice scoop ice machines was maintained in clean and sanitary condition to prevent food and beverages contamination, that staff washed hands before handling clean equipment or food items to minimize the potential for contaminating food items for residents who received meals from 1 of 1 kitchen, and that hot food items were maintained at or above 135 degrees Fahrenheit while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 94 residents who received food from 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 · Ecited before2024-02-16 · tag F0641 — patternEnsure each resident receives an accurate assessment.
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 accurately assess the Minimum Data Set [MDS] accurately reflected on Section J1800, any falls since Admission/Entry or Reentry or Prior Assessment, a history of falls affecting 1 sampled (Resident #68) of 4 residents with falls on 2A. The facility failed to update the Minimum Data Set [MDS] with a discharge with anticipation to return in a timely manner for 1 (Resident #32) of 46 residents discharged in the last 120 days. The findings are: 1. Resident #68 with a diagnosis of ALZHEIMER ' S DISEASE, Dementia, CHRONIC OBSTRUCTIVE PULMONARY DISEASE and OBSTRUCTIVE AND REFLUX UROPATHY. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 07/21/2023 shows a Brief Interview for Mental Status (BIMS) of 99 (99 means unable to complete the interview). Resident #68 required extensive one person assistance for bed mobility, transfers dressing, eating, toileting and personal hygiene. a. A Care Plan (Revised, 01/05/2024) for Resident #68 documented, .The resident is High risk for falls r/t past…
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 before2024-02-16 · 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
Based on observation, record review, and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 2 (Resident #33, and #73) of 5 sampled residents. The facility failed to store oxygen tubing appropriately when not in use to prevent possible respiratory complications for 1(Resident #27) of 5 sampled residents. This failed practice had the potential to affect 15 residents that had physicians' orders for Oxygen as documented on a list provided by the Director of Nursing on 02/15/24 at 3:50 PM. The findings are: 1. Resident #33 had diagnoses of Pulmonary fibrosis, Chronic obstructive pulmonary disease, and Heart failure. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/24 documented that the resident scored 7 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS) and received oxygen therapy. a. The physician's order dated 8/3/23 documented, .O2 (Oxygen) at 3L/M(Liters per Minute) via NC (Nasal Cannula) continuously. May…
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 · E2024-02-16 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
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 that a call light was in reach for 1 Resident #3 of 4 sampled residents (Residents #69; #86; #91) who utilize the call light on unit 1-D. The facility failed to ensure that call lights located in the resident's bathroom were equipped with a device that would enable them to reach the call light should they fall for 1 Resident #34 who resides on unit 1-B and 2 Residents #86 and #399 sampled residents who reside on unit 1-D. The findings are: 1) Resident #3 has a diagnosis of shortness of breath, genetic causes of short stature, and glaucoma. On the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of December 23, 2023. The resident received a score of 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS). a) On 02/12/2024 10:54 AM, Resident #3 stated Sometimes I have a hard time getting my call button when it falls to the floor. It doesn't stay clipped. I have to beat on the table to get them. The Resident's call light was noted to be lying on the floor. b) On 02/13/2024 11:22…
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 20 citations
- Potential for harm · D2024-02-16 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview the facility failed to ensure that 1 (Resident #76) of 2 sampled residents on 2 C had a hand roll as care planned for an intervention. The findings are: 1. Resident #76 had diagnoses of Cerebrovascular accident (CVA), Polyneuropathy, Type 2 Diabetes Mellitus. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 01-17-2024 indicates a Brief Interview for Mental Status [BIMS] of 15 (13-15 indicates cognitively intact). a. During observations while speaking with Resident #76 had limited mobility with right hand contracture with no hand roll in place to maintain, improve or prevent avoidable decline in range of motion. b. On 02/12/2204 at 10:58 AM, Resident had a closet care plan listing a right-hand roll, but it was not in place. The Surveyor was unable to locate a care plan or orders for a hand roll. The Surveyor asked Resident #76 if they used a hand roll, who stated, I used to have one but I haven't in about a month, I'm not sure where it is. c. 02/14/2024 at 11:45 AM, observed Resident #76 without hand…
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 · D2024-02-16 · 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 observation, record review and interview, the facility failed to ensure an accident/hazard free environment was provided for 1 Resident (#10) resident in the case mix. This failed practice had the potential to affect 7 ambulatory residents who resided on hall 1-D. The findings are: 1. Resident #10 has Diagnoses: EDEMA, CHRONIC KIDNEY DISEASE. On the Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of January 26, 2024, the resident received a score of 13 (Cognition is intact) on the brief interview for mental status (BIMS). a. On 2/12/24 at 12:02 PM, the Surveyor noted a bottle of rubbing alcohol sitting on the floor beside Resident #10 ' s room. When asked if she used the rubbing alcohol Resident #10 stated, Yes, I put it on my legs and then I put the Vaseline on my legs to keep them well. b. On 2/12/2024 at 12:05 PM, the Surveyor interviewed Licensed Practical Nurse (LPN) #1 and asked if a resident could keep rubbing alcohol at their bedside or beside their chair, LPN #1 stated No, it is not permissible. They can ingest it. LPN #1 was informed of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-16 · 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 observations, interviews and record review, the facility failed to ensure that 1 (Resident #39) resident received proper incontinence care. This failed practice had the potential to cause skin breakdown, poor hygiene, and/or infection. This failed practice had the potential to affect 4 Residents on 2B hall dependent on staff to provided incontinence care. The findings are: 1. Resident #39 had a diagnosis of memory deficit following cerebral infarction. According to a Quarterly Minimum Data Set (MDS) with Assessment Reference Date of 10/11/23 documented that Resident #39 was unable to complete the Brief Interview of Mental Status (BIMS), and Resident #39 was always incontinent of bowel/bladder. a. On 02/12 /2024 at 10:22 AM, Resident #39 was sitting up in Geri-chair, wearing jeans that were visibly soiled and room had an odor. b. On 02/12/2024 11:00 AM, the Surveyor observed 3 Certified Nursing Assistant (CNA) ' s enter Resident #39 ' s room with a lift and linens in a clear bag. CNA #1 operated the Hoyer lift while CNA #2 set up for perineal care then when prompted by CNA…
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 · E2023-12-28 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for the following Residents (#3, #6, #7). The findings are: 1. Resident #3 had a diagnosis of dementia in other disease classified elsewhere, and quarterly minimum data set with assessment reference date 09/29/23 Resident had a BIMS of 5. According to Care Plan the resident has an ADL (Activities of Daily Living) self-care performance deficit related to history of Cerebrovascular Accident, Dementia, vision deficit, COPD (Chronic Obstructive Pulmonary Disease), contractures to left hand fingers and left knee, and Malaise (general discomfort) Resident required extensive assistance by 1 staff for dressing. A. On 12/28/23 at 8:30 AM, the Surveyor observed Resident #3 sitting in the day room with a hospital gown on with blanket covering her lower extremities. B. On 12/28/23 at 8:35 AM, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-28 · 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
Based on observations, interviews and record reviews, the facility failed to ensure the connector for an internal feeding was stored properly for Resident #5. The finding are: 1. Resident #5 had a diagnosis of encounter for attention to gastrostomy and had an order for enteral feeding at 82 ml (milliliter)/hour, flush 30 ml every 1 hour. According to care plan Resident is totally dependent on staff for eating via tube feeding and is receiving nothing by mouth. a. On 12/27/23 at 11:00 AM, the Surveyor observed Resident #5 lying flat in bed with enteral feeding off and disconnected from the Resident. The end connection of tubing was lying on floor. b. On 12/27/23 at 11:15 AM, the Surveyor overheard Licensed Practical Nurse (LPN) #2 ask Certified Nursing Assistant (CNA) #1 Who unplugged him? c. On 12/27/23 at 11:16 AM, the Surveyor asked LPN #2 are you Resident #5 nurse? LPN #2 stated yes. The Surveyor asked LPN #2 did you unplug his feeding? LPN #2 stated, no. d. On 12/28/23 at 8:48 AM, the Surveyor asked the Director of Nursing is it standard practice for a Certified Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-18 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the Resident and/or Responsible Party was notified of medication changes related to diabetic medications for 1 (Resident #2) of 5 (Residents #1, #2, #3, #4 and #5) sampled residents. The findings are: A Physicians Progress Note dated 09/19/23 noted Resident #2 was to have the Aspart insulin discontinued and was to continue Glargine Insulin 12 units every morning. A Physicians Order Recap Report noted Resident #2 was to receive Aspart Insulin per sliding scale every morning and at bedtime, Order Date 05/01/23 End Date 09/19/23. A review of the Progress Notes with an effective date range of 09/18/23 to 10/19/23 did not contain documentation that the family was notified. On 10/18/23 at 9:04 AM, the Surveyor asked the Assistant Director of Nursing (ADON), When you entered the physician order to discontinue [Resident #2's] short acting insulin on 09/19/23 who did you contact to inform of the change in her medication? She stated, We would've notified her [family member] to just let her know the doctor discontinued 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 · D2023-10-18 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 Representative with concerns and complaints regarding discontinued medication notification were allowed to be voiced through grievances as part of the process of Resident Rights for 1 (Resident #2) of 5 (Residents #1, #2, #3, #4 and #5) sampled residents. The findings are: A Physicians Order Recap Report noted Resident #2 was to receive Aspart Insulin per sliding scale every morning and at bedtime, Order Date 05/01/23 End Date 09/19/23. On 10/18/23 at 8:59 AM, in an interview the Social Services Director said Resident #2's family called to complain the residents blood sugar was high, and insulin was discontinued without the family being notified. The Social Services Director confirmed a grievance was not completed. The October 2023 Grievance Log did not show a grievance from Resident #2's family. On 10/18/23 at 3:24 PM, the Administrator confirmed a complaint from the family about not receiving notification about a discontinued medication should be filed on the grievance log. A facility policy titled,…
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 · Fcited before2022-12-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: [NAME], [NAME] Based on observation and interview, the facility failed to ensure food items were promptly removed and/or discarded on or before the expiration or use by date to prevent the growth of bacteria; failed to ensure food items were dated, covered or sealed to prevent cross contamination for residents who received meals from 1 of 1 kitchen; failed to ensure two jars of jelly were stored in the refrigerator after opening to prevent potential for spoilage; failed to ensure the deep fryer, cooking utensils, appliances and a food rack were maintained in clean condition to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure there was not a broken/missing tile at the entrance of the dish room; failed to ensure proper handling of plates to prevent the potential for food borne illness; failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross…
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 before2022-12-22 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to transmit the Minimum Data Set (MDS) within 14 days of the Completion Date for 2 (Residents #53 and #80) of 3 (Residents #14, #53 and #80) sampled residents whose MDS were reviewed for timely transmission. The findings are: 1. On 12/20/22 at 12:45 PM, Resident #53's MDS list was reviewed. A DRA (Discharge Return Anticipated)/End of PPS (Prospective Payment System) MDS was dated 7/15/22 and with a completion date of 7/21/22, did not document that it was transmitted. 2. On 12/20/22 at 12:55 PM, Resident #80's MDS list was reviewed. A DRNA (Discharge Return Not Anticipated) MDS was dated 7/11/22 and with a completion date of 7/21/22, did not document that it was transmitted. 3. On 12/20/22 at 01:13 PM, the Surveyor asked MDS Coordinator #1, When was [Resident #53's] DRA/End of PPS dated 7/15/22 transmitted? She answered, She went to the hospital and was expected back. It was not transmitted. The Surveyor asked, When was [Resident #80's] DRNA dated 7/11/22 transmitted? She answered, It was not. The Surveyor asked, Should it…
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 · E2022-12-22 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to provide nail care for a resident who was unable to carry out Activities of Daily Living (ADL) to maintain good grooming and personal hygiene for 1 (Resident #49) of 7 (Residents #9, #14, #45, #46, #49, #70 and #98,) sampled residents on 1A and 1B halls who were dependent or required assistance with nail care as documented on a list provided by the Administrator on 12/21/22 at 8:47 a.m. The findings are: 1. Resident #49 had a diagnosis of Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/22 documented the resident scored 12 (12-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required limited physical assistance from one staff member for personal hygiene. a. The Care Plan dated 6/29/22 documented, .PERSONAL HYGIENE: The resident requires total dependence by (1) staff with personal hygiene and oral care . b. On 12/19/22 at 10:53 AM, Resident #49 was lying in bed watching TV. Her fingernails were approximately 1/3 inch past…
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 before2022-12-22 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 provide care and services to address residents positioning needs for two (Residents #73 and #35) of 10 (Residents #1, #9, #14, #17, #18, #35, #58, #73, #94, and #104) sampled residents who had limited Range of motion and/or contractures as documented on a list provided by the Administrator on 12/21/22. The findings are: 1. Resident #73 had a diagnosis of Parkinson Disease and Muscle Wasting, and Atrophy not elsewhere classified, Multiple Sites. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/06/22 documented the resident scored 9 (8-12 indicates moderately cognitively intact) on a Brief Interview for Mental Status (BIMS) and had no impairment to the upper or lower extremities, received occupational and physical therapy from 10/05/22 to 10/28/22 and did not have passive or active range of motion (ROM) or require splint or brace assistance in the last 7 calendar days. a. On 12/19/22 at 1:41 PM, Resident #73 was sitting in his room in a Geri chair with feet elevated. He had…
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 before2022-12-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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, record review, and interview, the facility failed to ensure a urinary catheter drainage bag was maintained in a privacy bag to maintain privacy and dignity for 1 (Resident #70); failed to ensure the urinary catheter drainage bag was kept off the floor to prevent the potential for infection for 1 (Resident #70) and failed to ensure the catheter drainage bag was maintained below the level of the bladder to prevent the potential for infection for 2 (Residents #73 and #76) of 6 (Residents #9, #16, #70, #73, #76 and #94) sampled residents who had a urinary catheters. The findings are: 1. Resident #70 had a diagnosis of Unspecified Symptoms and Signs Involving the Genitourinary System. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/21/22 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had an indwelling catheter. a. The Physician Orders dated 1/11/22 documented, .Foley cath [catheter]: (specify: 18/FR [French] 10 balloon) change every night shift…
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 · E2022-12-22 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
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 fluids were readily accessible to promote adequate hydration for 3 (Residents #70, #73 and #94) of 30 (Residents #1, #3, #9, #14, #16, #17, #18, #21, #25, #29, #33, #35, #41, #45, #46, #49, #58, #63, #64, #66, #67, #70, #73, #76, #82, #89, #92, #94, #98 and #105) sampled residents. The findings are: 1. Resident #73 had diagnoses of Parkinson ' s Disease and Acute Kidney Failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/06/22 documented the resident scored 9 (8-12 indicates moderately cognitively intact) on a Brief Interview for Mental Status (BIMS) and required physical assistance of one person with eating and was on a mechanically altered diet. a. The Care Plan dated 08/03/22 documented, .[Resident #73] has a potential fluid deficit r/t [related to] history of Osteomyelitis . Educate the resident/family/caregivers on importance of fluid intake . Invite the resident to activities that promote additional fluid intake. Offer drinks during one-to-one visits.…
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 before2022-12-22 · 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
Based on observation, record review and interview, the facility failed to ensure an oxygen nasal cannula tubing was stored in accordance with professional standards of practice when not in use for 2 (Residents #82 and #63); failed to ensure Oxygen in Use signs were posted on the doors of 2 (Residents #46 and #82) and tubing was changed out per physicians orders for 2 (Residents #63 and #82) of 6 (Residents #16, #46, #63, #64, #70 and #82) sampled residents who had a physician's order for oxygen. The findings are: 1.Resident #82 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Pneumonia Unspecified. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/29/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy while a resident. a. The Physicians Orders dated 12/15/22 documented, .O2 [oxygen] @ [at] 2L [liters] per nasal cannula prn [as needed] sob [shortness of breath] or to keep sats [saturations] above 92 as needed for sob, or sats below…
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 · E2022-12-22 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure medications were locked in a secured cart and not left in a resident's room to prevent accidental ingestion by ambulatory residents and/or residents who were independently mobile for 3 (Resident #58, #66 and #82) of 3 sampled residents. This failed practice had the potential to affect 7 residents who were ambulatory with or without a device who resided on 2A and 2B Halls as documented on a list provided by the Administrator on 12/21/22 at 8:47 AM. The findings are: 1.Resident #82 had diagnoses of Chronic Obstructive Pulmonary Disease and Pneumonia Unspecified. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/29/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 12/19/22 at 11:19AM, there were two vials of Ipratropium-Albuterol Solution on the bedside table in Resident #82's room. There was no nurse present. b. On 12/20/22 at 8:00 AM, one vial of Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML…
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 · E2022-12-22 · tag F0800 — patternProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
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 the menu was followed for two meals observed for 8 (Residents #1, #18, #25, #35 #66, #67 and #70 this is only seven) who had a physician ' s order for a mechanical soft and/or an enhanced or pureed diet to ensure nutritional wellbeing. The findings are: 1. On 12/19/22 at 11: 25 AM, the lunch menu documented the residents were to receive Baked Ham, [NAME] Beans, Greens, Cornbread, [NAME] (Margarine) Spread, Buttermilk Pie, and Coffee and/or Tea. The residents who required a mechanical soft diet were to receive the same items, except they were to receive ground Ham. 2. On 12/19/22 at 11:28 AM, the Surveyor asked Dietary Aide (DA) #5 to identify the enhanced menu item for the day. He stated, It's mashed potatoes, but I don't have any. 3. On 12/19/22 at approximately 1:00 PM, DA #2 reported that he had utilized all of the white beans that had been prepared for the noon meal. The Dietary Manager instructed the DAs to prepare lunch…
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 · D2022-12-22 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete a Significant Change in Status (SCSA) Minimum Data Set for 1 (Resident #9) of 25 (Residents #1, #3, #9, #16, #17, #21, #25, #29, #35, #45, #46, #49, #58, #63, #67, #70, #73, #76, #82, #89, #92, #94, #98, #115 and #116,) sampled residents whose MDS was reviewed. The findings are: 1. Resident #9 had a diagnosis of Cerebral Infarction. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/22 documented the resident scored 12 (12-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required total physical assistance of one staff member for eating and extensive physical assistance of one staff member for toilet use. a. The Quarterly MDS with an ARD of 8/26/22 documented the resident required supervision and set up help for eating and limited physical assistance of one staff member for toilet use. b. On 12/20/22 01:24 PM, the Surveyor asked MDS Coordinator #1, Did [Resident #9] experience a decline in eating and toilet use? She answered, Yes. The Surveyor asked,…
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 before2022-12-22 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 identify residents positioning needs for two (Residents #73 and #35) of 10 (Residents #1, #9, #14, #17, #18, #35, #58, #73, #94, and #104) sampled residents who had limited range of motion and/or contractures as documented on a list provided by the Administrator on 12/21/22. The findings are: 1. Resident #73 had diagnoses of Parkinson Disease and Muscle Wasting, and Atrophy not elsewhere classified, Multiple Sites. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/06/22 documented the resident scored 9 (8-12 indicates moderately cognitively intact) on a Brief Interview for Mental Status (BIMS) and had no impairment to the upper or lower extremities, received occupational and physical therapy from 10/05/22 to 10/28/22 and did not have passive or active range of motion (ROM) or require splint or brace assistance in the last 7 calendar days. a. On 12/19/22 at 1:41 PM, Resident #73 was sitting in his room in a Geri chair with feet elevated. He had bilateral contractures of hands…
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 before2022-12-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to revise the resident Care Plan to meet the residents' needs for 1 (Resident #82) of 24 (Residents #3, #9, #11, #16, #17, #21, #25, #29, #35, #45, #46, #49, #58, #63, #67, #70, #73, #76, #82, #89, #92, #94, #98 and #115) sampled residents whose Care Plans were reviewed. The findings are: 1. Resident #82 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Pneumonia Unspecified. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/29/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy. a. The Care Plan with a revision date of 03/11/22 documented, .The resident has Emphysema/COPD . Give aerosol or bronchodilators as ordered . The Care Plan did not address oxygen therapy. b. The Physicians Order dated 12/15/22 documented, .O2 [oxygen] @ [at] 2L [liters] per nasal cannula prn [as needed] sob [shortness of breath] or to keep sats [saturations] above 92 as needed for sob, or sats below…
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 · D2022-12-22 · 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
Based on observation and record review, the facility failed to ensure the diagnosis for the medication was relevant to the class of the medication ordered to minimize the potential for complications for 1 (Resident #16) of 3 (Residents #16, #29 and #35) sampled residents who had Physician Orders for Seroquel. The findings are: Resident #16 had diagnoses of Alzheimer Disease, Unspecified and Other Recurrent Depressive Disorders. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/24/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received antipsychotic medications 7 days of the 7 day lookback period. a. The Physician's Order dated 11/11/22 documented, .Seroquel tablet 25 mg [milligrams] give one tablet by mouth two times a day related to Alzheimer disease, unspecified . b. The Pharmacy MRR [Medication Regimen Review] - Antipsychotics dated 11/16/22 documented, .Antipsychotics recommendation: Unnecessary Psychotropic Medications . Med. [medication] Antipsychotic: Seroquel Tablet…
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
$50,700 in federal fines across 1 penalty.
- $50,700 — penalty dated 2025-12-04
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 CENTRAL ARKANSAS NURSING CENTERS — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.6 | -1.6 vs chain |
| Health inspection | 1 of 5 | 3.2 | -2.2 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.2 | +0.8 vs chain |
The other 37 homes this chain runs (chain average 3.6★, 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 | Since |
|---|---|---|---|
| MCGRAW, SHERI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/20/2004 |
| ARGENTA HEALTH SERVICES | Organization | ADP OF THE SNF | since 12/12/2024 |
| NORSWORTHY, DAVID | Individual | ADP OF THE SNF | since 08/01/2025 |
| SHAH, BUSHRA | Individual | ADP OF THE SNF | since 12/10/2024 |
CMS files one row per role, so the 5 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.
1 organizational owner 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.
This home reported $3.3M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 045460. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-24, 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.