Pleasant Valley Rehabilitation And Nursing
12111 Hinson Road, Little Rock, AR 72212 · For profit - Limited Liability company · 97 certified beds · (501) 225-8888 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- about 70% 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 5.5% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.4% | 4.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.4% | 1.4% | 6.5% | better than state‡ — see note marked double-dagger 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 | 2.2% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.6% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.6% | 21.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 5.6% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.7% | 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 | 93.9% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 32.8% | 24.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.1% | 12.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.90 | 2.01 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.82 | 2.13 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.5% 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 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 91.2% 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 34 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 19% 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 | 46.5%CMS range 31.0–64.5 | 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 | 10.2%CMS range 7.3–15.6 | 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 | 91.2% | 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 | 79.4% | 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 | 94.1% | 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 | 97.7% | 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 | 100.0% | 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 | 2.3% | 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 4.3–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 97 beds and averages 77.4 residents a day — about 80% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.70 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 3.41 hrs/resident/day on weekends vs 4.29 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.54 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · D2025-04-24 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation of medication administration, interview, record review and facility document review, the facility failed to ensure an insulin pen was primed and the plunger was held down for a count of five (5) seconds after an administration of insulin, according to manufacturer's instructions for 1 (Resident #11) sampled resident reviewed for medication administration. The findings are: A review of a Living Well with Diabetes instruction document, provided by the Director of Nursing (DON), was reviewed and read in part Prime your pen; Step one (1): turn the dose knob clockwise, until the number two (2) is in the dose window. Step two (2): hold the pen, with the needle pointing up, and tap the cartridge to gently move air bubbles to the top. Step three (3): with the needle still pointing straight up, push the dose knob in while counting to five (5). When the dose knob stops, the number zero (0) will appear in the dose window. Take your shot; Step two (2): when the needle is under your skin, use your thumb to press the dose knob all the way in. Push the knob firmly and slowly,…
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 before2024-02-08 · 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 F0812 F Based on observations and interview, the facility failed to ensure deep fryer was free of debris to prevent potential cross contamination, floor throughout the kitchen and wall air vent were free of grease, and stains, food items stored in the freezer or refrigerator were sealed, covered and dated, expired food items were promptly removed /discarded by the expiration or use by dates, and foods were dated as when received to ensure first in and first out usage to prevent the potential for food borne illness, 1 of 2 ice machines and 1 of 2 ice scoop holders were maintained in clean and sanitary condition to prevent food and beverage contamination, staff washed their hands between dirty and clean tasks and before handling clean equipment to minimize the potential for contaminating food items for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 67 residents who received meals from the kitchen (total census 69), The findings are: 1. On 02/05/23 09:03 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 · E2024-02-08 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure the state survey results were posted in a place readily accessible to residents. The findings are: On 2/06/24 at 3:02 PM a resident council meeting was conducted. The residents were asked if they knew were the state inspection results were located, and if they could get them without having to ask staff for them. There were 10 (Resident #3, Resident #5, Resident #7,Resident #14, Resident #34, Resident #43, Resident #45, Resident #47, Resident #55, and Resident#66) residents in the resident council meeting that did not know where the survey results information was located. On 2/06/24 at 3:30 PM there were a binder located on the wall at the beginning of the 100 that had Survey Results written on it. The Annual survey results for 2023 was not in the binder. On 2/06/24 at 3:35 PM the surveyor asked the Director of Nurse (DON), Can you show me where the 2023 Annual Survey results are located? She looked in the survey results binder that was located on the wall at the beginning of the 100 hall. She stated,…
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 · E2024-02-08 · 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure a homelike environment for 1 (room [ROOM NUMBER]) room on the 200 Hall. The facility also failed to ensure residents meals were removed from 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 2 (Resident's #21 & #42) sample mix residents who received a tray on the 200 Hall during lunchtime Sunday 2/4/24 according to a list provided by the Nurse Consultant on 2/7/24 at 1:01pm. The findings are: 1. On 02/04/24 at 11:01 AM, the Surveyor observed 2 holes approximately 1 inch each side by side in room [ROOM NUMBER]'s bathroom wall by the commode. 1A. On 02/05/24 at 08:34 AM, the Surveyor observed 2 holes approximately 1 inch each in the wall by the commode where a toilet paper holder would be placed. 1B. On 02/06/24 at 10:47 AM, the Surveyor observed 2 holes approximately 1 inch each in the wall by the commode of room [ROOM NUMBER]'s…
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 · E2024-02-08 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure 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 interview and record review the facility failed to ensure 1 (Resident #35) of 5 (Residents #13, #21, #35, #42, #66) sample mix residents that were reviewed for unnecessary medications received a diagnosis prior to receiving an anti-depressant medication. The findings are: Resident #35 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/9/23 showed a Brief Interview for Mental Status (BIMS) of 99. A Staff Assessment for Mental Status (SAMS) was completed that showed short term and long-term memory problems. The resident is taking an antidepressant. The diagnoses showed type 2 diabetes mellitus; anxiety disorder; cerebral infarction; heart failure; stiffness of right hand; contracture of right hand, right knee, and left knee. No diagnosis observed in the resident's chart for depression. The Physician's Order Summary showed Remeron Oral Tablet 30 milligrams (mg) (Mirtazapine) Give 30 mg by mouth in the evening for Depression with an order date of 5/1/23 and a start date of 5/2/23. The Care Plan showed the resident uses antidepressant medication. Nursing staff…
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 · E2024-02-08 · 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 that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 5 residents who received pureed diets, as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 02/08/2024 The findings are: 1. On 02/04/24 at11:34 AM DE #1poured the pureed vegetable into a pan. He covered the pan with foil and placed it in a pan of hot water on the stove. The consistency of the pureed vegetable blend was not smooth. There were pieces of carrots in the mixture. 2. On 02/04/24 at 11:38 AM Dietary Employee (DE) #1 used a #8 scoop to place 6 servings of rice pilaf into a blender, added broth and pureed. At11:40 AM DE# 1 poured the pureed rice into a pan. The consistency was gritty, sticky and not smooth. 3. On 02/04/24 at 12:08 PM A pan of pureed bread to be served to the residents who required pureed diets was on the steam table.…
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 · E2024-02-08 · 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 interview the facility failed to ensure isolation laundry was handled correctly to prevent the spread of infection. This failed practice had the potential to affect 15 (Resident's #1, #6, #7, #11, #20, #21, #25, #27, #36, #37, #42, #50, #53, #54, #64) sample mix residents who depend on the facility to provide laundry services according to a list provided by the Social Services Director on 2/7/24 at 3:48pm. The findings are: On 02/05/24 at 01:37 PM, the Surveyor asked Housekeeper (HKP) #1 What jobs do you perform? HKP #1 stated I'm a housekeeper, but I do laundry too. The Surveyor asked How do you wash isolation laundry? HKP #1 stated The aides on the floor bring the laundry to us. I pick up the outside of the bag that they bring it to us in and shake it out into the washer. The Surveyor asked Do you wear Personal Protection Equipment (PPE) when you do isolation laundry? HKP #1 stated No, I've never been told to wear PPE while doing isolation laundry. I don't know why a person would need to. On 02/05/24 at 01:43 PM, the Surveyor asked the District Manager of Housekeeping…
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 · E2024-02-08 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 and interview the facility failed to ensure a safe environment for 1 (room [ROOM NUMBER]) room on the 200 Hall. This failed practice had the potential to affect 3 (Resident #13, #42, & #53) residents who were ambulatory on the 200 Hall, and the facility failed to ensure the residents were provided a homelike environment for 5 (room [ROOM NUMBER], room [ROOM NUMBER], Room112, room [ROOM NUMBER], and room [ROOM NUMBER]) rooms on the 100 Hall . The findings are: 1. On 02/04/2024 at 09:24 AM the shower in room [ROOM NUMBER]'s bathroom lacked on/off knobs (exposed metal posts 2 ½ inches long) on the hot and cold water handles. 1A. On 02/04/2024 at 01:03 PM the shower lacked on and off knobs in room [ROOM NUMBER], leaving metal posts exposed 2 ½ inches long. 1B. On 02/05/2024 at 08:27 AM the Surveyor observed exposed metal posts 2 ½ inches long in room [ROOM NUMBER]'s shower. 1C. On 02/04/2024 at 12:48 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1, Does the resident use this…
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 · D2024-02-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure a vial of long-acting insulin was properly labeled with an open date. This failed practice had the potential to affect 1 (Resident #12) sample mix residents according to a list provided by the Nurse Consultant on [DATE] at 1:01pm. The findings are: On [DATE] at 02:41 PM, the Surveyor observed Hall 300 cart with one 10 milliliter (mL) multi-dose vial of Insulin Glargine (Lantus) 100 Units/mL with an expiration date of 8/2025 with no open date listed on the vial. On [DATE] at 03:02 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 When opening a new vial of insulin what should be done? LPN #1 stated It should be dated. The Surveyor asked What could happen if it is not dated? LPN #1 stated You could give expired medication. On [DATE] at 03:05 PM, the Surveyor asked the Director of Nursing (DON) Should insulin be dated when opened? The DON stated Yes. The Surveyor asked What could happen if it is not dated? The DON stated It may not work…
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 · D2023-09-12 · 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
Based on record review and interview, the facility failed to ensure an injury of unknown source/origin was reported to the Office of Long-Term Care (OLTC) and other agencies in accordance with state and federal laws for 1of 1 (Resident #2) of 3 sampled residents. This failed practice had the potential to affect 73 residents that reside in the facility. The findings included: Review of Resident #2's progress notes dated 09/11/2023 showed the following: a. A diagnosis of severe dementia with agitation. b. A nursing progress note dated 08/21/2023 at 4:19 PM showed the nurse was informed Resident #2 was experiencing pain when the left leg is moved. The nurse assessed Resident's left leg and noted an open area to the LLE (left lower extremity). The Advanced Practice Nurse was notified, and a X-ray of Resident #2's LLE was performed. The X-ray finding was an acute femoral intertrochanteric (hip) fracture. Record review of an Office of Long-Term Care (OLTC) DMS (Division of Medical Services) /7734 Form showed the date & time of discovery as 08/21/2023 at 3:50 PM and the date incident…
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 5 citations
- Potential for harm · Fcited before2022-11-04 · 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, record review, and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed /discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before they handled clean equipment or food items to prevent potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 82 residents who received meals from the kitchen (total census: 83) as documented on a list provided by Dietary Supervisor on 10/31/22. The findings are: 1. On 10/31/22 at 11:14 AM, during the initial tour of the kitchen with the Dietary Manager the dry storage room contained the following: a. A flat of 12 cans of chicken noodle soup with no received date. 2. On 10/31/22 at 11:39 AM, the following on a metal…
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 · E2022-11-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the resident's environment was free from accident hazards for 2 (Resident #19 and Resident #80) of the 7 sample residents (R #6, R #10, R #19, R #61, R #64, R #74, and #80) at the facility, who were ambulatory or propel themselves in a wheelchair, as evidenced by Resident #19 had two bottles of peri wash on his over bed table, and R #80 had 1 (1.5 Liter) bottle of mouthwash, 1 can of aerosol hairspray, four bottles of shampoo and two bottles of hair conditioner on the floor next to his nightstand. This failed practice had the potential to affect 39 residents who ambulated by any means, or self-propelled according to a list provided by the Interim Administrator on 11/3/22 The findings are: 1. Resident #19 had diagnoses of Unspecified Sequelae of Cerebral Infarction and Functioning Quadriplegic. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/22 documented a score of 14 (13-15 Indicates Cognitively Intact) on the Brief Interview for Mental Status (BIMS) and required extensive assist…
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 · D2022-11-04 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure pneumococcal immunizations were administered to eligible residents and immunization records were tracked and documented completely for 6 (Resident #6, R #22, R #25, R #52, R #56, R #61) of 6 sample selected residents who had signed consents for the Pneumococcal vaccine to help protect against Pneumococcal bacteria which could cause serious infections and be potentially fatal. This failed practice had the potential to affect 133 admissions since the facility's last survey on 11/4/21 per the admission Lists provided by the Interim Administrator on 11/3/22. The findings are: 1.On 10/31/22 at 02:45 PM, the Assistant Administrator provided the Resident Immunization Lists. 2.On 10/31/22 at 08:40 PM, review of the Resident Immunization Records showed the following: a. Resident #25 had a diagnosis of Alzheimer's and had a signed Pneumococcal consent dated 8/1/22. b. Resident #61 had diagnoses of chronic kidney disease and Dementia and had a signed Pneumococcal consent dated 9/16/22. c. Resident #22 had diagnoses of Chronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2022-11-04 · 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 record review and interview, the facility failed to ensure 1 (Resident #55) of 1 sampled resident had a ventilator as documented on the resident Minimum Data Set (MDS) Assessments. The findings are: 1. Resident (R) #55 had Diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Dementia and Bipolar. The Brief Interview for Mental Status (BIMS) showed the resident scored 10 (8-12 Indicates Moderately Impaired) on a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/11/22 documented Section O100 Respiratory treatment F. Invasive Mechanical Ventilator (ventilator or respirator) 1. while not a resident, 2. while a resident. Check all that apply and both the 1. And 2. Was marked with an X. a. R #55's Physician's Order documented, Order Date 8/16/22 start date 8/16/22: BIPAP (Bilevel Positive Airway Pressure) WHILE IN BED at bedtime. b. On 11/01/22 at 01:45 PM, R #55 was standing by a resident's door in the hall on the secured unit, neatly dressed in sweater and slacks. Resident #55 followed the Surveyor to her room. She saw the Surveyor looking at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2022-11-04 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to include the recommendations from the Preadmission Screening and Resident Review (PASARR) determination and evaluation report into the Care Plan for 2 (Resident #10 and Resident #28) of 2 sampled residents who had Level 2 screening recommendations. The findings are: 1. Resident #10 had diagnoses of Paranoid Schizophrenia, Major depressive disorder recurrent, and suicidal ideations. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/21/22 documented on Section A1500, Preadmission Screening and Resident Review (PASARR) . Is the resident currently considered by the state Level 2 PASARR process to have serious mental illness and/or intellectual disability or a related condition? NO. a. At 11/2/22 the Resident's Plan of Care did not include the recommendations from the PASARR Level 2 determination and the PASARR evaluation report. b. On 11/2/22 at 11:00 AM, the Interim Administrator provided a document dated 12/16/16 from the contracted state agency for PASARR screenings that documented,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
No federal fines in the current CMS record.
Part of a chain
This home belongs to SOUTHERN ADMINISTRATIVE SERVICES — 35 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 | 4 of 5 | 3.8 | +0.2 vs chain |
| Health inspection | 3 of 5 | 3.2 | -0.2 vs chain |
| Staffing | 3 of 5 | 3.9 | -0.9 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 34 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 |
|---|---|---|---|---|
| 4P2T1 OPS HOLDING LP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/14/2022 |
| JEJ ASSETS LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/14/2022 |
| PONTHIE, SHARLOT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/15/2022 |
| NICHOLS, COURTNEY | Individual | W-2 MANAGING EMPLOYEE | — | since 08/15/2022 |
| PONTHIE, JOHN | Individual | CORPORATE OFFICER | — | since 08/15/2022 |
| ALEXARK1 LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/14/2022 |
| JEJ MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/14/2022 |
4 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 74% 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 $6.0M paid to related parties — landlords or management companies under common ownership — equal to about 70% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 045390. 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.