Barnes Healthcare
1010 Barnes Street, Lonoke, AR 72086 · For profit - Limited Liability company · 141 certified beds · (501) 676-3700 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- it has an abuse, neglect, or exploitation citation (F0602), cited Apr 2024
- it has a citation for mishandling residents’ money or property (F0568)
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $34,623 in federal fines (most recent 2023-12-28)
- 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)
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 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 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.4% | 9.5% | 15.4% | typical |
| Long-stay residents who lose too much weight | 7.0% | 4.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.6% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.8% | 1.2% | 2.0% | worse |
| 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 | 1.1% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.1% | 10.1% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 20.7% | 21.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.9% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.7% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 33.0% | 10.9% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.72 | 2.01 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.22 | 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.
Therapy staffing: this home’s payroll records show 0.03 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 72% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 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 141 beds and averages 48.3 residents a day — about 34% occupied, or roughly 93 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.98 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.65 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 3.29 hrs/resident/day on weekends vs 4.18 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.11 to 0.65 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 more than at the previous inspection — worsening. 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.
29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · J2023-12-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the vent-a-hood in the kitchen was kept free of a buildup of grease, grime and debris which could result in improper functioning and/or fire resulting in serious injury, serious harm, serious impairment, or death. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility. The Administrator was notified of the Immediate Jeopardy on 12/06/23 at 05:02 PM. The facility also failed to ensure potentially hazardous items were stored in a secure location to prevent potential access by cognitively impaired, independently mobile residents for 1 (Resident #19/31) of 1 sampled resident; the mattress fit the bed for 1 (Resident #23) of 1 resident to prevent the potential for harm; and oxygen cylinders containing oxygen were stored and secured in an oxygen holder to prevent the potential for accidents/hazards. The findings are: 1. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2023-12-28 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 Based on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a clean condition to minimize the risk of food borne illness; food products were used or removed prior to their expiration dates/viability; hands were washed between clean and dirty tasks and prior to applying gloves; dishes and utensils were cleaned prior to being used for residents during meal service; and food was stored in a manner that was free of exposure/contamination due to the presence of insects or rodents. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility. The Administrator was notified of the Immediate Jeopardy on 12/06/23 at 05:02 PM. The facility also failed to ensure orange was stored in the refrigerator and hand washing was practiced when feeding residents snacks. The findings are: On 12/05/23 at 02:05 PM Surveyors observed initial kitchen rounds with Dietary Aide #1. 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.
- Immediate jeopardy · J2023-12-28 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
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 essential equipment in the kitchen was maintained in safe, operational order to ensure food was kept at a safe temperature to minimize the risk of food borne illness. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility due to the potential risk for food borne illness The Administrator was notified on 12/6/23 at 5:02 PM. The findings are: On 12/5/23 at 2:51 PM, in the first two door freezer there was a thick layer of ice observed in the bottom underneath multiple boxes of food items. The ice was covered in a variety of debris including food stuff. The ledge and bottom of the freezer contained dust and debris which extended to the vent and grate in the front of the freezer. The right side of the freezer contained a layer of ice 2 to 3 inches thick. Adhered to the bottom of the freezer was a bag containing a bright red food product that had been liquid at one time. The Dietary Aide was unable to…
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 before2025-01-09 · tag F0641 — patternEnsure each resident receives an accurate 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, interviews, and facility document review, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for 7 (Residents #5, # 25, #16, #27, #41, #14, #22) of 11 sample mix residents. The findings are: Review of Resident #5's admission Record noted the resident was admitted on [DATE] with diagnoses of peripheral vascular disease (PVD) (slow and progressive disorder of the blood vessels), cerebral infarction(stroke) and presence of cardiac pacemaker. Review of Resident #5's Order Summary Report dated 1/8/2024 noted [anti-platelet medication name] Tablet 75 milligrams (MG) give 1 tablet by mouth one time a day for blood clot prevention; [nonsteroidal anti-inflammatory (NSAID) medication name] enteric coated (EC) tablet delayed release 81 MG give 1 tablet by mouth one time a day for prophylactic. Review of Resident #5's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/2024 noted in section N0415. High Risk Drug Classes: Use and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-09 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility document review, it was determined that the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed prior to admission to ensure the resident received the needed care and services in the most appropriate setting for 3 (Residents #16, #22,#32) of 4 sampled residents whose records were reviewed for PASRR screening information. The findings are: Review of Resident #16's [company name] letter, submitted by another facility, dated 5/14/2018, for a Level I application and the resident was considered a change of condition. Review of Resident #16's Division of Medical Services (DMS) 787 dated 6/11/2018 noted in Section II the resident had a diagnosis of Mental Retardation (MR)/ Intellectual Development disorder (IDD). Mental Retardation developed before the resident reached age [AGE], and the resident had a Developmental Disability before reaching the age of 22. Mental Illness section noted Resident #16 has a diagnosis of schizophrenia…
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 · E2025-01-09 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined the facility failed to document and complete a person-centered care plan to facilitate the ability to plan and provide necessary care and services for 6 (Residents #32, 22, 27, 3, 7, 14) of 19 sampled residents whose Care Plans were reviewed. The findings include: A review of the admission Record, indicated the facility admitted Resident #32 with diagnoses that included schizophrenia, vascular dementia with behavior disturbance, psychosis, mood disorder, convulsions, anxiety disorder, and abnormal weight loss. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had severe cognitive impairment. Resident #32 was marked as having 2 or more falls since admit or prior assessment. A review of Resident #32's Care Plan, initiated on 06/22/2023, revealed the resident had a high potential for fall and/or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility document review, it was determined the facility failed to ensure that residents who smoke have a smoking assessment for 2 (Resident #14, #41) of 2 sample mix residents reviewed for smoking and to ensure hand rolls were used for residents with contractures for 1 (Resident #27) of 1 sample mix residents reviewed for contractures and to ensure specialized shampoo was used during showers as ordered by physician instead of regular body wash for 1 (Resident #47) of 1 resident reviewed for ADL (activities of daily living) care for dependent residents. The finding are: During an interview with Resident #14 on 1/7/2025 9:11 AM, the resident stated there are smoking times and confirmed staff keep cigarettes and lighters. Resident #14 confirmed that they don't wear an apron when smoking. Review of Resident #14's admission Record noted the resident was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of Resident #14'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 · E2025-01-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure adequate nutrition and hydration was provided for dependent residents for 1 (Resident #47) of 1 resident reviewed for nutrition and hydration status and weight loss. Findings include: A review of the facility policy titled, Assistance with Meals, revised in September 2013, indicated that residents would receive assistance with meals to meet the individual needs of the resident and that resident who could not feed themselves would be fed with attention to safety, comfort, and dignity. A review of the admission Record indicated the facility admitted Resident #47 with diagnoses that included down syndrome, seizures, abnormal weight loss, and dysphagia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) of 0 and no staff assessment for mental status (SAMS) had been…
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 before2025-01-09 · 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, interview, record review, and facility policy review, the facility failed to ensure food items stored in the freezer were covered, sealed, dated; manufacturer specification was followed; kitchen ceiling tiles were replaced, cleaned to provide a sanitary environment for food preparation; floors, dish washer, kitchen walls, were free of chipped and stains and dietary staff washed their hands before they handled clean equipment or food for 1 of 1 meal observed. The findings are: 1. On 1/6/25 at 10:01 AM, the following observations were made on a rack above the food preparation counter: a. An opened bag of cornmeal. The bag was not sealed. b. An opened box of baking soda. c. An opened bottle of dill weed. 2. On 1/06/25 at 10:11 AM, the following observations were made on a shelf in the 2-door freezer: a. An opened box of hamburger patties. The bag was not covered or sealed. b. An opened box of catfish. The box was not covered or sealed. c. An opened box of cod fish. The box was not covered or sealed. d. An opened box of veggie sausage. The box was not sealed or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
Based on observation, interviews, record review, and policy the facility failed to ensure bed linens were maintained in clean condition for two (Resident #28 and #36) of seven residents sampled for safe, clean, and comfortable homelike environment. The findings are: A review of Resident #28 ' s admission report showed Resident #28 had diagnoses of bipolar, depressive episodes, stroke, and psychosis. A review of Resident #36 ' s admission report showed Resident #36 had diagnoses of Alzheimer's disease, dementia, and schizophrenia. During observations on 1/6/2025 at 10:37AM and 2:45PM, Resident #36 ' s bed on the right side of the room was covered with a blue bed spread that had white unknown substance scattered on top of the cover. The folded blue blanket at the head of the bed had an unknown dried smeared white stain on the top right corner. The side of the bed cover that hung towards the floor had unknown brownish stains along the middle third of the linen. During observations on 1/6/2025 at 10:38AM and 2:46PM, on the left side of Resident #36 ' s room, a second bed contained…
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 · D2025-01-09 · tag F0644 — isolatedCoordinate 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 observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure preadmission screening and resident review (PASRR) was completed for 1 (Resident #32) of 1 resident reviewed for preadmission screening due to diagnosis. Findings include: On 01/08/2025 at 9:30 AM, the Director of Nursing (DON), stated the facility did not have a policy for Preadmission Screening and Resident Review. A review of the admission Record, indicated the facility admitted Resident #32 with diagnoses that included schizophrenia, vascular dementia, mood disorder, anxiety disorder, and psychosis. Resident #32's actual admission date to the facility was 07/13/2020. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Active diagnoses were marked for mood disorder, anxiety disorder, psychotic disorder, schizophrenia. The admission 5-day MDS…
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 before2025-01-09 · 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 interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure family/responsible party and resident were included in the care plan process for 1 (Resident #47) of 1 resident reviewed for care plan meetings. The findings include: A review of the admission Record, indicated the facility admitted Resident #47 with diagnoses that included down syndrome, abnormal weight loss, seizures, dysphagia, anxiety disorder, and insomnia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident had severe cognitive impairment. The MDS was marked resident and family participation in assessment and goal setting. A review of Resident #47's Care Plan, initiated on 07/03/2023, revealed the resident/family or physician had determined the resident had a need for long term care. Interventions included: educate resident/family of benefits of nursing home care. A review of Progress…
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 · D2025-01-09 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure treatment was provided for the left foot for 1 (Resident #47) of 1 resident reviewed for skin and wound treatments and care. Findings include: A review of a facility policy titled, Medication Policy, revised in April 2007 stated, all the resident's clinical record must have an order for over-the-counter medications and if ordered will be supported by the appropriate care processes and practices. A review of the admission Record, indicated the facility admitted Resident #47 with diagnoses that included down syndrome, seizures, abnormal weight loss and dysphagia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) of 0 and no staff assessment for mental status had been completed. No area was marked for issues with the feet. A review of Resident #47's Care Plan, revised on 10/09/2023, revealed the resident had a slight risk for impaired…
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 16 citations
- Potential for harm · D2025-01-09 · 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, interviews, record review, and facility policy review, it was determined that the facility failed to ensure the medication regimen was free from unnecessary medications without adequate indications for its use for 1(Resident #7) of 1 resident reviewed for unnecessary medications. Findings Included: Review of a facility policy titled, Medication Therapy Policy, no date indicated Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. A review of an admission Record indicated the facility admitted Resident #7 with chronic kidney disease stage 3 (kidneys have mild to moderate damage and have difficulty filtering waste and excess fluid from the blood) The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/20/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During a record review, Resident #7 ' s order summary, revealed three medications without proper indications for their…
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 · D2025-01-09 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. The findings are: 1. On 1/6 /25 at 12:35 PM, a #12 (3 ounces) scoop was used by Dietary [NAME] (DC) #4 in the mechanical soft yogurt baked chicken for serving. The menu for the 01/06/25 lunch meal indicated 4 ounces per serving, a difference of 1 ounce. 2. On 1/6/25 at 12:37 PM, the menu for the lunch meal indicated 4 ounces for pureed yogurt baked chicken and 1 pureed wheat dinner roll. A #12 scoop (3 ounces) was used in the pureed yogurt baked chicken for meal service, a difference of 1 ounce. No pureed dinner roll was served to pureed diets. There were no substitutions served to the residents in place of a dinner roll. 3. On 1/6/25 At 1:03 PM, DC #1 was interviewed and was asked why no dinner roll was served to the residents on pureed diets. DC #1 stated she was told by the previous Dietary Manager not to serve bread to the residents on pureed diets. DC…
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 before2025-01-09 · 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 observation, interview, and facility policy review, it was determined that the facility failed to ensure staff did not place dirty meal trays on the meal transport cart while clean trays were still on the metal transport cart being served to residents to avoid cross-contamination. The findings are: During an observation of the lunch meal on 1/6/2025 at 12:54 PM, this surveyor observed Certified Nursing Assistant (CNA) #9 placed lunch meal trays that were dirty, due to the residents already consuming the meal, on the meal transport cart with four (4) resident meal trays that still needed to be served to the residents. During an interview with CNA #9 on 1/6/2025 at 12:54 PM, he confirmed that he should not place dirty meal trays on the meal cart with meal trays that had not been served to the residents. During an interview with the Director of Nursing (DON) on 1/9/2025 at 9:43 AM, the DON confirmed that staff should not place dirty meal trays on the meal cart with meal trays that had not been served to the residents due to it being an infection control issue. Review of 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 · E2024-04-30 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, resident and staff interview, facility document review, and facility policy review, it was determined that the facility failed to provide quarterly statements of their trust account managed by the facility to the resident or their representative for 34 (Residents #1, 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, and 36) of 41 residents reviewed for trust account statements. Findings include: A review of the facility's undated policy titled, Resident Trust Fund Policy indicated, The purpose of this policy is to provide uniform guidelines for the management of the Resident Trust Account .Accurate records will be kept of resident's money and are available upon request .A quarterly statement of financial transactions will be available for residents and mailed to their responsible party . During an interview on 04/26/2024 at 9:56 am, Resident #11 confirmed not receiving quarterly statements. During an interview on 04/26/2024 at 10:01 am, Resident #7 confirmed not receiving any quarterly…
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 · E2024-04-30 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure residents were free of misappropriation of resident funds for 34 (Residents #1, 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, and 36) of 41 residents reviewed for misappropriation of resident funds. Findings include: A review of the facility's undated policy titled, Resident Trust Fund Policy, Revised 03/2024 indicated, The purpose of this policy is to provide uniform guidelines for the management of the Resident Trust Account. 4.Accurate records will be kept of resident's money and are available upon request . 14. The Trust Account Representative will provide all receipts to the business Office on a daily/weekly basis and key all withdrawals. Business Office staff will reconcile the RTA [Resident Trust Account] Petty Cash Box. 15. A separate individual other than Trust Account Representative and Business Office staff will reconcile the RTA Petty Cash box on a weekly…
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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure resident's dependent on staff for activities of daily living (ADLs), were provided assistance to protect and promote the rights and dignity of 2 (Residents #38 and #26) of 2 sampled residents. The findings are: Review of a facility policy titled, Resident Rights, dated December 2016 specified, .Employees shall treat all residents with kindness, respect, and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .b. be treated with respect, kindness, and dignity . 1. A review of Resident #38's admission Record indicated the facility admitted Resident #38 with a diagnosis that included schizophrenia. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #38 had a Staff Assessment for Mental Status (SAMS) score of 3, which indicated the resident had severe cognitive impairment. The resident required 1 person to physically 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 · Ecited before2023-12-28 · 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, record review, and interview, the facility failed to maintain a safe, functional, sanitary, and homelike environment for the residents to promote dignity and prevent the potential injury or spread of disease. The findings are: On 12/05/23 at 02:02 PM, 6 window blinds on the Secure Unit were torn with missing panes. Pictures were taken. On 12/05/23 at 02:04 PM, observed a brown recliner with torn and peeling vinyl exposing the foam on the left and right arm pads and the headrest, a black recliner with torn and peeling vinyl exposing foam on the left and right arm pads and a wire hanging 4 feet from the ceiling in the shape of a noose was observed in the Common Area of the Secure Unit. On 12/05/23 at 02:06 PM, the privacy curtain in room [ROOM NUMBER] was tied in a knot and not connected to the track on the ceiling. On 12/05/23 at 02:57 PM, a wire hanging 4 feet from the ceiling in the shape of a noose observed in the common area of the secure unit. (Photo taken.) On 12/05/23 at 03:02 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-28 · 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 interview and record review, the facility failed to code the Minimum Data Sets (MDS) accurately for 2 (Residents #14, and #35) to facilitate, plan, and provide necessary care, and to complete a medication self-administration assessment for 1 (Resident #14). The findings are: 1. Resident #35's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/23 documented in Section GG - Functional Abilities and Goals GG0115 0, no impairment under functional limitation in range of motion of A. upper extremity (shoulder, elbow, wrist, hand) On 12/08/23 at 09:50 AM, the Surveyor asked the MDS Coordinator to pull up the MDS section GG for Resident #35 in the electronic medical record and asked if Range of Motion was documented correctly since it was coded as no impairment. The MDS Coordinator answered, It's not a risk for injury for him. That's what I was taught. The Surveyor accompanied the MDS Coordinator to assess Resident #35's ability to perform activities of daily living with his left hand, arm, and side. The MDS Coordinator stated, You are right. I can…
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 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fingernails and toenails were trimmed for 1 (Resident #35) and chin hairs were removed for (Resident #19) to promote good hygiene and dignity. The findings are: A review of an admission Record indicated the facility admitted Resident #19 with a diagnosis that included major depressive disorder. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was unable to complete the interview and required extensive assistance with activities of daily living (ADLs). Review of Resident #19's Care Plan, initiated on 3/1/2023, revealed the resident had an alteration in activities of daily living (ADL) functions. Interventions included bathing/showering: extensive assist by staff initiated on 3/1/2023; and personal hygiene/oral care: the resident is totally dependent on staff for personal hygiene and oral care initiated on 3/1/2023. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician, to minimize the potential for hypoxia or other respiratory complications for 1 (Resident #31) of 1 sampled resident who had orders for oxygen therapy. The findings are: A review of an admission Record indicated the facility admitted Resident #31 with diagnosis that included pulmonary embolism. The Annual Minimum Data Set (MDS), dated [DATE], revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score 00, which indicated Resident #31 was unable to complete the interview. The resident required extensive total assistance with activities of daily living (ADL's). A review of Resident #31's Physician's Orders, for 12/2023, revealed an order dated 10/06/2022 for oxygen at 2 liters via nasal cannula as needed. Review of Resident #31's Care Plan, initiated 09/07/2022, revealed the resident had oxygen therapy prn (as needed) related to acute…
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 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure medications were not in a residents room and were stored in in a secure location for 1 (Resident #31) of 1 sampled resident and medications were not left unattended on top of the medication cart. The findings are: A review of an admission Record indicated the facility admitted Resident #19 with a diagnosis that included major depressive disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident was unable to complete the interview and required extensive assistance with activities of daily living (ADLs). A review of Resident #19 Physician Orders, for 12/2023, revealed no order for Preparation H suppositories. A review of a facility policy titled, Storage of Medications, revised April 2007, specified, Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals shall be…
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 before2023-12-28 · 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 observation, record review, and interview, the facility failed to ensure staff changed gloves/washed hands between providing incontinent care and handling of clean items to reduce the potential for infection and failed to ensure dirty gloves and incontinent briefs were stored off of the shower floor to prevent cross-contamination and the potential spread of infection to other residents for 1 (Resident #26) of 1 sampled resident. The findings are: A review of an admission Record indicated the facility admitted Resident #26 with diagnoses of diabetes mellitus and schizophrenia. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. A review of Resident #26's Physician Orders, for the month of December 2023, revealed an order, dated 3/7/2023 for admission to memory unit deemed appropriate. Review of Resident #26's Care Plan, initiated on 1/3/2023, revealed 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 · E2023-12-28 · tag F0924 — patternPut firmly secured handrails on each side of hallways.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, the facility failed to ensure handrails were securely attached to the wall to provide support and prevent potential resident injury on 1 (Hall 300) of 3 halls. The findings are: On 12/05/23 at 03:09 PM, observed 4 feet of handrail on the right side of the wall, outside of room [ROOM NUMBER] was not secure and sticking out 6 inches. A picture was taken. On 12/05/23 at 03:11 PM, observed 7 feet of handrail on the wall between the shower room and room [ROOM NUMBER] was not secure and was sticking out 8 inches from the wall with screws being exposed. A picture was taken. On 12/05/23 at 03:12 PM, the handrail between the shower room and room [ROOM NUMBER] was not secure and was loose. On 12/07/23 at 9:11 AM, Maintenance #1 was asked if the handrails in the hall on the Secure Unit had been reported to be loose. Maintenance #1 stated, It was reported a rail was loose in the past and I fixed them before, and I fixed them the day you came in because someone reported that you were looking at them.
- Potential for harm · Ecited before2022-10-06 · tag F0657 — failed to keep the care plan current — patternDevelop 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 observation, record review, and interview, the facility failed to review and revise the Care Plan and reassess the effectiveness of interventions to meet the resident needs for 1 (Resident #34) of 5 (Resident #6, #28, #32, #34, #38) sampled residents. This failed practice had the potential to affect 10 resident's that had an order for Oxygen therapy in the facility per the list provided by the Director of Nursing (DON) on 10/6/22 at 10:13 am and failed to review and revise the Care Plan and reassess the effectiveness of interventions to meet the resident needs for 1 (Resident #49) of 3 (Resident #28, #49, #153) sampled residents. This failed practice had the potential to affect 7 resident's that had orders for anticoagulation therapy in the facility per a list provided by the DON on 10/6/22 at 10:13 am. The findings are: 1. Resident #34 had Diagnoses of Respiratory Failure with Hypoxia, Epilepsy, Vascular Dementia. The Significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/22 documented a score of 00 (0-7 indicates severe impairment) on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-06 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 a Comprehensive Care Plan was developed to address the current, individualized care needs for 1 of 1 (R#32) sampled residents and had the potential to effect 4 residents that were admitted in the past 60 days per the resident roster matrix provided by the Director of Nursing (DON) on 10/4/22, as evidenced by: 1. Resident #32 had diagnoses of Chronic Obstructive Pulmonary Disease, Opioid Dependence, Acute and Chronic Respiratory failure with Hypoxia, Anxiety Disorder unspecified, Essential Primary Hypertension. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/01/22 documented the resident scored 12 (8-12 indicates moderately Impairment) on a Brief Interview for Mental Status (BIMS). a. On 10/05/22 at 11:50 am, the record review completed for R#32 showed a Comprehensive Care Plan was not in the Medical Record. b. On 10/05/22 at 1:30 pm, The Surveyor asked the DON, Should a Comprehensive Care Plan be completed for residents? The DON stated, Yes. The Surveyor asked, When…
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 · D2022-10-06 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to develop and implement a Baseline Care Plan for 1 resident of 1 sampled (R#32) that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The findings are: 1. Resident #32 had diagnoses of Chronic Obstructive Pulmonary Disease, Opioid Dependence, Acute and Chronic Respiratory failure with Hypoxia, Anxiety Disorder Unspecified, Essential Primary Hypertension. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/01/22 documented the resident scored 12 (8-12 indicates moderately Impairment) on a Brief Interview for Mental Status (BIMS). a. On 10/05/22 at 11:45 am, the record review for R#32 showed a Base Line Care Plan was not in the medical record. b. On 10/05/22 at 1:30 pm, The Surveyor asked the DON (Director of Nursing), Should a Base Line Care Plan be completed for residents? The DON stated, Yes, on admission. The Surveyor asked When should the Base Line Care Plan be completed? The DON 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.
“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
$34,623 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $34,623 — penalty dated 2023-12-28
- Medicare payment denial — starting 2024-01-27 for 48 days
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 MARSH POINTE MANAGEMENT — 6 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 | 2.5 | -0.5 vs chain |
| Health inspection | 1 of 5 | 2.2 | -1.2 vs chain |
| Staffing | 5 of 5 | 3.8 | +1.2 vs chain |
| Quality measures | 3 of 5 | 3.0 | ≈ chain avg |
The other 5 homes this chain runs (chain average 2.5★, 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 |
|---|---|---|---|---|
| BROGDON GRANDCHILDREN TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2018 |
| BROGDON, CHRISTOPHER | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2018 |
| NICHOLS, CHERYL | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 02/01/2018 |
| MARSH POINTE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2018 |
| CLYBURN, LYNDSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/23/2019 |
| EDALA, ARPANA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/28/2025 |
CMS files one row per role, so the 12 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 83% 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 $188K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 045314. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-09, 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.