The Lakes At Maumelle Health And Rehabilitation
103 Alexandria Drive, Maumelle, AR 72113 · For profit - Corporation · 70 certified beds · (501) 734-1400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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 an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
- 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 (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (82%) runs well above the national median (45%)
- about 24% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 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 | 3.5% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.4% | 4.3% | 5.4% | typical |
| 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 | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.1% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.5% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.9% | 21.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.2% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.1% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 9.3% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.7% | 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 | 75.9% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.1% | 24.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 19.5% | 12.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.65 | 2.01 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.68 | 2.13 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
38.6% 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 48 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 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 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at 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 | 38.6%CMS range 28.9–53.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 7.4–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 64.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 52.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 55.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.1% | 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 | 7.9%CMS range 4.4–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 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 70 beds and averages 43.5 residents a day — about 62% occupied, or roughly 26 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 4.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.551 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.09 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 3.87 hrs/resident/day on weekends vs 5.30 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 0.53 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 82% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.
- Potential for harm · E2025-11-25 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents were free from neglect for one (Resident #42) of three residents reviewed. The findings include: A review Resident #42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 06/26/2025, revealed the facility admitted Resident #42 on 09/22/2022. Resident #42 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also revealed, Resident #42 used a manual wheelchair for mobility. A review of Resident #42's Medical Diagnoses report revealed diagnoses that included a long-lasting open sore that developed due to poor circulation in the veins of left lower extremity, swelling, paralysis and weakness following a stroke which affected the left side, muscle wasting and atrophy, unsteadiness on feet, stage 3 chronic kidney disease, venous insufficiency, depression, anxiety, and high blood pressure. A review of Resident #42's Active Orders revealed active orders to assess the left lower extremity…
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 before2025-11-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 record review, interview, and facility policy review, the facility failed to ensure a Physician's Order for the administration of oxygen was received for one (Resident #50) of two residents reviewed for oxygen administration. The findings include: A review of Resident #50's admission Record from the Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD) and congestive heart failure. A review of Resident #50's Physician's Orders from the resident's EHR revealed there was no order for the administration of oxygen. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 02/14/2025, revealed Resident #50 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also indicated that Resident #50 received oxygen therapy while a resident at the facility. A review of Resident #50's Care Plan Report, initiated on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-05 · 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 it was determined that the facility failed to ensure dishes were properly sanitized. The findings are: 1. On 6/03/2024 at 11:06 AM the surveyor asked Dietary Consultant if she could check the temperature of the dishwasher. The dishwasher was currently in a rinse cycle. Dietary Consultant placed the thermometer in bowl of hot water inside dishwasher. The temperature reached 130. Dietary Consultant then ran the rinse cycle a little longer and then rechecked the water. The thermometer then reached the temperature of 140. The Dietary Manager stated, sometimes the dishwasher may need to run a few cycles before the temperature climbs. The surveyor then showed the Dietary Consultant the binders where temperatures should be documented. The book had not yet been documented for the month of June. The Dietary Consultant stated that the kitchen staff most likely have the temperatures written down on paper that had not yet been added to the binder. a. On 6/04/2024 at 7:47 AM, Surveyor spoke with Dietary Manager (DM) regarding temperatures from…
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 · E2024-06-05 · 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
Based on record review and interview, the facility failed to ensure the comprehensive care plan was individualized to addressed appropriate care and services for use of fall mats for 2 (Resident #26, and #43) of 2 sampled residents. The findings are: 1. Resident #26 had a diagnosis of fall from slipping, tripping, and stumbling with subsequent striking against other objects and displaced intertrochanteric fracture of right femur. a. Annual Minimum Data Set with the Assessment Reference Date of 04/17/24 that documented that Resident #26 scored 04 (0-7 indication severe cognitive impairment) on the Brief Interview of Mental Status and b. A Care Plan for Resident #26, revision date 03/25/22, documented that Resident #26 was at risk for falls related to (r/t) poor balance, weakness, Cerebrovascular accident (CVA), Hypertension (HTN), Diabetes Mellitus (DM), and Seizures. The Care Plan for Resident #26 did not note that a fall mat was put into place as an intervention. c. On 06/02/24 at 10:34 AM, the Surveyor observed Resident #26 lying in bed and the fall mat was placed under the bed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-05 · 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, record review, and interview the facility failed to ensure residents that require fall mats at the bedside have them placed in a manor to prevent injury in event of a fall for 1 (Resident #26) of 1 sample mix residents; to ensure fall mats at the bedside were properly maintained for 1 (Resident #43) of 1 sample mix residents; to ensure housekeeping carts and janitors closet was kept secure. The findings are: On 06/02/24 at 2:52 PM, the Surveyor observed Resident #43 lying in bed, lunch tray with 25% eaten on over the bed table sitting on fall mat that has tears and edges are peeling up. Progress note dated 04/12/2024 noted Nursing Incident and Accident Report showed the following: Description: Was found on the floor of bedroom lying on left side. Aide found resident on the floor. Immediate Intervention: Check head to make sure resident didn't hit it. Complained of pain in the left arm and left hip, no bruising on the hip, but was discoloration on the left forearm. Progress note dated 4/16/2024 at 03:01 noted Nursing-Hot Rack Charting: Neuro checks completed. No…
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 · E2024-06-05 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and facility policy reviews the facility failed to store drugs and biologicals in accordance with professional principles and the facility's policy. This failed practice had the potential to affect every Resident residing in the building. The findings include: 1. On 06/03/24 at 7:38 AM, the Surveyor observed the Licensed Practical Nurse (LPN) #8 walk to the dining room, with a medication cup in hand, leaving the medication cart unlocked. a. On 06/03/24 8:31 AM, the Surveyor observed an unattended unlocked medication cart in the hallway up against the wall not in front of a doorway. The Surveyor could hear talking in the room across the hall encouraging a Resident to take medication. The Surveyor walked up the hall father to see in the room and observed LPN #9 at the head of bed with her back to the door. b. On 06/03/24 at 8:35 AM, LPN #9 confirmed she was the nurse who left the medication cart unlocked and the medication cart was not viewable from position in the room. c. On 06/05/24 at 9:34 AM, the Director of Nursing (DON) voiced the cart should…
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 · D2024-06-05 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the observations, interviews, and facility policy review the facility failed to ensure 1 sampled (Resident #20) did not self-administer medication prior to an assessment conducted by the interdisciplinary team to determined it clinically appropriate and safe for the Resident to do so. The findings include: Resident #20 had a diagnosis of dysphagia, acute kidney failure, and chronic pulmonary edema. Resident #20 had an order for sore throat oral liquid (Acetaminophen) give 1 spray by mouth every 2 hours as needed for pain - moderate related to COVID-19 throat pain. Quarterly Minimum Data Set with an Assessment Reference Date of 04/09/24 that documented that Resident #20 was unable to complete the Brief Interview of Mental Status and had long term memory problems. A Care Plan for Resident #20 did not document that Resident self-administers medications. On 06/03/24 at 8:45 AM, the Surveyor noted sore throat spray was on Resident #20 ' s bedside table. On 06/03/24 at 8:56 AM, the Surveyor asked the Director of Nursing (DON) are there any residents in the facility that…
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 · D2024-06-05 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and facility policy reviews the facility failed to protect the Patient Health Information (PHI) of 1 (Resident #2) sampled resident. This failed practice had the potential to affect all residents residing in the facility. The findings include: 1. On 06/03/2024 at 7:38 AM, the Surveyor observed Licensed Practical Nurse (LPN) #8 walk to the dining leaving the computer screen on the laptop mounted to a medication cart unlocked displaying Resident #2's personal and medical information. The following was observed: a. Facility name b. Resident's name c. Status d. Location e. Gender f. date of birth g. Age h. Physician i. Allergies j. Code status k. Ordered medications 2. On 06/03/2024 at 7:40 AM, the Director of Nursing (DON) observed the Surveyor standing at the medication cart taking notes and pictures and instructed LPN #8 to leave the facility. The Surveyor was unable to conduct an interview with LPN #8 due to LPN #8 no longer being in the building. 3. On 06/05/2024 at 9:34 AM, the Director of Nursing (DON) confirmed the computer screen should 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 · D2024-06-05 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to complete an accurate Minimum Data Set (MDS) for 01 (Resident #40) of 1 sample mix residents. The findings are: Resident #40's Quarterly MDS with an Assessment Reference Date (ARD) of 02/29/2024 documented the Resident as taking an anticoagulant, however there is no physician order on the order recap report dating back to 02/28/2024 noting the resident taking an anticoagulant. On 06/04/24 at 10:23 AM, the Surveyor interviewed the MDS Coordinator and asked, Does resident #40's MDS with an ARD of 02/29/2024 indicate the Resident is taking an anticoagulant? MDS Coordinator stated, It's saying yes. When asked, Can you tell me when resident #40 was ordered an anticoagulant? She stated, On [Resident #40] current orders it doesn't say [Resident #40] takes one let me look on [Resident #40's] other. I'm not seeing where [Resident #40] had an anticoagulant. When asked, Is Resident #40's MDS coded correctly? She stated, No ma'am it's not and we will be doing a modification on that.
- Potential for harm · D2024-06-05 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to provide palatable food to Residents. The findings are: Resident #4 has a medical diagnosis of: Encephalopathy, muscle wasting & atrophy, pulmonary edema, anxiety disorder, restlessness, Type II Diabetes with Hyperglycemia, Parkinsonism, and edema. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date [ARD] of 4/12/2024 shows Resident to have a score of 15 on the Brief Interview for Mental Status (BIMS), cognitive assessment summary. On 6/03/24 at 9:00 AM, Surveyor asked Resident #4 if pleased with the food received at this facility. Resident told surveyor that the food doesn't taste very good most of the time. On 6/03/2024 at 1:02 PM, the surveyor checked the Resident's meal card and there was an order for sweet and low. The Resident told the surveyor there was none on the tray. The surveyor observed there to be no sweet and low on resident's meal tray to go in resident's beverage. On 6/04/2024 at 8:57 AM, the surveyor observed the Resident's breakfast meal being set up…
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 11 citations
- Potential for harm · D2024-06-05 · 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, record review, interview, and facility policy review it was determined the facility failed to ensure staff washed/cleaned hands after changing gloves during incontinent and wound care for 1 (Resident #32) of 1 sampled resident reviewed for pressure ulcers; to ensure wound care supplies were cleaned or replaced when contaminated to reduce the risk infection for Resident # 32. The findings are: 1. Resident # 32 with diagnoses of: Complete traumatic amputation at level between right hip and knee, gastrointestinal hemorrhage, pulmonary embolism, esophagitis, muscle wasting, pressure ulcer of sacral region, stage 2, pressure ulcer, unspecified site stage 2, schizophrenia. a. A physicians order dated 6/3/24 documented, . Order Summary: Treatment: Pressure Ulcer to Right superior dorsal thigh area, (W #3). Clean with wound cleanser, pat dry, apply Silvadene, cover with foam dressing. Change daily and as needed every day shift for Wound care. skin integrity. Replace dressing and notify Treatment nurse. and as needed for Ineffective or soiled dressing. Change and notify…
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 · D2024-06-05 · 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 and interview, it was determined that the facility failed to ensure kitchen equipment was in safe, working condition. The findings are: 1. On 6/02/24 at 11:07 AM, the surveyor entered the facility kitchen. Upon entry, the surveyor found water in a puddle between the dishwasher and sinks. 2. On 6/04/24 at 7:42 AM, the surveyor entered the kitchen to find a large puddle of water in the floor between the steam table and refrigerators. The surveyor showed Director of Nurse's (DON) and Dietary Manager (DM) the dishwasher had water coming from it and going all over the floor and running down the table beside the dishwasher. a. On 6/04/2024 at 7:50 AM, the surveyor asked DM how long dishwasher had been leaking water on the floor. DM said he did not know but not for that long. b. On 6/04/2024 at 7:51 AM, the surveyor asked DM if he had reported the dishwasher to anybody. DM said he had not, but he would let somebody know. c. On 6/04/2024 at 7:52 AM, the surveyor noticed a long strip of white trim that runs between the dishwasher and the wall with a black substance. 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 · E2024-06-05 · 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
Based on observation, interview, and record review, it was determined the facility failed to ensure residents rooms are sanitary, clean, and homelike for Resident #4 and the heating and air conditioning unit was maintained and in good repair for Resident #6. The findings are: On 6/02/2024 at 11:38 AM, during initial rounds, surveyor observed Resident #4's room to have an unpleasant odor, the floor was sticky, there was a brown liquid substance on the floor near the left side of the foot of Resident's bed. The puddle of brown liquid substance had napkins laying on top of it. There was a bag of chips laying under the Resident ' s bed, and the over the bed table had spills and trash on top. The room had a clutter of personal belongings throughout the room. On 6/03/2024 at 7:45 AM, while making rounds in facility, there was a puddle of clear liquid substance in the middle of 100 hallway. There was a caution wet floor sign sitting over the wet substance. There is a strong smell of urine/odor on 400 Hall. Surveyor asked Social Services Director (SSD) to look at the puddle of liquid in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-29 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff members (Floor Nurse, Certified Nursing Assistant and Human Resource Director) reported an allegation of physical abuse immediately to the Administrator for 1 (Resident #1) of 4 (Residents #1, #2, #3 and #4) case mix residents. The finding include: Resident #1 was admitted to the facility on [DATE] with a diagnosis of Cerebral Infarction due to Thrombosis of unspecified cerebral artery. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed the resident's Brief Interview for Mental Status (BIMS) was a 12. A score of 8 to 12 indicates Resident #1 was moderately cognitively impaired and required cueing to answer questions. The Care Plan dated 8/01/23 documented Resident #1 had an ADL (activities of daily living) self-care performance deficit related to hemiplegia and hemiparesis affecting the right dominant side. Intervention: When bathing/showering avoid scrubbing and pat dry sensitive skin. A Nurses Note dated 10/27/23 at 12:01 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 · Dcited before2023-11-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 that a humidification bottle was present to humidify oxygen for 1 (Resident #1) of 1 sampled resident who received oxygen. The findings are: 1. Resident #1 was admitted on [DATE] with a diagnosis of Shortness of Breath. a. The Care Plan dated 07/26/2023 documented, .OXYGEN SETTINGS: O2 [oxygen] via nasal prongs @ [at] 2-4LM [2 to 4 liters per minute]. Humidified . b. The Physician Orders dated October 2023 documented, .OXYGEN as needed for SHORTNESS OF BREATH 2 LITERS/MIN [minute] PER NASAL CANNULA PRN [as needed] .Change and date o2 tubing and water bottle q [every] week every night shift every Sun [Sunday] .OXYGEN as needed for SHORTNESS OF BREATH 2 LITERS/MIN PER NASAL CANNULA PRN AND every shift for Shortness of Breath . Change and date o2 tubing and water bottle q week . c. During observation on 11/07/2023 at 02:14 PM, the Surveyor observed Resident #1 lying in bed on her left side with two liters of oxygen per nasal cannula.…
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 before2023-06-29 · 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
FACILITY Kitchen Based on observation, interview, and record review, the facility failed to ensure food items stored in the refrigerators, freezers, and dry storage were sealed or closed, and labeled and dated when received and opened; expired or spoiled items were discarded promptly, and facility dietary staff washed their hands before serving food and picked up plates during service without touching the food surface area to prevent the potential of food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 49 residents who received meals from the kitchen (total census: 50), as documented on the diet list provided by the Administrator on 06/29/23 at 08:05 AM. The findings are: 1. On 06/25/23 at 11:00 AM, observed a paper liquid egg carton dated 6/16/23 with the spout open on a shelf in refrigerator #1. [NAME] #1 stated, Oh that's just from breakfast. I forgot to close it. a. On 6/25/23 at 11:04 AM, [NAME] #1 was asked to describe the cardboard box of bell peppers and the plastic open bin of non-dated cabbage 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 · E2023-06-29 · 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 provide bathing assistance for 3 (Residents #1, #13, #107) of 16 (Residents #1, #13, #15, #17, #19, #21, #26, #37, #38, #40, #49, #101, #103, #105, #107, and #157) sampled residents who required staff assistance with bathing. The findings are: 1. Resident #107 admitted on [DATE] and discharged on 6/1/23. She had diagnoses of unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing. The 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/23 documented the resident scored 15 (cognitively intact) on a Brief Interview for Mental Status (BIMS), required limited assistance with personal hygiene, extensive assistance for bed mobility, transfers, dressing, and toileting and bathing was documented as did not occur. a. The Baseline Care Plan initiated on 5/26/23 documented, .The resident has an ADL (Activities of Daily Life) self-care performance deficit r/t [related to] ORIF [open…
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 before2023-06-29 · 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 residents environment was free of potential accident/hazards for 27 residents who are ambulatory and who reside in the facility according to a list provided by the Nurse Consultant on 6/29/23 at 9:03 AM. The Findings are: 1.On 6/25/23 at 11:56 AM, a red topped container of Germicidal Disposable Cloth wipes was sitting on a crash cart uncovered against the wall outside an office in the common area. Observed residents sitting and ambulating by it throughout the survey. 2. On 6/27/23 at 09:30 AM the Surveyor observed a red topped container of Germicidal Disposable Cloth wipes in the 200 -shower room. The door was unlocked and standing wide open with residents outside the door. There was no staff nearby for during an observation of 17 minutes. 3.On 6/27/23 at 10:00 AM, a red topped container of Germicidal Disposable Cloth wipes was sitting on a crash cart uncovered, against the wall, in the common area at the nurse's desk. Observed residents sitting and ambulating by it throughout the survey. 4.On 6/27/23 at 9:40 AM…
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 before2023-06-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure oxygen was administered per physicians' orders for 1 (Resident #259) of 5 (Resident # 1, #17, #19, #49, & #259) sampled residents who had a physician's order for oxygen on a list provided by the Administrator on 6/29/23 at 8:00AM. The findings are: 1. Review of Resident #259 physician's orders with an order date of 6/2/2023 noted an order for 4 liters of oxygen as needed for shortness of breath. 2. Review of Resident #259 Care Plan, last revised on 6/15/23 noted the resident had altered cardiovascular status due to high blood pressure, with an intervention to use oxygen at 4 liters per minute. 3. On 06/25/23 at 11:37 AM during initial rounds, resident #259 was lying in bed with Oxygen on at 3 Liters Per Minute by nasal cannula. 4.On 06/25/23 at 3:37 PM observed Resident #259 lying in the bed with oxygen at 3 Liters Per Minute by nasal cannula. 5. On 06/25/23 3:46 PM observed Resident #259 lying in bed with oxygen at 3 Liters Per Minute by nasal cannula. 7. On 6/29/23 at 8:39 AM the Surveyor asked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 resident food preferences were communicated to reflect preferences and dislikes for 1 (Resident #21) of 11 (Residents # 1, 15, 17, 19, 21, 33, 34, 40, 46, 49, and 259) sampled residents who were able to voice food preferences per list provided by the Registered Nurse (RN) Consultant on 06/29/23 at 09:03 AM. The findings are: 1. Resident #21 admitted on [DATE] with diagnoses of age-related osteoporosis, abnormal weight loss, and iron deficiency anemia. a. On 06/25/23 at 11:40 AM, Resident #21 stated she does not like scrambled eggs and was served them every morning. The Surveyor asked if she requested eggs in another form from staff. Resident #21 stated, I asked them for fried or boiled eggs, and they said they don't do that. Only scrambled. Resident #21 family, who was visiting, stated she had informed a nurse that her mother did not like scrambled eggs, and asked if they would they provide another form, so she would eat since she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents with consents for the Pneumococcal vaccine received the immunization in a timely manner after admission for 1 (Resident #33) of 5 (Residents #18, 25, 33, 34, and 35) sampled residents for immunization review. The findings are: 1. Resident #33 was admitted on [DATE]. a. Review of the Participation in Immunization Programs consent form revealed an electronic signature of consent for vaccine dated 11/23/22 at 3:41 PM. b. Review of Physician Orders for Resident #33 revealed an order for pneumovax as indicated. c. Review of Resident #33 electronic health record failed to reveal documentation of a Pneumococcal vaccination. 2. On 06/28/23 at 09:22 AM, the Surveyor asked the Infection Preventionist (IP) to locate Resident #33 Pneumococcal vaccination consent or refusal. The IP stated, I don't see one. It says consent. Resident #33 does not have a vaccine documented in the state vaccination web page. The IP showed the document to the Surveyor…
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 ANTHONY & BRYAN ADAMS — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.8 | -0.8 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 37 homes this chain runs (chain average 3.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OVATION HEALTH SYSTEMS, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/13/2012 |
| KINTNER, ANDREA | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/2021 |
| ADAMS, ANTHONY | Individual | CORPORATE OFFICER | — | since 11/13/2012 |
| ADAMS, BRYAN | Individual | CORPORATE OFFICER | — | since 11/13/2012 |
| EDALA, ARPANA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/23/2024 |
CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 77% 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 $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AR
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arkansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045422. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-25, 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.