Monette Manor, LLC
669 Hwy 139 North, Monette, AR 72447 · For profit - Limited Liability company · 86 certified beds · (870) 486-5419 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — 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 (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $24,309 in federal fines (most recent 2024-02-20)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure 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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 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 | 19.3% | 9.5% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.0% | 4.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.8% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.5% | 1.4% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.0% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.9% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 36.4% | 21.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.5% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.3% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.0% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.8% | 10.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 4.3% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 34.2% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.0% | 24.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.5% | 12.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.50 | 2.01 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.03 | 2.13 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
40.8% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 20.0% 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 25 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.8%CMS range 27.8–55.6 | 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 | 11.5%CMS range 8.0–16.7 | 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 | 20.0% | 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 | 12.0% | 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 | 20.0% | 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 | 96.2% | 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 | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.9% | 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 | 10.0%CMS range 5.8–16.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 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 86 beds and averages 81.2 residents a day — about 94% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.06 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 3.66 hrs/resident/day on weekends vs 4.22 on weekdays — 13% thinner on weekends. RN hours go from 0.31 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · F2026-04-23 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure the Infection Preventionist had completed specialized training in infection prevention and control before taking the position. The failed practice had the potential to affect all 79 residents residing in the facility. The findings include: Review of the facilities Infection Prevention and Control Program (IPCP) states the facility must designate one or more individuals who are responsible for the facility IPCP who have the specialized training in infection prevention and control. During an interview on 04/22/2026 at 12:39 PM the Director of Nurses (DON) indicated she had not completed specialized training beyond her initial professional training as a nurse, nor received a completion certificate for infection prevention and control. The DON stated I have not completed a full module of the necessary training as of yet for the Infection Preventionist.
- Potential for harm · E2026-04-23 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to maintain an infection prevention and control program that included an Antibiotic Stewardship Program (ASP) ) this failed practice had the potential to affect all residents who resided in the facility. The findings include: Review of an undated facility Antibiotic Stewardship Manual revealed that the Infection Preventionist (IP) will track antibiotic use and monitor adherence to evidence-based criteria and compile reports related to monitoring antibiotic usage and resistance data. Review of a facility Antibiotic Stewardship Tracking and Trending document revealed no documentation for the months of March and April of 2026. Last documentation for tracking/trending was February. Documentation in February showed antibiotic use, with a resident's name, s/s were documented, but the tracking/trending of the different halls for the month of February were not completed. During an interview on 04/22/2026 at 12:36 PM, the Director of Nursing indicated they were responsible for the Antibiotic Stewardship Tracking and Trending as the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observations, interviews, record review, and facility policy review, it was determined that the facility failed to develop and implement a Comprehensive Person-Centered Care Plan for one (Resident #36) of five residents reviewed that included measurable objectives and timeframes to meet a resident's medical, nursing, needs that were identified in the Comprehensive Assessment Specifically, Resident #36's Care Plan did not address or focus on an active diagnosis of type 2 diabetes, nor include interventions to guide staff in monitoring for complications. The findings include: Review of an admission Record revealed the facility admitted Resident #36 on 12/29/2025 with diagnoses that included type 2 diabetes with elevated blood sugars, congestive heart failure, chronic kidney disease, Alzheimer's, high blood pressure, cognitive communication deficits, depression, insomnia and anxiety. Review of Resident #36's admission Minimum Data Set (MDS), with an Assessment Reference Date of 01/05/2026, revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14 which…
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 before2026-04-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to ensure that antibiotic medications were administered promptly and as ordered, and that the accuracy of orders entered into a resident's electronic health record was verified for one (Resident #76) of one resident reviewed for medication administration. Specifically, the facility failed to ensure ordered antibiotics were not left in the medication room's overflow box for seven days prior to initiating administration, and to ensure the duration of the antibiotics were entered as ordered. The findings include: Review of Resident #76's Medical Diagnosis report revealed, the facility admitted Resident #76 with diagnosis that included chronic obstructive pulmonary disease (COPD) [damage to the airways causing inflammation and other problems that block airflow and make it hard to breath]; urinary tract infection (UTI) [infection in any part of the urinary system]. Review of an Order Summary…
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 · D2026-04-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #83) of three residents reviewed for accidents. Specifically, the facility failed to follow the person-centered care plan interventions for Resident #83, resulting in an accident. The findings include: Review of an admission Record revealed the facility admitted Resident #83 on 08/15/2025 with diagnoses that included brain cancer, heart failure, need for assistance with personal care, muscle wasting and atrophy, abnormalities of gate and mobility, cognitive communication deficit, infection following a procedure at surgical cite, repeated falls, syncope and collapse, and fracture to left femur. Review of a discharge return anticipated Minimum Data Set (MDS), with an Assessment Reference Date of 10/25/2025, revealed Resident #83 had a Brief Interview for Mental Status score of 3, which indicated the resident had severe cognitive impairment. The 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 · D2026-04-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for one (Resident #36) of three residents reviewed. The findings include: Review of an admission Record revealed that the facility admitted Resident #36 on [DATE] with diagnoses that included type 2 diabetes with elevated blood sugars, congestive heart failure, chronic kidney disease, Alzheimer's, high blood pressure, and cognitive communication deficits. Review of Resident #36's admission Minimum Data Set (MDS), with an Assessment Reference Date of [DATE], revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact and was independent for daily decision making. The MDS indicated Resident #36 used a wheelchair for…
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 before2026-04-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review and facility policy review, it was determined that facility staff failed to wear proper Personal Protective Equipment (PPE) while providing direct care to a resident that had an indwelling catheter in place and was on Enhanced Barrier Precautions (EBP) for one (Resident #11) of one resident reviewed for Infection Control. The findings include: Review of Resident #11's Medical Diagnosis revealed the facility admitted Resident #11 with diagnosis that included Urinary Tract Infection (UTI) [bacteria in urinary tract] Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 01/26/2026, revealed Resident #11 had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. Review of Resident #11's Care Plan initiated on 04/17/2026, revealed Resident #11 had EBP in place due to indwelling catheter. Care Plan interventions included appropriate PPE to be worn by staff. Review of an Order Summary revealed Resident #11 had an order for EBP in place related to indwelling catheter…
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 before2025-12-31 · 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, facility document review, interview, and facility policy review, it was determined that the facility failed to ensure fall interventions were placed in a person-centered care plan following falls for five (Resident #4, Resident #5, Resident #7, Resident #8, and Resident #9) of seven residents reviewed for fall interventions in a person-centered care plan. The findings include: Resident #4: A review of Resident #4's admission Record indicated the facility admitted the resident on 02/13/2024 with diagnoses which included a nondisplaced fracture of coracoid process, right shoulder (broken part of the shoulder blade), multiple rib fractures to the right side, and a wedge compression fracture of the T7-T8 vertebra (fracture to the middle of the spine). A review of Resident #4's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/26/2025, revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had severe cognitive impairment. Resident #4's MDS also revealed the resident required partial/moderate…
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 · E2024-09-26 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, document review, and facility policy review, the facility failed to report 3 of 3 incidents of resident-to-resident abuse reviewed, failed to report an unwitnessed fall with serious injury, and failed to complete a thorough investigation of the incidents. The findings are: 1. A review of an admission Record indicated the facility admitted Resident # 46 with diagnosis Dementia, Severe with other Behavioral disturbance. The quarterly Minimum Data Set with an Assessment Reference Date 6/27/2024 revealed Resident # 46 had a Brief Interview for Mental Status (BIMS) score of 01 (0-7 suggest severe cognitive impairment). In Section E0200. Behavioral Symptoms revealed Physical behavioral symptoms directed towards others and B. Verbal behavioral symptoms directed towards others. A review of nursing Health Status Note dated 8/16/2024 at 8:04 revealed Resident was aggressive and combative toward another resident. Resident being sent to ER (Emergency Room) for evaluation.…
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 · E2024-09-26 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility document review and interview, it was determined the facility failed to electronically transmit encoded, accurate, and complete, Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days to provide accurate and up-to-date information for quality measures for 6 (Residents #1, #2, #26, #34, #41, and #44) sampled residents whose MDS assessments were reviewed. The findings are: On 09/26/2024 the following observations were made in resident health records: Resident #1 had an admission assessment with an ARD of 11/08/2023 exported but not accepted. Resident #2 had a Significant Change assessment with an ARD 1/28/2024 that was export ready. Resident #26 had an admission assessment with an ARD 11/5/2023 that was exported but not accepted. Resident #34 had an admission assessment with an ARD 11/13/2024 that was exported but not accepted. Resident #41 had an admission assessment with an ARD 3/12/2024 that was exported but not accepted. Resident #44 had an admission assessment with an ARD of 2/07/2024…
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 9 citations
- Potential for harm · Ecited before2024-09-26 · 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, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan to reflect the residents needs and preferences for 5 residents (Resident #37, Resident #13, Resident #14, Resident #220, and Resident #120) of 19 residents reviewed for care plans. The facility failed to properly assess residents and implement care plan interventions which affect the residents' highest practicable physical, mental, and psychosocial well-being. The findings are: 1. A review of an admission Record, indicated the facility admitted Resident #120 with diagnoses that included congestive heart failure, atrial fibrillation, chronic kidney disease and repeated falls. A review of Resident #120's electronic records revealed on 9/17/2024, an admission MDS had not been completed and a Baseline Care Plan had not been initiated. There was not a Plan of Care to document Resident #120's cognitive function, fall risk or the administration of Oxygen…
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 before2024-09-26 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete clinical assessments to accurately portray the resident's care for the Minimum Data Set (MDS) and care plan intervention implementation for 6 (Residents #2, #14, #37, #48, #70, and #220) residents of 19 sampled residents affecting their quality of care. These are our findings: A review of the electronic health record revealed that Resident #2 had the following overdue assessments: wandering risk assessment due on 05/02/2024, side rail assessment due on 05/02/2024, fall scale due on 05/29/2024, pain interview due on 05/29/2024, neurological check list due on 05/30/2024 at the following times 1:15 AM, 1:30 AM, 2:00 AM, and 9:00 AM, pain interview due on 07/09/2024, fall scale due on 07/09/2024, skin observation tool on 08/16/2024, and skilled charting on 09/08/2024 at 8:49 AM. A review of the Clinical - Assessment revealed Resident #14 had the following overdue assessments: side rail assessment due on 05/30/2024, functional abilities and goals-admission due on 05/31/2024, skin observation tool due on 08/16/2024,…
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 · E2024-09-26 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to follow the menu for pureed diets for the lunch service. The findings are: On 09/26/2024 at 11:50 AM, Dietary Aide #2 was overheard stating they did not puree white beans. On 09/26/2024 at 12:10 PM, the Surveyor observed that while plating the pureed trays during lunch that the resident's received pureed pork chop, pureed turnip greens, puree cornbread, and pureed banana crème pie for dessert, an alternate was not observed for the white beans. On 09/26/2024 at 2:11 PM, during an interview the Assistant Dietary Manager stated that yesterday for lunch the puree diets should have got pork chops, turnip greens, white beans, cornbread, and banana crème pie. The Assistant Dietary Manager continued stating that they were not aware until later that the pureed white beans were not served with the lunch meal. The Assistant Dietary Manager stated that Dietary Aide #2 had come to them and explained that she had forgotten to puree the white beans for lunch service. The Assistant Dietary Manager then stated that it was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interview, the facility failed to ensure infection control procedures were followed by not performing hand hygiene between residents while assisting at the assisted diner table in the dining room to prevent the potential spread of infection for 2 residents observed during a lunch meal, and failed to ensure infection control procedures were followed in the areas of perineal care, catheter care, and enhanced barrier precautions to prevent the spread of infections for 1 of 1 sampled resident (Resident #13). The findings are: A review of the Order Summary Report revealed Resident #13 had diagnoses of chronic kidney disease stage 3, retention of urine, and need for assistance with personal care. A review of the Order Summary Report revealed Resident #13 had an order for Enhanced Barrier Precautions active as of 08/23/2024, related to the resident having a percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube that's inserted through the abdominal wall and into the stomach) and a suprapubic catheter placement (a tube that drains urine 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 · D2024-09-26 · 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 record review, and interview, it was determined the facility failed to ensure a baseline care plan was completed with the minimum necessary information within 48 hours after admission to promote continuity of care for 1 (Resident #120) sampled resident who was admitted within the last 30 days. The findings are: A review of the admission Record indicated the facility admitted Resident #120 with diagnoses that included congestive heart failure, atrial fibrillation, chronic kidney disease and repeated falls. A review of Resident #120's electronic records did not include an admission assessment on the admission date of 9/17/2024, a Minimum Data Set (MDS), or indicate a care plan had been initiated. During an interview on 9/26/2024 at 2:14 PM, the Director of Nursing (DON) said the nurses were responsible for the assessments upon admission or readmission to the facility and responsible for the functional and abilities assessments which must be completed within 24 hours. She does the baseline care plan within 4 hours of admission. She looked in Resident #120's record and said…
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 · D2024-09-26 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review, the facility's administration failed to ensure the administrator was knowledgeable regarding reporting requirements, which resulted in failure to immediately report a resident to resident altercations, and an unwitnessed fall with major injury, to the State Survey Agency (SSA). The findings are: a. On 01/14/2024, a resident to resident altercation involving Resident #71 was not reported to the SSA. b. On 07/10/2024, Resident #48's unwitnessed fall with major injury was not reported to the SSA. c. On 08/16/2024, a resident to resident altercation involving Resident #46 was not reported to the SSA. Review of the Administrator's job description provided by Business Office Manager (BOM) on 09/25/2024 indicated the nursing home administrators are responsible for managing the daily operations of long-term care facilities, including hiring personnel, developing budgets, and ensuring that the facility meets all local, state, and federal regulations. During an interview on 09/25/2025, the Administrator was asked who was responsible for…
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 · D2024-09-26 · tag F0837 — isolatedEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interviews, the facility failed to have an effective governing body in place to ensure proper management and operation of the facility's: Quality Assurance and Performance Improvement Plan (QAPI) feedback system to ensure resident care areas were addressed, for baseline, implementation, and revision of care plans and for timing and transmitting the Minimum Data Sets (MDS). The findings include: On 09/23/2024 at 11:30 AM, the survey team confirmed with the Administrator that there had not been a Minimum Data Set (MDS) Coordinator at the facility. That the previous MDS Coordinator put in her two weeks and her last day was 08/14/2024. On 09/23/2024 at 4:00 PM, the survey team confirmed during record review for initial pool that there was a widespread issue with MDS timing and transmitting, and care plan implementation. On 09/24/2024 at 3:00 PM, during an interview the Administrator stated, We do have the Director of Nursing (DON) and the MDS new hires starting in the next week or so and that should help us get caught up on anything we are behind 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 · D2024-09-26 · tag F0839 — isolatedEmploy staff that are licensed, certified, or registered in accordance with state laws.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interviews, the facility failed to ensure qualified staff was hired in a position to accurately encode, transmit, and implement assessments and care plans. The findings are: A facility review of the job description for Minimum Data Set Coordinator (MDS) revealed the staff member was in charge of completing all MDS and Care Area Assessments (CAAs), schedules, and leads the Care Plan Conferences, transmits completed MDS assessments to the state in compliance with federal regulations, completes, or ensures that the Unit Nurses can complete special quarterly assessments, and writes all chronic nursing care plans for all residents in the facility and monitors acute nursing care plans. On 09/23/2024 at 11:30 AM, the survey team confirmed with the Administrator that there had not been an MDS Coordinator at the facility. That the previous MDS Coordinator put in their two weeks and that their last day was 08/14/2024. On 09/24/24 at 10:09 AM, during an interview the Director of Nursing (DON) stated she had worked here for seven years and came back after the tornado…
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 · D2024-09-26 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure an effective feedback system was in place for the Quality Assurance and Performance Improvement Plan (QAPI). The findings are: A review of the Quarterly QAPI Minutes revealed that admissions, staffing issues, facility issues (such as the Certified Nursing Assistants (CNAs) needing smaller linen carts), ongoing staff education, shower scheduling, improving transport, and staff scheduling had been discussed. The was no mention of falls, behaviors, Minimum Data Sets (MDS), care plans or other resident concerns identified during the survey had been discussed. A review of the Quality Assurance and Performance Improvement Plan (QAPI) Program stated, .1. Systems and reports demonstrating systematic identification, reporting investigation, analysis, and prevention of adverse events . A review of the QAPI Committee stated, Purpose: Review all facets of the facility's operations to ensure that care and services promote the environment needed to identify issues that may impede quality of life for the residents. Implement 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.
“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
$24,309 in federal fines across 6 penalties.
- $4,178 — penalty dated 2024-02-20
- $3,798 — penalty dated 2024-02-12
- $9,116 — penalty dated 2024-01-22
- $2,279 — penalty dated 2024-01-08
- $1,764 — penalty dated 2024-01-02
- $3,174 — penalty dated 2023-12-11
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WILLIAM C. BULLOCH FAMILY TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 50% | since 08/01/2023 |
| SAMPSON, RICK | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 08/01/2023 |
| CARE MANAGEMENT, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/07/2025 |
| LYERLY, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2023 |
| STEWART, KEVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2023 |
| BIXLER, CINDY | Individual | ADP OF THE SNF | — | since 01/01/2005 |
| TURNER, MIKE | Individual | ADP OF THE SNF | — | since 01/01/2005 |
CMS files one row per role, so the 12 rows in the source record cover these 7 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.
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 045477. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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.