Belle View Estates Rehabilitation And Care Center
1052 Old Warren Road, Monticello, AR 71655 · For profit - Limited Liability company · 80 certified beds · (870) 367-0044 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $7,443 in federal fines (most recent 2023-09-25)
- about 63% 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 | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 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 | 3.7% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.8% | 4.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.4% | 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 | 3.9% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.5% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.2% | 21.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.1% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.9% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.1% | 10.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 81.0% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 23.4% | 24.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.9% | 12.5% | 12.0% | worse |
* 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.
64.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 194 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 79.6% 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 49 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 64.0%CMS range 57.5–69.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.6%CMS range 9.2–14.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 79.6% | 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 | 73.5% | 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 | 75.5% | 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 | 99.0% | 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 | 98.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.0% | 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 | 1.0% | 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 | 5.7%CMS range 3.5–9.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 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 80 beds and averages 71.0 residents a day — about 89% occupied, or roughly 9 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 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below 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 3.10 hrs/resident/day on weekends vs 3.76 on weekdays — 17% thinner on weekends. RN hours go from 0.30 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Actual harm · Gcited before2023-09-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to properly secure a resident wheelchair in the facility van prior to transport, which resulted in a fall with injury to the head and spinal vertebrae requiring emergency room evaluation for 1 (Resident #1) of three (Resident #1, #2 and #3) sampled residents. The findings are: Review of Resident #1's progress note dated 09/25/2023 showed, a diagnosis of absence of right leg above the knee and absence of the left leg below the knee. Review of Resident #1's care plan dated 08/24/2022 showed limited physical mobility and is unable to walk. Review of the Incident and Accident report dated 09/06/2023 showed the following: a. On 09/06/2023 the Maintenance Director and Certified Nursing Assistant (CNA) #1, transported Resident #1 from the hospital back to the facility. Upon arrival back to the facility the Maintenance Director said the Resident hit his head and had a laceration. Resident #1 was assessed by the medical provider and was transported back to the emergency room for an abrasion and hematoma to the back of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-03-14 · 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, interview, and record review, the facility failed to ensure 1 of 1 puree machine was maintained in a clean condition to prevent the potential contamination of residents' food which had the potential to affect 6 residents who received puree meals from the kitchen; food items prepared for meals were covered or sealed to prevent potential cross contamination or food borne illness, and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 64 residents who received meals from the kitchen total census of 68. The findings are: 1. On 03/11/2024 at 09:44 AM, the can opener had a black unknown sticky looking substance surrounding the cutting blade. The Surveyor asked the Dietary Manager (DM) to describe the can opener. The DM confirmed it needed to be washed, and stated it looked like little pieces of something. 2. On 03/13/2024 at 06:35 AM, the Surveyor observed bowls containing cereal on the serving area…
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 before2024-03-14 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 2 (Residents #111 and #161) of 2 sampled residents who required assistance with nail care. The findings are: 1. Resident #111 had a diagnosis of Hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral (Brain) infarction (tissue death) affecting left non-dominant side. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/2024 documented the resident had a Brief Interview for Mental Status (BIMS) score of 07 (00-07 indicates severely impaired) and required substantial/maximal assistance with personal hygiene, by which the helper does more than half the effort. a. A Care Plan with a review date of 03/11/2024 documented, .[Resident #111]'s usual performance is Specify weight bearing with ADLs [Activities of Daily Living] due to recent CVA [Cerebrovascular Accident…
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 · E2024-03-14 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure physician ' s orders were followed to maintain a medication error rate of less than 5% to prevent potential complications for 3 (Residents #9, #33, and #45) of 4 residents observed during the medication passes The Findings are: a. A Physician Order for Resident #9 dated 01/13/2024 documented, [Named brand] Ophthalmic Solution 1.4 % (Polyvinyl Alcohol) Instill 2 drops in both eyes one time a day for Dry Eyes. b. A Physician Order for Resident #9 dated 02/25/2023 documented, Multivitamin-Minerals Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for supplement. c. A Physicians Order dated 02/25/2023 documented, Aspirin Tablet 325 MG (milligram). Give 1 tablet by mouth one time a day for HEART HEALTH. d. On 03/12/2024 at 07:55 AM, Licensed Practical Nurse (LPN) #1 prepared medications for administration. LPN#1 gave medications to Resident # 9 then signed them off. LPN #1 gave an Aspirin 81 MG with the expiration date of 05/26 on the bottle instead of the Aspirin 325 MG. LPN #1 only…
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 · E2024-03-14 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the refrigerated narcotic medications in the medication storage room for the 200 and 400 Halls were stored in a permanently affixed compartment in 1 of 2 medication storage rooms to prevent the potential of misappropriation of resident property. The findings are: 1. On 03/13/2024 at 03:06 PM, Licensed Practical Nurse (LPN) #4 was in the medication room located in the nursing station for the 200 and 400 Halls. There was a specimen refrigerator and lower refrigerator that had a black box inside that was locked. The nurse stated it contained liquid narcotics such as Lorazepam and Morphine vials. 2. On 03/14/2023 at 01:50 PM, the medication room was inspected with another Surveyor and LPN #3. Inside the refrigerator was a locked narcotic box containing narcotics, but it was not permanently affixed. LPN #3 was asked to put the box on the counter so the medications inside could be counted. The refrigerator door was not locked. The narcotics inside were Lorazepam Oral Solution 0.5 ml (milliliter) syringes- 5…
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 · E2024-03-14 · 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 observation, interview, and record review, the facility failed to ensure clean linens were transported in a manner to prevent the potential for contamination; failed to ensure staff performed proper hand sanitation to decrease the potential for cross contamination and to provide a safe and sanitary environment; failed to ensure an ice scoop was not placed inside of an ice cart while passing ice to residents on the 300 hall These failed practices had the potential to affect 67 residents residing in the facility. The findings are: On 03/11/2024 at 01:05 PM, a laundry employee was on the 200 Hall with a linen cart that had residents' clothing hanging on it and it was uncovered. The staff member was observed removing items from the cart and taking them into resident's rooms on the 200 hall. There was nothing covering the linen to prevent the linen being contaminated while in the hallway. This surveyor took a photo of the linen cart with the laundry items hanging and uncovered. On 03/13/2024 at 11:16 AM, Laundry Employee #1 was asked, Tell me how you transport clean linen to 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 · D2024-03-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a catheter tubing was secured to prevent complications from trauma for 1 (Resident #57) of 1 sampled resident who had a catheter. The findings are: A. Resident #57 had diagnoses of Urinary retention and Neurogenic bladder. B. On 03/11/2024 at 10:52 AM, Resident #57 was sitting in a wheelchair with a catheter in place, with the tubing pulled taunt with no leg band securement device in place. C. On 03/11/2024 at 02:41 PM, Resident #57 was lying in bed with the catheter tubing pulled taunt with no leg band securement device in place. D. A physician's order dated 02/16/2024 documented, .Catheter 16 FR (French, which indicates the size of the catheter tubing) with 10 CC (cubic centimeter) balloon record output every shift for urine retention. E. On 03/12/2024 at 01:30 PM, Resident #57 was lying in bed. Certified Nurse Assistant (CNA) #4 was in room, giving care. CNA #4 was asked to check the resident ' s leg band. CNA #4 pulled back the covers and the catheter tubing was pulled taunt hanging down the right…
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 · D2024-03-14 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure an Antibiotic Stewardship Program was consistently implemented, as evidenced by an antibiotic was prescribed for a diagnosis of Abnormal UA (urinalysis) without confirmation of a culture report, to decrease the potential for harm caused by unnecessary antibiotic use and to decrease the potential for resistance for 1 (Resident #41) of 1 (Resident #41) sampled residents who were prescribed an antibiotic without confirmation of a urinary tract infection (UTI) as documented on a list provided by the Administrator on 3/14/24. The findings are: 1. Resident #41 had a diagnosis of Personal history of urinary (tract) infection. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/2024 documented the Resident had a Brief Interview for Mental Status (BIMS) score of 08 (08-12 indicates cognitively impaired), was dependent for toileting hygiene, and was always incontinent of urine and bowel. a. A Urinalysis with Microscopic collected on 03/10/2024 indicated that Resident #41 had bacteria and yeast…
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 before2023-01-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure leftover food items were maintained to promote food quality and/ or prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; failed to ensure foods stored in the kitchen areas, freezer and refrigerator were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure expired food items were promptly removed/discarded on or before the expiration or use by dates; failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; and failed to ensure 1 of 1 ice machine was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages. These failed practices had the potential to affect 54 residents who received meals from the kitchen (total census: 59), as documented on a list provided by Dietary Supervisor on 1/23/2023 at 10:57 AM. The findings are:…
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 · E2023-01-26 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide reasonable accommodations of needs by not having the call light within reach for 2 Residents (R #34 and R #108) that required assistance with Activity of Daily Living (ADLs) and required the call light to request assistance. The findings are: 1.Resident #34 had a diagnosis of Hemiplegia and Parkinson's Disease. The Quarterly MDS [Minimum Data Sheet] with an ARD [Assessment Reference Date] of 10/20/22 documented the resident had a BIMS [Brief Interview for Mental Status]-15 (13-15 indicates cognitively intact), required physical assistance of one-person for bed mobility, transfers, and toileting. a.Review of Resident #34 Care Plan with and initiation date of 1/05/23 and no revision date, documented . (Resident #34) IS AT RISK FOR FALLS R/T [Related To] LIMITED MOBILITY D/T [Due To] HEMIPLEGIA AFFECTING RT [Right] DOMINANT SIDE .FALL 01/24/2022, FALL 04/04/22, FALL 04/24/22, FALL 08/28/22, FALL 1/23/23 .ENCOURAGE TO USE CALL LIGHT FOR ASSIST . b. 01/23/23 at 06:23 AM, Resident #34's was on isolation 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 · E2023-01-26 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 promote and facilitate resident self-determination through support of resident choices for 2 residents (R #14 and R #108) who chose not to get up before 5:00 am daily. The findings are: 1.Resident #14 had diagnoses of Unilateral Primary Osteoarthritis, right hip, chronic respiratory failure with Hypoxia, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The Medicare - 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/22 documented a Brief Interview for Mental Status (BIMS) score of 12 (8-12 indicated moderately impaired). a. On 1/23/23 at 5:00 am, Resident #14 was sitting in a wheelchair in the doorway to his room. The Surveyor stated, Good Morning. R #14 stated to the Surveyor, it would be better if they didn't get me up so early. The Surveyor asked R #14, did you get up too early? R #14 stated, they get me up way too early. The Surveyor asked R #14, why? R #14 stated, they said I have to get up early because I have therapy. I'm told that I…
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 6 citations
- Potential for harm · E2023-01-26 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure planned fall prevention interventions were consistently implemented to promote safety and prevent falls for 1 (Resident #54) of 8 (Residents R #21, R #24, R #38, R #52, R #53, R #54, R #55, and R #208) sampled residents who had a history of falls in the past 120 days. This failed practice had the potential to affect 14 residents who had falls in the past 120 days, according to a list provided by the Assistant Director of Nursing (ADON) on 1/25/23 at 2:15PM. The findings are: 1. Resident #54 had Diagnoses of Fractured left femur, Non-Alzheimer's, Malnutrition, Anxiety, Stenosis of Carotid Artery. The admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/2/23 documented the resident scored 11 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and limited assistance with eating.…
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 before2023-01-26 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure Activity of Daily Living (ADL)s were carried out to promote good health and wellbeing for one (Resident #25) of 19 (R #2, R #9, R #10, R #12, R #14, R #15, R #21 R, #24, R #25, R #34, R #38, R #39, R #40, R #52, R #53, R #54, R #108, R #109, R #208) sampled residents. The failed practice had the potential to affect all 59 residents who required assistance with ADLs. The findings are: 1.Resident #25 had diagnoses of Diabetes Meletus and Hemiplegia. The Quarterly MDS [Minimum Data Set] with an ARD [Assessment Reference Date] of 12/13/22 documented a BIMS [Brief Interview of Mental Status] of 14 (13-15 indicates Cognitively Intact) and one-person extensive physical assistance with bathing and grooming. Rejection of care was marked no. a. Review of Resident #25's tasks sheet from 12/25/22, to 01/24/23 documented the resident had refused a bath three times, received a bath 3 times and had no adverse behaviors. b. Review of Resident #25's Care Plan dated 01/04/23 documented, .(Resident #25) HAS AN ADL SELF…
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 before2023-01-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure planned fall prevention interventions were consistently implemented to promote safety and prevent falls for 1 (Resident #54) of 8 (Residents #21, #24, #38, #52, #53, #54, #55 and #208) sampled residents who had a history of falls in the past 120 days. This failed practice had the potential to affect 14 residents who had falls in the past 120 days, according to a list provided by the Assistant Director of Nursing (ADON) on 1/25/23 at 2:15 p.m. The findings are: 1. Resident #54 had diagnoses of Fractured left femur, Non-Alzheimer's, and Anxiety, Malnutrition, and Stenosis of Carotid Artery. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/2/23 documented the resident scored 11 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and limited assistance with eating. a. 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 · E2023-01-26 · 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, interview, and record review the facility failed to ensure respiratory equipment was properly store and dated to prevent contamination for 1 (Resident #34) of 4 (Resident #15, R #34, R #108, and R #208) sampled residents. This practice had the potential to affect 7 resident who received nebulizer treatments. 1.Resident #34 had diagnoses of Hemiplegia, Parkinson's Disease and Active COVID-19 infection. The Quarterly MDS [Minimum Data Set] with an ARD [Assessment Reference Date] of 10/20/22 documented the resident scored a 15 on a BIMS [Brief Interview for Mental Status] (13-15 indicates cognitively intact), required physical assistance of one-person for bed mobility. a. Resident #34's Physician's Orders dated 1/22/23 documented, .Droplet Isolation Precautions for COVID-19 every shift for 10 Days related to COVID-19 . May have Oxygen 2 LPM [Liters per minute] Via N/C [Nasal Canula] as needed every shift for Oxygen Therapy .Albuterol Sulfate Nebulization Solution (2.5 MG/3ML [milligrams/milliliter] 0.083% [percent] 1 vial inhale orally via nebulizer every 8 hours…
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 · E2023-01-26 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets, as documented on the list provided by the Dietary Supervisor on 1/23/2023 at 10:57 AM. The findings are: 1. On 1/23/23 at 6:44 AM, Dietary Employee #1 placed 4 servings of sausage into a blender, added warm milk and pureed. She poured the pureed meat in a pan, covered the pan with foil and placed it on the steam table. The consistency of the pureed sausage was not smooth. 2. On 1/23/23 at 7:16 AM, Dietary Employee #2 placed 4 servings of biscuits into a blender, added warm milk, and pureed. She poured the pureed biscuits in 3 bowls to be served to the residents on pureed diets. The consistency of the pureed biscuit was not smooth. The Surveyor asked Dietary Employee #2 to describe the consistency of the pureed food items. She stated, we should have…
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 · D2023-01-26 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 a resident's wishes regarding Cardiopulmonary Resuscitation (CPR) was accurately conveyed in the resident's chart for 1 (Resident R #55) who had a document titled, Do Not Resuscitated (DNR) signed by the Physician present in the Electronic Medical Chart under the Documents tab. The findings are: a. On [DATE] at 9:08 am, during the record review of R #55 Electronic Medical Record, there was a document titled, Do Not Resuscitate (DNR) signed by the Physician present. While reviewing the orders for R #55 there was a Physician telephone order dated [DATE] stating, Full Code . The Care Plan for R #55 stated, .I have requested that no CPR measures be performed. My code status is DNR . b. On [DATE] the Surveyor asked the ADON, should a resident's wishes regarding code status match the order for code status located in a resident's Physician Orders? The ADON stated, Yes. The Surveyor asked, why is important for a resident's code status…
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
$7,443 in federal fines across 1 penalty.
- $7,443 — penalty dated 2023-09-25
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to SOUTHERN ADMINISTRATIVE SERVICES — 35 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.8 | +1.2 vs chain |
| Health inspection | 5 of 5 | 3.2 | +1.8 vs chain |
| Staffing | 3 of 5 | 3.9 | -0.9 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 34 homes this chain runs (chain average 3.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| 4P2T1 OPS HOLDING LP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2020 |
| ALEXARK1 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| JEJ ASSETS LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| JEJ MANAGEMENT, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| PONTHIE, SHARLOT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| TRUCKS, JULIE | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 07/01/2020 |
| PONTHIE, JOHN | Individual | CORPORATE DIRECTOR | — | since 01/01/2022 |
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $4.4M paid to related parties — landlords or management companies under common ownership — equal to about 63% 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 045239. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, 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.