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Brookridge Cove Rehabilitation And Care Center

1000 Brookridge Lane, Morrilton, AR 72110 · For profit - Individual · 134 certified beds · (501) 354-4585 Medicare & Medicaid certified

Call the home — (501) 354-4585 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citations (F0565, F0568)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has citations for mishandling residents’ money or property (F0565, F0568)
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 57% 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1711 E Harding St · (501) 354-4637 · Call to confirm hours
Pharmacy
10 Hospital Dr · (501) 354-1460 · Call to confirm hours
Grocery
100 Walmart Dr · (501) 693-8838 · Call to confirm hours
Park
1000 Branch St · (501) 354-4122 · Typically dawn to dusk
Place of worship

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 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.6%9.5%15.4%better
Long-stay residents who lose too much weight7.0%4.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.6%0.9%better
Long-stay residents with a urinary tract infection0.3%1.2%2.0%better
Long-stay residents with depressive symptoms0.3%1.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.1%3.9%3.3%better
Long-stay residents whose ability to walk worsened5.7%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.9%21.7%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers1.5%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control13.1%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table3.5%10.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine78.4%77.7%79.4%typical
Short-stay residents rehospitalized after admission15.7%24.1%22.6%better
Short-stay residents with an outpatient ER visit7.3%12.5%12.0%better
Long-stay hospitalizations per 1,000 resident days0.922.011.67better
Long-stay outpatient ER visits per 1,000 resident days2.042.131.80worse

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.

49.1% 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 79 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.1%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
81.6%U.S. median 56.6%
Met the expected recovery
0.19U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 81.6% 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 38 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.1%CMS range 39.9–58.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 6.6–15.210.7%Oct 2022–Sep 2024no 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 discharge81.6%56.6%Oct 2024–Sep 2025CMS 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 discharge73.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge76.3%50.0%Oct 2024–Sep 2025CMS 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 identified88.2%98.7%Oct 2024–Sep 2025CMS 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 setting98.2%100.0%Oct 2024–Sep 2025CMS 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 dischargenot 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 stay1.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.9%CMS range 4.6–14.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.141.02Oct 2022–Sep 2024CMS 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

0.41
RN hours/ resident / day
0.88
LPN hours/ resident / day
3.03
Aide hours/ resident / day
4.32
Total nurse hours/ resident / day
0.21
RN hoursweekends
36.7%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 134 beds and averages 102.2 residents a day — about 76% occupied, or roughly 32 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.32 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.03 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 3.84 hrs/resident/day on weekends vs 4.51 on weekdays — 15% thinner on weekends. RN hours go from 0.49 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2025-08-01)
3
at the previous standard inspection (2024-04-25)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · F2025-08-01 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility document review, interviews, record review, and facility policy review, it was determined that the facility failed to ensure sufficient staffing to meet the residents' needs as evidenced by not following the facility assessment staffing guidelines for 15 of 15 shifts reviewed from 01/04/2025 day shift through 03/06/2025 night shift. The findings include: The Facility Assessment indicated the facility acuities affecting licensed nurses included cancer treatments, respiratory treatments, behavioral and mental health, medication management, high risk of intravenous or intramuscular medications and infusions, dialysis care which was contracted with an outside vendor, ostomy care, hospice care also contracted with an outside vendor, respite care, isolation precautions/education/monitoring, wound care, tube feedings/parenteral nutrition and drain/tube management. The Facility Assessment indicated the facility acuities affecting nurse aides indicated assistance provided with dressing 90%, assistance provided with bathing 100%, assistance provided with transfers 90%,…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 facility policy review, the facility failed to ensure that the dish washing machine vent hood was free of rust; the pest trap was free of rust and dirt; two of three ice machines were maintained in a clean and sanitary condition in one of two kitchens; expired food item was promptly removed / discarded on or before the expiration or use by date, and dietary staff washed their hands before handling clean equipment or food items for two of two meals observed.Based on observation, interview, and facility policy review, the facility failed to ensure a pest trap was free of rust and dirt and kept away from meal preparation areas; two of three ice machines were maintained in a clean and sanitary condition in one of two kitchens; expired food items were promptly removed and discarded on or before the expiration or use by date, and dietary staff washed their hands before handling clean equipment or food items for two of the two meals observed. The findings include: During an observation and concurrent interview on 07/28/25 at 10:10 AM, one box on a shelf…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-01 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interviews, and social media observations, the facility failed to ensure a resident's photograph was not posted on social media without permission and was not visible to the public or other residents, to maintain dignity and privacy for one (Resident #70) of one resident observed.The findings include:Record review of a document titled, Division of Aging and Adult Services, dated 03/06/2017, indicated that Adult Protective Services (APS) was Resident #70's custodian.Record review of a document titled, Physician Affidavit, dated 12/03/2018, indicated Resident #70 was mentally and physically impaired and the physician recommended that the resident remain in the protective custody of the Arkansas Department of Human ServicesReview of photos posted on social media under the facility's page revealed photos of Resident #70. Included were photos showing Resident #70 with food stains on the resident's shirt and the resident eating with food on their mouth. During an interview on 07/31/2025 at 9:47 AM, Human Resources indicated that the Activities Department 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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, interviews, and facility policy review, it was determined the facility failed to ensure that staff performed proper hand hygiene when providing incontinent care for two (Resident #56 and Resident #92) of two residents observed and followed Enhanced Barrier Precautions (EBP) for one (Resident #92) of one resident observed for EBP. The findings include: Resident #56 On 07/30/2025 at 9:40 AM, during an observation of incontinent care for Resident #56 this surveyor observed that Certified Nursing Assistant (CNA) #8 and CNA #7 did not utilize hand sanitizer at any time while providing incontinent care for Resident #56. After removing dirty gloves, CNA #8 and CNA #7 did not sanitize their hands before putting on clean gloves. Both CNA #8 and CNA #7 removed the dirty gloves, placed them in the trash bag and then reached into their scrub top to obtain new gloves without hand sanitizer being utilized. CNA #8 and CNA #7 both participated in the dirty and clean tasks of incontinent care. CNA #8 tucked used wipes between the resident's legs. CNA #8 wiped…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-04 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, and homelike environment as evidenced by not ensuring safe wall mounted railings for safety and convenience. The findings are: Review of a policy titled, Accidents, Hazzard Prevention, specified the frailty of some residents increases their vulnerability to hazards in the resident environment and can result in life-threatening injuries. It is important that all facility staff understand the facility's responsibility, as well as their own, to ensure the safest environment possible for residents. On 09/03/2024 at 10:22 AM, on the 200 Hall, standing facing room [ROOM NUMBER], to the immediate right approximately 6 inches, the wall mounted handrail was not anchored, and the bracket was disconnected from the sheetrock. On 09/03/2024 at 12:33 PM, on the 300 Hall, standing facing room [ROOM NUMBER], 5 feet on the left toward the double doors, the wall mounted handrail bracket connected to the handrest was loose. On 09/03/2024 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 1 of 1 kitchen was in sanitary condition. The findings are: On 04/24/2024 at 09:04 AM, the ice machine had a cloth trimming under the lid. It was wet and had brown and black stains. On 04/24/2024 at 09:05 AM, the Dietary Manager was asked, What's the cloth material on the ice machine? She stated, I don't know what that is. It's been on there since I've been here. I've been here for 2 years. On 04/24/2024 at 09:30 AM, the Administrator stated, We are taking the ice machine out of commission. On 04/24/2024 at 10:22 AM, the Dietary Manager stated, A new ice machine has been ordered. On 04/24/2024 at 11:54 AM, a thick layer of dust and lint was observed on a spice rack on the counter in the kitchen. A lid on top of a blue bin that had coffee in it was dirty. A cart with dessert on it had a grease and dirt built up. On 04/24/2024 at 11:56 AM, the Dietary Manager was asked, Can you tell me what's on the spice rack, and the food cart? She stated, Dust on the spice rack and build up on the food cart. She was asked, How often…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-25 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure Resident ' s bedding was clean and in place for 1 (Resident #1) of 1 sampled residents. The findings include: An admission Record indicated Resident #1 was admitted with diagnoses of Dementia and Multiple sclerosis. A Care Plan indicated that Resident #1 had an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) disease process of MS (Multiple Sclerosis) and needed assistance with his/her ADL's. On 04/22/2024 at 09:17 AM, Resident #1 had a yellowish/brown ring on the pillowcase on the pillow that was used for positioning in the reclining chair. On 4/23/24 at 9:20 AM Resident #1 was observed with a blanket covering that was stained with yellow/brown substance and 1 pillow under the Resident's head had no slip covering. On 04/24/2024 at 09:28 AM, Certified Nursing Assistant (CNA) #3 was observed pushing Resident #1 into his/her room and the Resident was noted to have a pillow under the right arm. The pillowcase had a yellowish- brown ring shaped stain. CNA #3 was asked what she thought 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 ensure an accident/hazard free environment was provided for smokers requiring a smoking apron. The findings are: 1) Resident #13 has diagnoses of Alzheimer's, Stroke with left side paralysis, and Seizure disorder. On the Quarterly Minimum Data Set (MDS) with the assessment reference date (ARD) of April 15, 2024, the resident received a score of 15 (cognition is intact) on the brief interview for mental status (BIMS). a) On 04/23/2024 at 11:45 PM, the Surveyor observed Residents #66, #16, and #13 outside smoking without wearing smoking aprons. b) On 04/24/2024 at 11:50 PM, Residents #66, #16, #13 were outside smoking without wearing a smoking apron. c) On 4/24/2024 at 3:10 PM, Surveyor asked Certified Nursing Assistant (CNA) # 1 what their procedure is when they take smokers out. CNA #1 stated they take them out together and make sure they have their cigarettes, then put their aprons on for the ones who require them. They look at a list where they get the cigarettes to see who needs aprons to prevent them 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-02-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 staff washed their hands between dirty and clean tasks and before handling clean dishes or food items to prevent the potential for food borne illness for residents who received meals from 1 of 2 kitchens; failed to ensure dairy products were maintained at or below a temperature of 41 degrees Fahrenheit; failed to ensure expired food items were promptly removed/discarded by the expiration or use by dates to prevent the potential for food borne illness for residents who received meals from 2 of 2 kitchens. These failed practices had the potential to affect 85 residents who received meals from the Main Kitchen and 11 residents who received meals from the Cottage (total census:107), as documented on the list provided by Dietary Supervisor on 02/14/23 at 2:27 PM. The findings are 1. On 02/13/23 at 10:15 AM, Dietary Employee (DE) #1 turned the hand washing sink faucet and washed her hands. She turned off the faucet with her bare hands, contaminating her hands. Without washing her hands, she picked up clean dishes and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-17 · tag F0568 — pattern
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure residents received an individual Quarterly Financial Record Statement for 2 (Residents #58 and #74) of 13 (Residents #5, #10, #14, #17, #31, #46, #53, #55, #58, #65, #74, #81 and #83) sampled residents who had Trust Funds managed by the facility. This failed practice had the potential to affect 44 residents who had Trust Funds managed by the facility as documented on the Trust Transaction Current Account Balance received from the Business Office Manager (BOM) on 02/15/23. The findings are: 1. Resident #58 had a diagnosis of Diastolic (Congestive) Heart Failure. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS). a. On 02/14/23 at 10:22 AM, the Surveyor asked Resident #58 if the facility managed her money. Resident #58 answered, I get $40.00 per month. The Surveyor asked if she received statements from the facility. Resident #58 answered No. 2. Resident…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · E2023-02-17 · tag F0574 — pattern
    The resident has the right to receive notices in a format and a language he or she understands.
    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 contact information for the State Long-Term Care Ombudsman, the Office of Long Term Care (OLTC) Complaint Department were posted and readily accessible to all 11 residents who resided in the Cottage at the facility. The findings are: 1. On 02/13/23 at 11:00 AM, the Surveyor was unable to locate an Ombudsman or OLTC information poster in the cottage at the facility. 2. On 02/14/23 at 2:30 PM, the Surveyor asked Resident #63, the Resident Council President of the Cottage, if the Cottage had an Ombudsman poster. He answered, I have not seen one. 3. On 02/14/23 at 2:45 PM, the Surveyor asked Resident #59 if she knew where the Ombudsman poster was. She answered, We don't have a poster. 4. On 02/14/23 at 3:00 PM, the Surveyor asked Certified Nursing Assistant (CNA) #5 where the Ombudsman poster was located. CNA #5 stated, When they built the Cottage, we were told there couldn't be anything on the walls, because this is supposed to be more homelike. The Surveyor asked if the Ombudsman poster was in a binder.…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-17 · tag F0576 — pattern
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    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 mail was provided on Saturdays to honor resident rights and prevent potential delays in receipt of mail. This failed practice had the potential to affect all 107 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on 02/14/23. The findings are: 1. On 02/15/23 at 10:45 AM, during a Resident Council Meeting, the Surveyor asked Residents #37, #59, #63, #70, and #71 if they received mail on Saturdays. The five residents in attendance stated they do not receive mail on Saturdays. Resident #63 and Resident #37 stated they see mail and packages delivered to the main building on Saturdays, but they don't receive mail on Saturdays. 2. On 02/15/23 at 1:38 PM, the Surveyor asked the Activities Director if she was responsible for passing out the mail to the residents. She replied, Yes, I am responsible for the mail. The Surveyor asked when it is handed out. She replied, When, every day that mail comes. Usually, every day when I am here, I pass it.…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-17 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    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 confidentiality of resident records were kept private by locking the computer screens when not in use. This failed practice had the potential to affect 93 residents who received medication from the medication carts in the facility's main building as documented on a list provided by the Registered Nurse (RN) Consultant on 02/16/23 at 4:03 PM. The findings are: 1. On 02/14/23 at 8:19 AM, during the morning medication pass the Surveyor observed Licensed Practical Nurse (LPN) #4 walk away from the computer with it left open and visible to anyone walking by the computer. LPN #4 walked off the hall then into the medication room. 2. On 02/14/23 at 8:26 AM, the Surveyor asked LPN #4 if she was aware that she had walked away from the computer with the medical record visible during medication pass. She stated, That is when I went to the Medication Room to find those updrafts. The Surveyor asked what could happen if a computer was left open with a resident's information on it visible to anyone. LPN #4 stated,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-17 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide 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, record review, and interview, the facility failed to ensure bathing services were regularly provided and chin hairs were removed to maintain good hygiene for 1 (Resident #93) of 30 (Residents #5, #10, #14, #16, #17, #18, #31, #35, #37, #42, #44, #50, #58, #59, #63, #65 #66, #70, #71, #83, #88, #93, #96, #96, #97, #99, #100, #104, #157, #457 and #507 sampled residents who required assistance with bathing and/or grooming. This failed practice had the potential to affect 74 residents who required assistance from staff for bathing/showers according to a list provided by the Registered Nurse (RN) Nursing Consultant on 02/16/23 at 4:03 pm. The findings are: 1. Resident #93 had diagnoses of Chronic Kidney Disease, Stage 4 (Severe) Dementia, Moderate with Anxiety, Alzheimer's Disease with Late Onset, Nondisplaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for closed Fracture with Routine Healing and Nondisplaced Lateral Mass Fracture of First Cervical Vertebra. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/22…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 ensure the metal bolts securing toilet seats were cut to a safe length to prevent potential accidents and injury to residents on the Secure Unit for 1 (Resident #96) of 7 (Residents #18, #65, #66, #88, #96, #99 and #100) sampled residents who were able to stand and move on their own. The failed practice had the potential to affect 18 residents on the Secure Unit who were able to stand and move on their own as documented on a list provided by the Registered Nurse (RN) Consultant on 02/17/23. The findings are: 1. Resident #96 had a diagnosis of Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/20/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS) and required extensive physical assistance of one person with transfers and toilet use and was not steady and only able to stabilize with staff assistance when moving from seated to standing position, on and off the toilet and from surface to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a residents Continuous Positive Airway Pressure (CPAP) mask was properly stored when not in use to prevent potential contamination that could result in respiratory infection and failed to ensure a malfunctioning CPAP machine was reported and replaced in a timely manner consistent with professional standards of practice and to prevent possible respiratory complications for 1 (Resident #34) of 2 (Residents #34 and #507) sampled residents who had Physician Orders for CPAP. The findings are: 1.Resident #34 had a diagnosis of Obstructive Sleep Apnea. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/22 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) did not receive oxygen therapy. a. The Clinical Physician Orders in the Facility Computer Software documented, .Apply CPAP at (bedtime) . On Hold 8/15/2022 . CPAP to be cleaned weekly . On Hold . 10/15/2022 . The February 2023…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-17 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets and 32 residents who received mechanical soft diets, 59 residents who received regular diets, in the Main Building and the residents on pureed diets were to receive a #8 scoop of pureed 4 Layer Delight according to a list provided by Dietary Supervisor on 02/14/23 at 2:27 PM. The findings are: 1. The facility menu for the lunch meal provided by the Dietary Supervisor documented the residents who received regular diets and mechanical soft diets were to receive 1/2 cup of Chopped Lettuce with Tomatoes and residents on pureed diets were to receive a #8 scoop of pureed 4 Layer Delight. 2. On 02/13/23 at 12:39 PM, the following observations were made during the noon meal service in the kitchen: a. Dietary Employee (DE) #2 used a tong to portion a pinch of Shredded Lettuce…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-17 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 1 (Resident #88) of 18 (Residents #2, #17, #21, #26, #31, #34, #35, #42, #53, #55, #74, #88, #93, #94, #96, #97, #257 and #507) sampled residents whose MDS was reviewed. This failed practice had the potential to affect 107 residents who resided in the facility as documented on the Daily Census provided by the Administrator on 02/13/23. The findings are: 1. Resident #88 had diagnoses of Vascular Dementia without Behavioral Disturbance, Psychotic Disorder, and Mood Disorder with Hallucinations. The Quarterly MDS with an Assessment Reference Date (ARD) of 01/27/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview of Mental Status (BIMS) and had a Psychiatric Disorder (other than Schizophrenia). 2. The electronic records for Resident #88 contained a (State Designated Professional Associates) document dated 11/05/2021 documented, You recently submitted a Level I application . on the above client. (State…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-17 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to reassess the effectiveness of interventions, and review and revise the Care Plan for 1 (Resident #74) of 4 (Residents #37, #59, #63 and #74) sampled residents whose Care Plans were reviewed. This failed practice had the potential to affect all 4 residents in the Cottage who received Diabetic Nail Care as documented on the Diagnosis Report provided by the Administrator on 02/15/23 at 11:28 AM. The findings are: 1. Resident #74 had a diagnosis of Type 2 Diabetes Mellitus without Complication. The Significant Change Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 11/30/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Assessment (BIMS) and required extensive physical assistance of one person for personal hygiene and was totally dependent on two plus persons for bathing. a. The Physician's Orders dated 12/04/21 documented, Diabetic Nail Care weekly (nurse to trim fingernails and toenails) . every day shift every Sat [Saturday] related to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-17 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure Diabetic Toenail Care was provided for 1 (Resident #74) of 4 (Residents #37, #59, #63 and #74) sampled residents who were dependent on assistance with Diabetic Nail Care as documented on the Diagnosis Report provided by the facility Administrator on 02/15/23 at 11:28 AM. The findings are: 1. Resident #74 had a diagnosis of Morbid (Severe) Obesity due to Excess Calories, Type 2 Diabetes Mellitus without Complication, and Other Idiopathic Peripheral Autonomic Neuropathy. The Significant Change Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 11/30/2022 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Assessment (BIMS) and required extensive physical assistance of one person for personal hygiene and was totally dependent on two plus persons for bathing. a. The Care Plan with a revision date of 12/13/22 documented, .Personal Hygiene: She requires extensive to total assistance with personal hygiene . has Diabetes Mellitus . Diabetic Toe…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-02-17 · tag F0888 — widespread
    Ensure staff are vaccinated for COVID-19
    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 all staff received complete primary COVID-19 vaccinations, had an approved or pending medical or religious exemption, or a temporary delay per the Center for Disease Control (CDC) per the Centers for Medicare and Medicaid Services (CMS) COVID-19 Health Care Staff Vaccination Regulations Quality Service and Oversight (QSO) and staff vaccination tracking records were updated timely. The findings are: 1. On 02/13/23 at 9:58 AM, the Administrator informed the Surveyor the facility currently had 16 COVID-19 positive residents. 2. The Community Transmission Level provided by the Administrator on 02/13/23 at 3:10 PM documented level was High for 02/02/23 and Substantial for 02/08/23. 3. The Staff COVID-19 Vaccination List provided by the Administrator on 02/13/23 at 3:10 PM documented 4 employees were listed as not fully vaccinated and 2 employees were COVID Vac [Vaccination] Exempt. 4. On 02/15/23 at 3:38 PM, the Surveyor asked the Human Resource (HR) Coordinator if she was responsible for tracking the COVID-19…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-02-17 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    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 the residents residing in the Cottage at the facility were allowed to hold Resident Council meetings without staff present. The findings are: 1. On 02/14/23 at 2:45 PM, the Surveyor asked Resident #59 if the Cottage residents were allowed to have Resident Council meetings without a staff member present. She answered, No. I was the council president, and I called a meeting. They didn't like it that I called a meeting without a staff member present, so I resigned. 2. On 02/15/23 at 10:45 AM, during a Resident Council meeting the Surveyor asked Residents #37, #59, #63, #70 and #71 if they were allowed to hold Resident Council Meetings without staff present. Resident #59 stated, We were told we did have to have staff present. Resident #63 stated, We were told we could not have a meeting without them. Resident #70 stated, We haven't had that many meetings because of that. Resident #37 stated, I have never been to one that was just residents. Resident #59 stated, We don't even know there is going to be a meeting until…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to SOUTHERN ADMINISTRATIVE SERVICES — 35 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.8+0.2 vs chain
Health inspection 3 of 53.2-0.2 vs chain
Staffing 4 of 53.9+0.1 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 34 homes this chain runs (chain average 3.8★, per CMS)
2 of 5Des Arc Nursing And Rehabilitation CenterDes Arc, AR 2 of 5The Green House Cottages of Southern HillsRison, AR 3 of 5Arbor Oaks Healthcare And Rehabilitation CenterMalvern, AR 3 of 5Ash Flat Healthcare And Rehabilitation CenterAsh Flat, AR 3 of 5Conway Healthcare And Rehabilitation CenterConway, AR 3 of 5Encore Healthcare And Rehabi Of MalvernMalvern, AR 3 of 5Lake Village Rehabilitation and Care CenterLake Village, AR 3 of 5Ouachita Nursing And Rehabilitation CenterCamden, AR 3 of 5Pocahontas Healthcare And Rehabilitation CenterPocahontas, AR 3 of 5River Ridge Rehabilitation And Care CenterWynne, AR 3 of 5Rogers Health And Rehabilitation CenterRogers, AR 3 of 5Sheridan Healthcare And Rehabilitation CenterSheridan, AR 3 of 5Southern Trace Rehabilitation And Care CenterBryant, AR 3 of 5The Cottages At TexarkanaTexarkana, AR 3 of 5The Green House Cottages Of Belle MeadeParagould, AR 3 of 5Willowbend Health And Rehabilitation, LLCMarion, AR 4 of 5Pleasant Valley Rehabilitation And NursingLittle Rock, AR 4 of 5St Johns Place Of Arkansas, LLCFordyce, AR 4 of 5The Green House Cottages Of Poplar GroveLittle Rock, AR 4 of 5The Pines Nursing And Rehabilitation CenterHot Springs, AR 4 of 5Three Rivers Health And Rehabilitation CenterMarked Tree, AR 4 of 5Twin Rivers Rehabilitation And Healthcare CenterArkadelphia, AR 4 of 5Valley Springs Rehabilitation And Health CenterVan Buren, AR 5 of 5Belle View Estates Rehabilitation And Care CenterMonticello, AR 5 of 5Courtyard Rehabilitation And Health Center, LLCEl Dorado, AR 5 of 5Greenhurst Nursing CenterCharleston, AR 5 of 5Heartland Rehabilitation And Care CenterBenton, AR 5 of 5Highland Court, A Rehabilitation And Resident CareMarshall, AR 5 of 5Ozark Nursing And RehabOzark, AR 5 of 5Summit Health & Rehab CenterTaylor, AR 5 of 5The Green House Cottages Of HomewoodMena, AR 5 of 5The Green House Cottages Of Northwest ArkansasBentonville, AR 5 of 5The Green House Cottages Of Walnut RidgeWalnut Ridge, AR 5 of 5The Green House Cottages Of Wentworth PlaceMagnolia, AR

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 / managerTypeRoleShareSince
4P2T1 OPS HOLDING LPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2020
ALEXARK1 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2022
JEJ ASSETS LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2022
JEJ MANAGEMENT, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2022
PONTHIE, SHARLOTIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2022
TINDELL, MICHAELIndividualW-2 MANAGING EMPLOYEEsince 01/01/2022
PONTHIE, JOHNIndividualCORPORATE DIRECTORsince 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.

$11.9M
Net patient revenuemost recent cost report
+15.6%
Operating marginrevenue minus expenses
$5.7M
Related-party expense57% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 7%Other / private 26%

This home reported $5.7M paid to related parties — landlords or management companies under common ownership — equal to about 57% 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

$254per resident / day
operating cost
$7,706per month
≈ monthly operating cost
$300per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Arkansas
$7,452/mo
Nursing home (semi-private)
$8,060/mo
Nursing home (private)
$4,637/mo
Assisted living

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 045147. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-01, 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.

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