Arkansas State Veterans Home At North Little Rock
2401 John Ashley Drive, North Little Rock, AR 72114 · Government - State · 96 certified beds · (501) 683-2382 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (62%) runs well above the national median (45%)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 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 |
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 4 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 | 5.5% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.5% | 4.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.6% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 1.2% | 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 | 2.5% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.1% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.6% | 21.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 86.2% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.1% | 13.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.3% | 10.9% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.60 | 2.01 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.75 | 2.13 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 96 beds and averages 87.7 residents a day — about 91% occupied, or roughly 8 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 5.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.48 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 4.44 hrs/resident/day on weekends vs 5.31 on weekdays — 17% thinner on weekends. RN hours go from 0.53 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% is well above 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.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · F2024-02-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed and dated to minimize contamination for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed / discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or contamination; meals from 8 of 8 kitchens; Hot food items were maintained at above 135 degrees Fahrenheit on the counter while awaiting service to prevent potential food borne illness for residents who received meals from the kitchen in Heroes Home #1, Heroes Home #2, Heroes Home #3, Heroes Home #4, Heroes Home #5 Heroes Home #6 Heroes Home #7 and #8, and hand hygiene was maintained during food service to minimize the risk of food borne illness in Heroes #4 and #6. These failed practices had the potential to affect 12 residents Heroes Home #1, 11 residents on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-23 · 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 to ensure a call light was in reach for 1 Resident #49. The findings are: Resident #49 diagnoses showed Dementia and Macular degeneration. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/15/24 showed a Staff Assessment of Mental Status (SAMS) documenting short- and long-term memory problems. The Resident requires substantial/maximum assistance with toileting and personal hygiene. The Resident is dependent on staff to put on or take off footwear. The care plan showed Resident #49 had an ADL (Activities of Daily Living) self-care performance deficit related to dementia. Staff are to encourage the resident to use the bell to call for assistance. On 02/20/24 at 11:26 AM, the Surveyor observed no call light in Resident #49's room. On 02/20/24 at 2:41 PM, the Surveyor observed no call light in Resident #49's room. On 02/21/24 at 11:09 AM, the Surveyor observed no call light in Resident #49's room. On 02/21/24 at 11:10 AM, the Surveyor asked Certified Nursing Assistant (CNA) #13 where is the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-23 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the 2023 survey results were located in the State Survey Binder, if. This failed practice had the potential to affect all sampled residents who chose to read the State Survey Binder. The findings are: On 02/20/24 at 02:07 PM, the Surveyor observed the State Survey Binder in Hero House #7 with the most recent survey in the book being a complaint on 9/22/2022. The most recent recertification survey was dated 12/09/2022. On 12/20/24 at 02:43 PM, the Surveyor did not observe a State Survey Binder in Hero House #8 readily available to residents and visitors. On 02/21/24 at 04:32 PM, the Surveyor asked the Administrator should each Hero House have a State Survey Binder readily available, and with the most current survey information, for residents and visitors to read? The Administrator said yes. The Administrator confirmed the most recent copy of the survey was not in the binder for Hero House #7 and the survey binder in Hero House #8 was not readily available. A document provided by the Director of Nurses on 2/22/24 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.
- Potential for harm · Ecited before2024-02-23 · 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 that 4 Resident's # 3, #26, #30, #75) of 19 sample mix residents had their nails cleaned and trimmed to promote good hygiene, cleanliness, and a sense of wellbeing. The findings are: On 02/20/2024 at 10:04 AM, surveyor observed Resident (#3) in room with ¼ inch nails on both hands with dark brown substance under jagged nails. On 2/20/2024 at 11:28 AM, surveyor observed Resident (#3) in room. Resident had long ¼ inch nails on both hands with brown substance under jagged nails on both hands. On 2/21/2024 at 10:04 AM, surveyor observed Resident (#3) in room. Resident had long ¼ inch nails on both hands with brown substance under jagged nails on both hands. On 2/21/2024 at 3:45 PM, surveyor interviewed Certified Nursing Assistant (CNA) (#3) and asked how often is nail care performed. CNA #3 confirmed, on their shower days if needed. Who is responsible for making sure nail care is completed. CNA #3 confirmed, the CNAs are. The surveyor asked what negative outcome can occur from nails being left with brown…
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 · E2024-02-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and observation, the facility failed to ensure an accident/hazard free environment was provided for 3 (#8, #45 and #56) residents in the case mix. This failed practice had the potential to affect 3 (#8, #49, #47) sampled ambulatory residents who resided in Unit 8. The facility also failed to ensure the residents were free of potential accidents and hazards, as evidenced by failure to ensure that all the end clips were in place on the Hoyer lift. This failed practice had the potential to affect 2 residents, (#26, and #59), of 2 sampled residents who reside in Cottage 1 and are dependent on a Hoyer Lift to transfer. The findings are: Resident (#8) had Diagnoses: Unspecified dementia, severe, with other behavioral disturbance, Dementia in other diseases classified elsewhere, severe, with agitation. On the Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of December 21, 2023, the resident is identified as (Moderately Impaired) on the Staff Assessment for Mental Status. On 2/20/24 at 12:15 AM, the light fixture in Resident #8 ' s…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-23 · 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 1 of 1 meal observed. This failed practice had the potential to affect 1 resident who received a puree diet. The findings are: 1. On 02/22/24 12:37 PM, Certified Nursing Assistant (CNA) #11 placed a serving of corn into a blender, added milk and pureed. At 12:42 PM, she poured the pureed corn on a divided plate on the counter. The consistency of the corn was runny, not formed and not smooth. There were pieces of corn skin visible in the mixture. 2. On 02/22/24 at 12:52 PM, CNA #11 deboned servings of fried chicken and placed them into a blender, added gravy and pureed. At 12:56 PM, CNA #11 poured the pureed chicken in a divided plate. The consistency of the purees chicken was gritty and not smooth. There were pieces of chicken visible in the mixture. 3. On 02/22/24 at 01:03 PM, CNA #11 placed one serving of cornbread into a blender, added milk and pureed.…
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 · E2024-02-23 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure a safe environment for 7 residents (#8, #11, 30, #32, #45, #47, #49) sampled residents living in Units 7&8. The findings are: 1) On 02/22/24 11:51 AM, the Surveyor surveyed cottages 7 and 8: a) Cottage 7 laundry room - chemical cabinet unlocked: a large amount of lint buildup was behind dryer, the lint pipe was not connected, releasing lint into the area behind the washer and dryer. Dirt, large white items, and a purple cigarette lighter were behind the washer, which sits beside the dryer. b) Cottage 8 laundry room - A significant amount of lint build-up was found on the floor and up the wall behind the dryer and washer. A camouflaged 912 bag was hanging over the back of the dryer. A magnifying screen was lying on the dryer. A broomlike handle, dirty mop head, brown cloth, brown stick were found behind the washer and dryer. 2) On 2/20/24 11:46 AM, Cottage 8 - Storage area unlocked with an e-cylinder sitting in just inside the doorway of the room with boxes, walkers, IV (intravenous) poles, accessible to all residents.…
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 · D2024-02-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure that 1 Resident #3 in Cottage 1 had a change of condition or a e- interact completed when the resident was sent to the hospital. The findings are: 1. On 2/20/24 at 10:03 AM, surveyor noted a large hematoma to head with staples and dried blood on back of Resident #3's head. The Resident was unable to inform the nurse what happened. 2. On 2/21/24 at 11:28 AM, surveyor noted a large hematoma with staples to back of Resident #3's head. 3. On 2/21/24 at 1:56 PM, surveyor noted while performing record review resident had no change of condition or e-interact form completed only a note that triggered off the incident and accident form that had been done. 4. On 2/21/24 at 3:48 PM, surveyor interviewed Licensed Practical Nurse (LPN)#1, what should be completed when a resident has a change in their health. LPN#1 confirmed, a change of condition form or an e-interact form. Why is it important to fill this form out. LPN#1 confirmed, to let upper management and family know and the patient could get worse and suffer…
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 · D2024-02-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record reviews, the facility failed to accurately complete weekly nursing assessment (body audit) by failing to document redness to the buttock of 1 sampled Resident (#44) of 8 Residents in Homes 5 and 6 who skin audit completed by Licensed Practical Nurse (LPN) #2. This failed practice had the potential to cause further skin breakdown to Resident 44. The Findings are: According to Quarterly Minimum Data Set with Assessment Reference Date of 12/19/23 documented Resident #44 had a Brief Interview of Mental Status of 15 (13-15 cognitively intact) and was frequently incontinent of bowel and bladder. Care plan document that Resident #44 had Activity of Daily Living self-care performance deficit related to Amputation right below knee and required limited assistance with personal hygiene and oral care. On 02/22/24 10:00 AM, Surveyor observed Resident #44 lying on right and Certified Nursing Assistants (CNA) #5 and #6 pulling up the Resident's pants. The Surveyor observed intact redden skin to Resident #44 bilateral buttock cheeks, seam of buttock, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · 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 observations, interviews, and record review the facility failed to ensure that 1 sampled (Resident #44) of 5 Residents receiving incontinence care in Home 6 received proper incontinence care . This failed practice had the potential to cause skin breakdown, poor hygiene, and/or infection. The Findings are: According to Quarterly Minimum Data Set with Assessment Reference Date of 12/19/23 documented Resident 44 had a Brief Interview of Mental Status of 15 (13-15 indicates cognitively intact) and was frequently incontinent of bowel and bladder. Care plan document that Resident 44 had Activity of Daily Living self-care performance deficit related to Amputation right below knee and required limited assistance with personal hygiene and oral care. On 02/22/24 10:00 AM, Surveyor observed Resident 44 lying on right and Certified Nursing Assistants (CNA) #5 and #6 pulling up the Resident's pants. The Surveyor received consent from Resident 44 to see his buttock and requested the 2 CNAs to expose the Resident's buttock. The Surveyor observed stool in the seam of buttock and between…
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 · D2024-02-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure an order for 1 (Resident #56) of 5 sampled residents who had physician orders for nebulizers received medication as ordered, and the facility failed to ensure supervision of nebulizer treatments for 1 ( Resident #56) who had nebulizer treatments and the facility failed to ensure inhaler was put in storage bag when not in use for 1 ( Resident #56) who had physician orders for inhalers. On 02/20/24 at 10:45 AM, Licensed Practical Nurse LPN #6 was standing outside of room [ROOM NUMBER] with door shut. The surveyor entered the room and Resident (#56 had a nebulizer mask on face and nebulizer machine running. After Resident #56 completed nebulizer treatment they took mask off and laid it down on table. Surveyor observed inhaler laying on bedside table. Resident #56 stated I keep that there in case I need it. On 02/21/24 at 11:08 AM, the surveyor asked Resident #56 if an updraft treatment was given this morning. Resident #56 stated no.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-09 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, it was determined the facility failed to provide an environment that promoted maintenance or enhancement of the resident's quality of life for 4 (Residents #36, #12, #51, and #27) of four residents reviewed for dignity. Specifically, the facility failed to ensure Resident #51, a resident with known behaviors, did not inappropriately expose their genitalia during meal service and failed to keep Resident #51 out of other residents' rooms to promote privacy and dignity. Findings included: Review of a facility policy titled, Dignity, revised February 2021, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. The policy also indicated residents were, e. provided with a dignified dining experience. Additionally, the policy indicated, Staff are expected to promote…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure an allegation of abuse was reported to the state survey agency (SSA) within the required timeframe for 1 (Resident #51) of 1 sampled resident reviewed for abuse. Findings included: Review of a facility policy titled, Abuse Prevention, revised 07/20/2020, revealed, 11. The facility will ensure that all allegations of abuse, neglect, exploitation, mistreatment, including injuries of unknown origin and misappropriation or suspicion of a crime against a resident are reported immediately; the administrator or designee will make an initial report to the local police department as applicable and to the state licensing agency not more than 2 hours after the allegation is made if the events that caused the allegation involve abuse or result in serious bodily injury. 12. The administrator or designee will report to the state licensing agency within 24 hours if the events that caused the allegation do not involve…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 observations, interviews, record review, and facility policy review, the facility failed to ensure a resident who required extensive assistance with personal hygiene was regularly offered trimming of nails to maintain good grooming and hygiene for 1 (Resident #40) of 1 sampled resident reviewed for activities of daily living (ADLs). Findings included: Review of a facility policy titled, Activities of Daily Living (ADL) Supporting, revised March 2016, revealed, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). A review of an admission Record revealed Resident #40 had diagnoses including Parkinson's disease, type 2 diabetes mellitus, other recurrent depressive disorders, and unspecified dementia. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure a physician documented a clinical rationale for continuing a psychotropic medication ordered on an as-needed (PRN) basis beyond 14 days and indicated a duration on the PRN order for 1 (Resident #60) of 5 residents reviewed for unnecessary medications. Findings included: Review of a facility policy titled, Antipsychotic Medication Use, revised 12/2016, revealed, 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #60 scored 10 on a Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. The MDS indicated the resident received an antianxiety medication on one day during the seven-day assessment period. A review of a care plan, dated as initiated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a Licensed Practical Nurse (LPN) washed her hands and/or changed gloves and followed universal precautions and clean technique during an enteral feeding to prevent the potential spread of infection for 1 (Resident #1) of 2 (Residents #1 and #17) who received enteral feedings by the LPN. This failed practice had the potential to affect 2 residents who required enteral feedings in Cottage 2. The findings are: Resident #1 had diagnoses of Malnutrition, Traumatic Brain Injury and Peripheral Vascular Disease. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), was totally dependent on feeding, and was always continent of bowel and bladder. a. On 12/7/22 at 3:26 PM, LPN #10 was standing in front of Resident #1. She poured Glucerna from the carton into a 60cc (cubic centimeter) syringe with no gloves on. LPN #10 then poured 120cc's of Glucerna into the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| LEE, PHOUA | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 11/20/2017 |
CMS files one row per role, so the 2 rows in the source record cover these 1 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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 045462. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-01, 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 →
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