Lakewood Health And Rehab, LLC
2323 McCain Boulevard, North Little Rock, AR 72116 · For profit - Limited Liability company · 85 certified beds · (501) 791-2323 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- 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
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (70%) runs well above the national median (45%)
- about 20% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.3% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.4% | 4.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.4% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.2% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 28.2% | 21.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.1% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 12.8% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.9% | 10.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.1% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 23.8% | 24.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.3% | 12.5% | 12.0% | 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.
47.9% 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 99 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.3% 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 39 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | 47.9%CMS range 39.4–57.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.2%CMS range 8.6–17.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 51.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 66.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 33.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 86.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 9.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.7%CMS range 5.8–16.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 85 beds and averages 70.0 residents a day — about 82% occupied, or roughly 15 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 4.28 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.18 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.15 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 3.61 hrs/resident/day on weekends vs 4.56 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.21 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 70% 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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · E2025-09-25 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Number of residents sampled: Number of residents cited: Based on record review and interviews, the facility failed to ensure signing of the facility Arbitration Agreement was not a condition of admission and the agreement contained the stipulation that it could be rescinded within 30 days of being signed for two (Resident #19 and Resident #56) of three residents reviewed. The findings include: Resident #19 Review of an admission Record for Resident #19 indicated the facility admitted the resident on 06/07/2021 with diagnoses which included interrupted blood flow to the brain causing weakness or loss of sensation on one side of the body (stroke with hemiplegia), nerve damage throughout the body (polyneuropathy) and difficulty swallowing (dysphagia). Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/2025, indicated Resident #19 scored 10, which indicated the resident had moderate cognitive impairment, on the Brief Interview for Mental Status (BIMS). During an interview on 09/24/2025 at 2:30 PM, this surveyor asked the Administrator for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure raw meat was thawed properly to prevent a potential foodborne illness; failed to ensure food stored in the freezer, refrigerator and dry storage area were covered, sealed and dated the day received and when opened to assure first in, first out usage to prevent potential for food bone illness, failed to ensure manufacturer specification was followed in order to prevent food spoilage, expired food items were promptly removed from stock in order to reduce the risk of food-borne illness for residents who received meal trays from 1 of 1 kitchen, dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen These failed practices had the potential to affect 72 residents who received meals from the kitchen. The findings are: On 07/08/2024 at 9:25 AM, the surveyor entered the facility kitchen and observed a sink with raw chicken thighs and legs soaking in standing water. The water was not running, and the sink was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-11 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained a palatable appearance, and at temperatures acceptable to the residents during 2 of 2 meals observed. This failed practice had the potential to affect 15 residents who receive meal trays in their rooms on the 100 Hall,10 residents who receive meal trays on the 200 hall, 15 residents who receive meal trays on 300 hall and 13 residents who receive meal trays in their room on the 400 -hall. The findings are: 1. On 07/08/2024 at 10:10 AM, the surveyor asked Resident #32, How is the food in the facility? Resident #32 stated, The food is always ice cold. 2. On 07/10/2024 at 11:53 AM, an unheated food cart that contained 15 trays for lunch was delivered to 300-hall by Staff #2. At 12:09 PM, immediately after the last resident was served in their room on 300-hall, temperature of the food items on the tray used as a test tray were taken by the and was and read by Certified Nursing Assistant (CNA)#14 with the following result: a. Milk 45 degrees Fahrenheit. 3. 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 · Ecited before2024-07-11 · 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 2 meals observed. This failed practice had the potential to affect 3 residents who received pureed diet. The findings are. 1. On 07/10/2024 at 10:16 AM, Dietary [NAME] (DC) #11 used a 4-ounce spoon to place 4 servings of lasagna into a blender and pureed. At 10:21 AM, DC #10 poured the pureed lasagna into a pan and placed it in the oven. The consistency was thick, lumpy, and was not smooth. There were pieces of pasta visible in the mixture. 2. On 07/10/2024 at 10:40 AM, DC #11 placed 3 servings of garlic bread into a blender, added a carton of whole milk and pureed. At 10:42 AM, DC #10 used a #20 scoop to portion pureed bread stick into 3 bowls. The consistency of the pureed bread was lumpy and was not smooth. 3. On 07/10/2024 at 12:30 PM, the surveyor asked the Dietary Manager to describe the consistency. of the pureed food items served to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-11 · 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
Based on observation, record review and interview, the facility failed to ensure nail care was consistently provided to promote good grooming and personal hygiene for 1 (Resident #39) of 2 (Resident #39 and #223) sampled residents who were reviewed for activities of daily living (ADL) care. The findings are: Resident #39 had diagnoses of abnormalities of way of walking (gait) and mobility and lack of coordination as indicated on the Order Summary. A quarterly Minimum Data Set with an Assessment Reference Date of 05/06/2024 indicated Resident #39 had a Brief Interview for Mental Status score of 4, which indicated the resident was severely impaired. Resident #39's Care Plan, initiated 05/24/2024, indicated the resident had an ADL (Activities of Daily Living) self-care performance deficit related to confusion and limited mobility and required supervision of staff with bathing/showering on Monday, Wednesday and Friday and staff were to check the resident's nail length and trim and clean on bath days and as necessary. On 07/08/2024 at 9:43 AM, Resident #39 was lying in bed. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-11 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 assessment for siderail use was completed for Resident #60 prior to installing siderails; to ensure an assessment of the bed, mattress and siderails was completed prior to the use of the siderails; to review the risks and benefits of siderails with Resident # 60; to obtain informed consent prior to the installation of the siderails on Resident #60 bed; to attempt the use of appropriate alternatives prior to installing siderails. The findings are: 1. A review of an annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/2024, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. Section GG0170 indicated Resident #60 is dependent on staff to do all the effort to complete an activity; or the assistance of 2 or more helpers is required for the resident to complete the activity of Mobility. Section P0100 indicated Resident #60 was coded, bed rail - not used. Section I-Active Diagnoses identified Resident #60 had…
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 · D2024-07-11 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure an inhaler was properly stored after use for 1 (Resident #35) of 1 sampled resident who had an inhaler on an over-bed table. The findings are: Resident #35 had a diagnosis of chronic obstructive pulmonary disease (COPD) as indicated in the Medical Diagnosis section of the electronic health record (EHR) An admission Minimum Data Set with an Assessment Reference Date of 04/07/2024 revealed Resident #35 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. A review of Resident #35's Care Plan dated 04/12/2024 indicated Resident #35 had Emphysema/COPD and an intervention specified giving the resident an aerosol or bronchodilators as ordered. Review of Resident #35's Order Summary indicated an order for budesonide-formoterol (Symbicort) 160-4.5 mcg (micrograms)/actuation inhaler and to take two puffs inhale orally two times a day for COPD. There was no physician's order that indicated the inhaler could be left at the resident's bedside. Review of 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.
- Potential for harm · D2024-07-11 · 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 enhanced barrier precautions (EBP) were consistently followed when administering medication and enteral feeding through a Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 (Resident #42) of 1 sampled resident who was on enhanced barrier precautions. The findings are: Resident #42 had a diagnosis of obstruction of the tube from the throat to the stomach (esophagus), difficulty swallowing (dysphagia) and gastrostomy status indicated on the Order Summary. A 5-day Medicare Minimum Data Set with an Assessment Reference Date of 06/16/2024 indicated Resident #42 had a Staff Assessment for Mental Status score of 3, which indicated the resident was severely impaired, and that the resident had a feeding tube. Resident #42's Order Summary indicated an enteral feeding order of (Named) 1.5 and to give a 220 cc (cubic centimeters) bolus through the PEG tube one a day. It also indicated an order for enhanced barrier precautions related to the resident's PEG tube. Resident #42's Care Plan initiated 06/11/2024 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-11 · tag F0583 — failed to protect personal privacy — patternKeep 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 and interview, the facility failed to ensure resident privacy and confidentiality of personal and medical information by posting photographs of residents to the facility's social media site without the written consent of the resident or the residents designated representative. The findings are: 1. On 07/09/2024 at 2:30 PM, the surveyor interviewed the Administrator, asking if the facility had a social media site. The Administrator stated, Yes, we have a social media page that we started during Covid. The surveyor asked if the facility had consents for posting to a social media site. The Administrator stated, I'm sure we do, we had to get those during Covid. I will check and see. The Surveyor asked the Administrator who has authorization to post to the facility's social media site. The Administrator stated, The Social Director and me. 2. On 07/09/2024 at 2:50 PM, the Consultant handed the surveyor a form titled HIPAA (Health Information Accountability Act) Authorization for Release of Health Information Media and for Use or Disclosure of Resident Photographic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow the smoking policy of securing smoking materials for all residents. The findings are: Resident #3 had diagnoses of Unspecified psychosis and Unspecified dementia. The Annual Minimum Data Set [MDS] with an Assessment Reference Date of 11/25/2023 documented a Brief Interview of Mental Status [BIMS] of 15, which indicated the resident was cognitive. Independent with transfers, ambulated with a walker and no impairment documented to upper or lower extremities. On 03/05/24 at 11:00 AM, Resident (R) #3 was observed sitting in a wheelchair in the facility courtyard smoking area. He/she was wearing a smoking apron and was smoking a cigarette. Dietary Staff Member (DSM) #1 was heard asking R #3 if he/she had a cigarette lighter they could borrow. R #3 then removed a cigarette lighter from a pants pocket and handed it to DSM #1. DSM #1 took the lighter and lit two resident's cigarettes, then handed the lighter back to R #3, who placed it back in his/her pocket. On 03/05/2024 At 3:10 PM, DSM #1 was asked if staff…
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 16 citations
- Potential for harm · Fcited before2023-08-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure foods stored in the refrigerator, freezer, and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure foods were dated the day received and when opened to assure first in, first out usage to prevent potential for food bone illness, expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen, dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure 1 of 2 ice machines and 2 of 2 ice scoop holders were maintained in clean and sanitary condition to prevent contamination of airborne particles. These failed practices had the potential to affect 81 residents who received meals from the kitchen (total census: 83) as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-18 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents and family representatives were involved in care plan meetings for 3 (Resident # 21, # 28, and #32) of 3 sampled residents The findings are: 1. A review of Resident #32 Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of June 16, 2023, noted the resident scored a 3 on the Brief Interview for Mental Status (BIMS) which indicates the resident is severely cognitively impaired. a. On 08/14/23 at 12:33 PM, an interview with Resident #32's representative revealed they have not been invited to care plan meetings and were not aware of the meetings. On 08/14/23 at 12:36 PM, in an interview with Resident #28 who stated, I don't get invited and have never attended. On 08/14/23 at 12:40 PM, in an interview with Resident #21 who stated, I don't know about being invited and so I evidently haven't been. On 08/16/23 at 1:30 PM, The Social Service Director (SSD) stated in an interview that she or the MDS Coordinator will call the family representatives and stated they do not mail anything out. The SSD noted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-18 · 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 dependent residents were provided nail care for 2 (Resident #41 and Resident #277) sampled residents and failed to ensure that 1 of 1 sampled resident (Resident #64) was free from facial hair. The findings are: 1. On 8/14/23 at 11:33 AM observed Resident #41 fingernails, were approximately ¼ inch past the fingertip, jagged and, with black substance under the nails. The nails were yellow in color. a. On 8/16/23 at 9:40 AM observed Resident #41 fingernails, were approximately ¼ inch past the fingertip, jagged and, with black substance under the nails. b. On 8/17/2023 at 8:30 AM observed Resident #41 fingernails, were approximately ¼ inch past the fingertip, jagged and with black substance under the nails. c. Review of Resident #41 Care Plan for Activities of Daily Living (ADL) deficit, initiated on 8/4/21 noted for staff to check nail length and trim and clean on bath day and as necessary and noted bath days as every Monday, Wednesday, Friday and as necessary. d. During an interview on 8/17/23 at 8:30 AM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure 1 (Resident #36) resident received the physician ordered flow rate of oxygen and the failed to ensure respiratory equipment tubing were changed and bagged in a closed container and failed to obtain a physician's order for oxygen and continuous positive airway pressure (CPAP) for 2 (Resident #21, and #276) residents, and failed to ensure portable oxygen cylinder was stored safely for 1 (Resident #276). These failed practices had the potential to affect 18 residents in the facility who received respiratory treatments as documented on a list provided by the Director of Nursing on 8/16/23 at 4:17 PM. The findings are: 1. On 08/14/2023 at 12:09 PM observed Resident #36 with oxygen via nasal cannula at 4 Liters per minute. a. On 08/15/2023 at 8:29 AM observed Resident #36 with oxygen via nasal cannula set at 2.5 Liters per minute. b. On 08/16/2023 9:45 AM observed Resident #36 with oxygen via nasal cannula set at 2.0 Liters per minute. c. Review of Resident #36 care plan with an initiation date of 08/03/2023…
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.
- Potential for harm · E2023-08-18 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 licensed nurses demonstrated competency with administering medications through a gastrostomy tube and providing respiratory services. This failed practice had the potential to affect all 83 residents in the facility as documented on the Resident Census and Conditions of Residents which was provided by the MDS Coordinator on 8/15/23 at 9:49 a.m. The Findings are: 1. On 8/16/23 at 7:53 AM, during medication pass observation for Resident #25, Licensed Practical Nurse (LPN) #1 stated, I am not going to give this medication because we don't have it. The medication was fexofenadine (an antihistamine). The Surveyor asked if it was in the building or on another cart she stated, No, it's not available. It's just over the counter. a. On 8/16/23 at 7:53 AM during medication pass observation for Resident #25 Pantoprazole (a medication used for gastroesophageal reflux disease) was not administered. b. On 8/16/23 at 7:53AM during medication pass observation for Resident #25, a multivitamin with minerals was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-18 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview the facility medication error rate was 15.38%. The failed practice had the potential to affect 28 residents who received medications from the 300 hall Medication Cart, as documented on a list provided by the Director of Nursing (DON) on 8/17/23 at 8:45 a.m. The findings are: During the medication pass observation, 26 opportunities were observed, with 4 errors. Error #1 Resident #25 had a Physician's Order dated 8/12/23 for fexofenadine 180 milligram (mg) tablet daily. On 8/16/23 at 7:53 AM, Licensed Practical Nurse (LPN) #1 stated, I am not going to give this medication because we don't have it. The Surveyor asked if it was in the building or on another cart. The nurse stated, No. It's not available but it's just an over-the-counter medication. There was no physician notification. Error #2 Resident #25 had a Physician's Order dated 8/12/23 for Pantoprazole Sodium Oral Tablet Delayed Release 40 MG daily. On 8/16/23 at 7:53 Am during medication pass observation, LPN #1 did not administer Pantoprazole to Resident #25. Error #3 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 · E2023-08-18 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 4 residents who received pureed diets and 10 residents who received regular diets diets from the kitchen according to a list provided by the Assistant Dietary Supervisor on 08/16/2023. The findings are: 1. The facility menu for lunch provided by the Administrator on 08/15/23 at 11:30 AM, documented that each resident on regular diets were to receive 3-ounces of ground herb pork loin and each resident on pureed diets were to receive a #16 scoop (1/4-cup) of pureed bread and a -#10 scoop (1/3 cup) of pureed buttermilk pie each. 2. The following observations were made during the noon meal preparation and meal service. a. On 8/07/23 at 11:45 AM there was no pureed bread or pureed buttermilk pie prepared. b. On 08/16/23 at 12:42 PM the residents on pureed diets did not receive pureed bread and pureed buttermilk pie.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-18 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained a palatable appearance, and at temperatures that were acceptable to the residents during 2 of 2 meals observed. This failed practice had the potential to affect 12 residents who receive meal trays in their rooms on the 100 Hall, 16 residents who receive meal trays on the 300 hall, and 17 residents who receive meal trays in their room on the 400 hall, as documented on a list provided by the Administrator on 8/17/2023 at 12:20 PM. The findings are: 1. On 8/14/23 at 1:15 PM the surveyor asked Resident #18 if your hot food stays hot and your cold food cold? The residents stated, I never get hot food especially breakfast. 2. On 8/14/23 at 11:58 AM the surveyor asked Resident #51 if your hot food stays hot and your cold food cold? The residents stated, food not always hot enough is my only complaint. 3. On 8/14/23 at 12:06 PM the surveyor asked Resident #33 if your hot food stays hot and your cold food cold? The Resident stated, No hot food. 4. 8/15/23 at 8:40 AM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-18 · 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 3 of 3 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets, as documented on the Diet List provided by the Dietary Employee #2 on 08/17/2023. The findings are: 1. On 08/16/23 at 11:24 AM Dietary Employee (DE) #2 placed 5 servings of pork roast into a blender, added broth and pureed. At 11:28 AM DE #2 poured the pureed meat into a pan, covered the pan with foil and placed it in the oven. The consistency of the pureed pork loin was gritty and was not smooth. At 1:14 PM The surveyor asked DE #6 to describe the consistency of the pureed meat served to the residents on pureed diets. She stated, It was gritty. Pureed should be pudding consistency. 2. On 08/17/23 at 7:25 AM the pureed grits served to the residents on pureed diets was gritty and not smooth. At 7:29 AM the surveyor asked DE #2 to describe the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-18 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure privacy and confidentiality of personal and medical information was maintained for 1 of 2 medication carts observed. The findings are: 1. On 08/15/23 at 7:58 AM, observed a medication cart on Hall 300 unattended with a laptop screen open and unlocked and residents name, medication information, and photo visible. 2. On 08/15/23 at 08:08 AM during an interview with Licensed Practical Nurse (LPN) #1 who confirmed the computer should have been locked, when the medication cart was unattended. 3. During an interview on 08/17/23 at 11:06 AM, the Director of Nursing (DON) confirmed the computer screen should be locked when the medication cart is unattended to hide any resident information. 4. On 8/17/23 at 11:53 AM the DON stated they do not have a privacy policy.
- Potential for harm · D2023-08-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure Resident assessments were accurately coded for oxygen for 1 (Resident #276) of 8 (Residents #13, #21, #31, #32, #36, #126, #276 and #277) sampled residents with physician orders for oxygen therapy. The findings are: Review of Resident #276 Physician Orders revealed an order for oxygen at 3 liters by nasal canula as needed, with a start date of 7/31/23. On 08/16/23 at 9:51 AM, an interview with the MDS coordinator was conducted, who confirmed the oxygen was not coded on the Minimum Data Set (MDS). The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 October 2019 documented, . (1) the assessment accurately reflects the resident's status. Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. This item may be coded if the resident places or removes his/her own oxygen mask, cannula.
- Potential for harm · D2023-08-18 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the assessment process with the Pre-admission Screening and Resident Review (PASARR) program were completed in entirety for 2 (Resident #4 and #43) of 6 (Residents #4, #16, #25, #42, #43 and #276) sampled residents with a serious mental health diagnosis as documented on a list provided by the Director of Nursing (DON) on 08/16/23 at 04:17 PM. The findings are: a. Review of a correspondence from the state contracted agency for pre-admission screening and resident review (PASARR) for Resident #4 dated 03/12/19 noted the nursing facility must contact the agency with the resident's admission date to receive the completed PASARR. 2. Review of Resident #43 medical diagnosis list noted diagnoses of bipolar disorder and unspecified dementia moderate with mood disturbance. a. Review of a correspondence from the state contracted agency for PASARR for Resident #43 dated 04/15/21 noted the nursing facility must contact the agency with the resident's admission date to receive the completed PASARR 3. On 08/15/23 at 3:08 PM, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a baseline care plan was accurately completed to provide effective and person-centered care for 1 (Resident #277) of 2 (Resident #276, #277) sampled residents whose baseline care plan was reviewed for oxygen therapy upon admission. The findings are: 2. Review of the Physician Order dated 8/7/23 noted Resident #277 was admitted to the facility on [DATE], and noted an order for oxygen therapy at 2 Liters per minute via nasal canula. b. A review of Resident #277 Baseline Care Plan noted the oxygen therapy section was not marked. 4. During an interview on 8/16/23 at 10:08 AM with LPN #2, who confirmed the oxygen therapy should have been marked for Resident #277. On 8/16/23 at 10:53 AM, the Director of Nurses stated the facility did not have a Baseline Care Plan policy.
- Potential for harm · D2023-08-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was included in the individualized comprehensive care plan for 1 (Resident #276) of 8 (Residents #13, #21, #31, #32, #36, #126, #276 and #277) sampled residents, failed to ensure an anticoagulant was included in the individualized comprehensive care plan for 1 (Resident #25) of 5 (Residents #6, #25, #75, #126 and #277) sampled residents. The findings are: 1. Review of Resident #276 Physician's Orders revealed an order for oxygen at 3 liters per minute via nasal canula as needed, dated 7/31/23. a. Review of Resident #276 Medication Administration Record (MAR) for July 2023 noted the resident used oxygen on 7/31/23. c. A review of Resident #276 care plan failed to reveal a care plan for oxygen use. a. A review of Resident #25 physician order summary noted an order for apixaban (an anticoagulant medication), with a start date of 8/12/23. b. A review of Resident #25 care plan failed to reveal a care plan for anticoagulant use. 5. On 08/16/23 at 9:51 AM, during an interview with the Minimum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · 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, record review and interview, the facility failed to ensure medications and respiratory treatments were administered only with a physician's order for 2 (Resident #21 and #25) of 2 sampled residents. The findings are: 1. On 8/14/23 at 11:26 AM, Resident #21 stated they use oxygen and a CPAP (continuous positive airway pressure) machine at night. a. Review of the Physician's Order Summary revealed an order for oxygen at 2 liters per minute as needed, dated 8/15/23. b. A Physicians Order for CPAP settings, and an order noting the resident to wear CPAP at bedtime for sleep apnea were both dated 8/15/23. 2. On 8/16/23 at 7:53 AM, observed LPN #1 administer one Multivitamin with Minerals tablet to resident #25. a. Review of the record for Resident #25 failed to reveal a Physician's Order for Multivitamin with Minerals. b. On 8/16/23 at 9:11 AM the Surveyor asked Licensed Practical Nurse (LPN) #1 if a resident needed a physician's order prior to administering medications. She said yes. LPN #1 was asked to look in the electronic record and locate the physicians order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure catheter drainage bag was positioned off the floor for 1 (Resident #70) of 2 (Resident #70 and #75) sampled residents with a catheter. The findings are: 1. On 8/14/23 at 11:54 AM, observed Resident #70 in bed with the catheter drainage bag on floor in an L shape hanging from the right bed frame. 2. On 8/14/23 at 2:29 PM, observed Resident #70 sitting in bed with the catheter drainage bag on floor in an L shape hanging from the right bed frame. 3. On 8/15/23 at 9:05 AM, observed Resident #70 in bed watching television with the catheter drainage bag on the floor hanging from the right bed frame. 4. On 8/16/23 at 9:33 AM, during an interview with Licensed Practical Nurse (LPN) #3, who stated the drainage bag should be in a privacy bag below the bladder and off the floor. 5. On 08/16/23 at 10:32 AM, interview with the Director of Nursing (DON) who stated the drainage bag should be in a privacy bag, below the bladder and off the floor. 6. The facility policy titled, Catheter Care, Urinary, last updated 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CENTRAL ARKANSAS NURSING CENTERS — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.6 | +0.4 vs chain |
| Health inspection | 4 of 5 | 3.2 | +0.8 vs chain |
| Staffing | 2 of 5 | 3.3 | -1.3 vs chain |
| Quality measures | 4 of 5 | 4.2 | -0.2 vs chain |
The other 37 homes this chain runs (chain average 3.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HURSH, PARALEA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 8% | since 12/12/2024 |
| SAMS, JERRY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 8% | since 12/12/2024 |
| REICHARD, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/20/2004 |
| NORSWORTHY, DAVID | Individual | LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | — | since 11/01/2014 |
| CENTRAL ARKANSAS NURSING CENTERS INC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| LAKEWOOD MANOR LLC | Organization | ADP OF THE SNF | — | since 12/12/2024 |
| NURSING CONSULTANTS INC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| DASS, SANJAY | Individual | ADP OF THE SNF | — | since 12/10/2024 |
| MORTON, MICHAEL | Individual | ADP OF THE SNF | — | since 12/12/2024 |
CMS files one row per role, so the 11 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AR
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arkansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045202. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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