No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Robinson Nursing And Rehabilitation Center LLC

519 Donovan Briley Blvd., North Little Rock, AR 72118 · For profit - Limited Liability company · 110 certified beds · (501) 753-9003 Medicare & Medicaid certified

Call the home — (501) 753-9003 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 25 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (68%) 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5013 John F Kennedy Blvd · (501) 916-2307 · Call to confirm hours
Pharmacy
5328 John F Kennedy Blvd · (501) 246-5035 · Call to confirm hours
Grocery
6201 Greenbank Rd · (501) 271-7029 · Call to confirm hours
Park
Pugh Park1.0 mi
5416 N Locust St · Typically dawn to dusk
Place of worship
900 Donovan Briley Blvd · (501) 753-0474

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 3 of 5
Long-stay residentspeople who live here 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 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.1%9.5%15.4%worse
Long-stay residents who lose too much weight0.3%4.3%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.6%0.9%better
Long-stay residents with a urinary tract infection0.6%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%1.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.9%3.9%3.3%worse
Long-stay residents whose ability to walk worsened16.5%10.1%16.1%typical
Long-stay residents on antianxiety or hypnotic medication24.8%21.7%18.9%worse
Long-stay residents given the seasonal flu vaccine58.8%96.1%95.3%worse
Long-stay residents with pressure ulcers2.9%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control28.3%13.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table4.2%10.9%17.1%better
Short-stay residents who newly got an antipsychotic medication1.8%1.3%1.4%worse
Short-stay residents given the seasonal flu vaccine28.1%77.7%79.4%worse
Long-stay hospitalizations per 1,000 resident days2.992.011.67worse
Long-stay outpatient ER visits per 1,000 resident days5.712.131.80worse

* 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.

53.6% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.6%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
0.05U.S. median 0.31
Therapy hours / resident / day
0.02hours / resident / day
Physical therapy
0.02hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.05 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.6%CMS range 33.1–70.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 6.8–17.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. 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 dischargenot reported — The number of residents or resident stays is too small to report. 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 dischargenot reported — The number of residents or resident stays is too small to report. 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 identified95.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened10.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.1%CMS range 3.9–15.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.431.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.24
RN hours/ resident / day
1.05
LPN hours/ resident / day
2.65
Aide hours/ resident / day
3.94
Total nurse hours/ resident / day
0.27
RN hoursweekends
67.6%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 110 beds and averages 88.6 residents a day — about 81% occupied, or roughly 21 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 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.65 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 3.69 hrs/resident/day on weekends vs 4.04 on weekdays — 9% thinner on weekends. RN hours go from 0.23 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% 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

7
deficiencies at the latest standard inspection (2026-06-04)
8
at the previous standard inspection (2025-01-09)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Ecited before2026-06-04 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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 and interviews, the facility failed to ensure Resident Assessment and Minimum Data Set [MDS] were coded correctly to ensure residents were provided with individualized treatment plans and goals for six (Resident #1, #31, #45, #51, #67, and #79) of six residents reviewed.The findings include:Resident #31Review of the admission Record for Resident #31 revealed the facility admitted Resident #31 with diagnoses that included fracture of left patella, sprain of anterior cruciate ligament of left knee, effusion, pain, hypertension, anxiety, and diabetes mellitus.Review of end of PPS Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed this was Resident # 31's most recent MDS.Review of a Progress Note dated [DATE] indicated Resident #31 discharged to a nursing home closer to family.During an interview on [DATE] at 3:12 PM, MDS #2 reported that Resident #31's most recent resident assessment did not accurately reflect the resident's status. She indicated that Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, it was determined that the facility failed to ensure a resident who had not been assessed to safely self-administer medications was not left alone while receiving medications via nebulizer for one (Resident #100) of one resident reviewed. The findings include:A review of facility policy Medication, General Administration of item 1. Stated Drugs and biologicals may be administered only by licensed physicians, licensed registered or practical nursing personnel, or other personnel wo are duly authorized to perform such services under state law. Item 9. Self-administration of drugs is permitted when approved by the interdisciplinary team and with a physician's order. A review of Resident #100 Medical record did not show an assessment for self-administering of the nebulizer/breathing treatment.A review of Resident #100 Care Plan does not identify the resident to receive Nebulizer treatments.During a concurrent observation and interview on 06/03/2026 9:45 AM, this surveyor observed Resident #100 receiving a breathing treatment. The…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 a significant change Minimum Data Set (MDS) was completed within 14 days from the effective date of hospice service election for one (Resident #84) of four residents reviewed.The findings include:Review of the Centers for Medicare and Medicaid Services' (CMS's) Resident Assessment Instrument (RAI) Version 3.0 Manual version 1.20.1 dated October 2025, revealed a Significant Change in Status Assessment (SCSA) is required when a terminally ill resident enrolls in a hospice program, or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice service election.Review of an admission Record revealed the facility admitted Resident #84 on 10/11/2024 with diagnoses that included malignant melanoma of skin.Review of Resident #84's Order Summary Report revealed an order dated 01/20/2025 for [name of hospice] to eval [evaluate] and admit.Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet one (Resident #100) of one residents reviewed. Specifically, the resident's care plan did not identify the resident as receiving medications via nebulizer (a medical device that turns liquid medication into a breathable mist, delivering it directly to the lungs). The findings include: Review of an admission Record revealed Resident #100 had diagnosis of type 2 diabetes mellitus, acute embolism and thrombosis, dementia, chronic obstructive pulmonary disease, asthma, tachycardia, depression, anxiety disorder, and edema. Review of Resident #100's quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. The MDS did not indicate Resident #100 received oxygen therapy. Review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Number of residents sampled: Number of residents cited: Based on record review and interview, the facility failed to ensure a comprehensive care plan was revised to include the signs, symptoms, and adverse reactions staff were to monitor for related to the use of a diuretic medication for one (Resident #84) of one resident reviewed. The findings include: Review of Resident #84's admission Record revealed the facility admitted Resident #84 on 10/11/2024 with diagnoses that included acute kidney failure. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/2026, revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #84 was taking high-risk drugs including a diuretic. Review of Resident #84's Care Plan with a last reviewed date of 04/17/2026, revealed Resident #84 was on diuretic therapy related to kidney failure. Interventions included to administer diuretic medication as ordered by the Physician and monitor for side…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Number of residents sampled: Number of residents cited: Based on observation, interviews, and record reviews, the facility failed to ensure a physician's order for a sensor device to check blood sugar results was placed on the physician orders and the medication administration record of a resident's electronic health record for one (Resident #99) of one resident reviewed. The findings include: Review of Resident #99's admission Record revealed that the facility admitted the resident on 06/11/2024 with diagnoses that included diabetes mellitus. Review of a quarterly Minimum Data Set with an Assessment Reference Date of 03/21/2026, revealed Resident #99 had a Brief Interview of Mental Status score of 15, which indicated the resident was cognitively intact. Review of a Care Plan with a revised date of 03/20/2026, revealed that Resident #99 was resistant to care as evidenced by refusing blood sugar checks and that Resident #99 refused finger pricks in the event the sensor device to check blood sugar results was not available. Review of Resident #99's Order Summary Report June 2026, did…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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 interview, the facility failed to ensure a written plan of care included both the most recent hospice plan of care and a description of the services provided by the long-term care (LTC) facility to maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #84) of one resident reviewed. The findings include: Review of the admission Record for Resident #84 revealed the facility admitted the resident on 10/11/2024 with diagnoses that included malignant melanoma (cancer) of skin. Review of Physician's Orders for Resident #84 revealed an order dated 01/20/2025 for [name of hospice] to eval [evaluate] and admit the resident. There was no information in the orders to indicate the diagnosis for admission to hospice services or contact information for the hospice agency. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/2026, revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure personal hygiene, as related to proper nail care, was not provided to residents who were dependent on nail care for 2 (Residents #83 and #87) of 2 residents reviewed for activities of daily living (ADL) care. The findings include: 1. A. Review of Resident #83 ' s Care Plan identified: i. Resident needs secured/special care neighborhood due to behaviors/psychosocial/dementia/ other psychiatric issues, initiated: 07/22/2024. ii. Resident has an ADL self-care performance deficit, initiated: 02/27/2024. iii. Resident has potential/actual impairment to skin integrity r/t (related to) fragile skin, incontinence of bowel and bladder, Dx (Diagnoses) of: Dementia, schizophrenia, and iron deficiency anemia. Initiated: 10/15/2024. B. Review of Resident #83 ' s Minimum Data Set (MDS) dated Dec. 5, 2024, reflects resident had a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #83 had severe cognitive impairment. C. MDS dated Dec. 5, 2024, reflected Resident #83 to have diagnoses of:…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, it was determined that the facility failed to ensure 1 (Resident #11) of 1 sampled resident ' s wheelchair was in good working condition. The findings are: A review of an Order Summary Report indicated that Resident #11 had diagnoses of type 2 diabetes and restless legs syndrome, and a physician ' s order for Apixaban, an anticoagulant medication used to treat and prevent blood clots, with common side effects that include bleeding. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/05/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #11 used a wheelchair for mobility. Review of Resident #11's Care Plan, revised 11/10/2024, revealed the resident had potential for skin tear and bruising related to fragile skin, and long-term use of anticoagulants. On 1/06/25 at 11:05 AM, Resident #11 indicated that the wheelchair was digging into her legs. She indicated that when she moves around in her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, interview, and facility policy review the facility failed to ensure a resident on 2 liters of oxygen had a physician ' s order for oxygen therapy to ensure resident received the appropriate and safe dosage of oxygen therapy affecting 1 (Resident #37) of 1 resident sampled for oxygen therapy. Findings include: 1.Review of Medical Diagnosis revealed Resident #37 had diagnoses of atrial flutter, opioid dependency, and diabetes. a. The significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15(13-15 suggest cognitively intact). MDS section C0110, C1 indicated Resident #37 was receiving supplemental oxygen. b. Review of a policy titled Oxygen Safety, with a revision date 11/22/2016, revealed that oxygen therapy is administered only upon a written order of a licensed physician. c. On 01/06/2025 at 3:06 PM, Resident #37 was observed on 2 liters of oxygen via nasal cannula (LNC). d. On 01/07/2025 at 2:22 PM, Resident #37 ' s oxygen concentrator was set…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Ecited before2025-01-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff washed their hands before they handled clean equipment or food, and manufacture specification was followed for 2 of 2 meals observed. The findings are: 1. On 01/07/25 at 1:59 PM, Dietary Aide (DA) #1 picked up the water hose with his bare hand, used it to spray leftover food from inside of the dishes, contaminating his hands. DA #1 placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, he moved to the clean side of the dishwasher area and picked up a clean blade and placed it inside the blender to be used in pureeing food items to be served to residents who required pureed diet and or mechanical soft diets without performing hand hygiene. DA #1 was interviewed and asked what he should have done after touching dirty objects or before handling clean equipment. He stated he should have washed his hands. 2. On 01/07/25 at 4:02 PM, Dietary [NAME] (DC) #2 removed a pan of cooked turkey from the oven and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the residents resided in a safe, functional, and comfortable environment as evidenced by two (rooms [ROOM NUMBERS]) exhibiting stained, soiled privacy curtains and damaged chairs. The findings are: 1. During facility rounds on 1/6/25 at 10:18 AM, the Surveyor observed the privacy curtains in Rooms 104 (Resident #38 was a resident in this room) and room [ROOM NUMBER] (Resident #82 resided in this room) had dark brown stains in several areas. The substance on the curtain in room [ROOM NUMBER] had dark brown lumps in it. The white bedside chair in room [ROOM NUMBER] had the vinyl peeled off the top corner of the chair, exposing the foam and fabric underneath. The white chair in room [ROOM NUMBER] had a large hole, approximately 2 in diameter, on the right arm of the chair. The vinyl edges of the hole were sharp and rough to the touch. 2. During facility rounds on 1/9/25 at 10:10 AM, the Surveyor observed the dark brown stains on privacy curtains in…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to encode and transmit a Minimum Data Set (MDS) assessment following a resident ' s discharge in a timely manner for one (Resident #36) of one resident sampled for MDS encoding and transmission. The findings are: Per review of a Nsg-Discharge Summary Progress Note dated 9/13/2024 at 1:45 PM, Resident #36 was discharged from the facility on 9/13/2024. Review of Resident #36 ' s medical record on 1/9/2025 at 11:10 AM revealed the resident ' s MDS discharge assessment had not been completed or transmitted to the Centers for Medicare & Medicaid Services (CMS) as required. This observation took place 118 days following the resident ' s discharge from the facility. On 1/9/25 at 11:20 AM, the MDS Coordinator confirmed the MDS discharge assessment for Resident #36 was overdue, stating she is allowed seven days to enter the discharge information. She verified that Resident 36 ' s discharge was not entered in a timely manner.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected section A1500, the preadmission screening and assessment resident record (PASRR), reflecting a serious mental illness and/or intellectual disability affecting 1 of 1 sampled (Resident #2) resident with a level II PASRR. Findings include: 1. Review of Medical Diagnosis revealed Resident #2 had diagnoses of paranoid schizophrenia, bipolar, and diabetes. a. The annual MDS with an Assessment Reference Date (ARD) of 02/23/2024, revealed a Brief Interview for Mental Status (BIMS) score of 14 (13-15 indicate cognitively intact). Section A1500 indicated 0 resident 2 does not have a level II PASRR. b. Review of Resident #2 ' s Care Plan, with a revision date of 06/19/2024, revealed Resident #2 had a level II PASRR. c. On 01/08/2025 at 10:54 AM, the Social Director (SD) provided Resident #2 ' s form 703 and 787 from 02/08/2022 and stated Resident #2 had a level II PASRR. d. On 01/08/2025 3:24 PM, the MDS…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to care plan oxygen to ensure 1of 1 sampled (Resident #37) resident received individualized, resident-centered care addressing interventions, treatment, and health care goals. Findings include: 1. Review of Medical Diagnosis revealed Resident #37 had diagnoses of atrial flutter, opioid dependency, and diabetes. a. The significant Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15 (13-15 suggest cognitively intact). Section C0110, C1 indicated the resident was receiving supplemental oxygen. b. On 01/06/2025 at 3:06 PM, Resident #37 was observed receiving two liters of oxygen. c. On 01/07/2025 at 2:53 PM, Licensed Practical Nurse (LPN) #5 was asked for assistance finding where oxygen was addressed on Resident #37 ' s care plan. LPN #5 stated, I cannot find a care plan for oxygen. When asked if Resident #37 should have a care plan addressing oxygen, LPN #5 stated care plans are important because if someone checked they would know how much…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-20 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and facility policy review, the facility failed to ensure showers were maintained in a clean and sanitary condition for resident use, as evidence by, black residue in the grout lines of the shower tiles on the floor and walls in two of four shower rooms. This failed practice had the potential to affect 90 residents (Census: 92) who received showers in the shower rooms. The findings are: The Surveyor observed a Proper Procedures for Disinfecting the Shower Rooms form on the wall in one of four shower rooms on 06/19/2024, which indicated, .Housekeeping is to disinfect the shower room in the morning before daily showers begin and at the end of the day when showers have been completed. Showers are disinfected as followed: 1) Spray disinfectant on shower chair, shower walls, and shower floor 2) Wait 10 minutes 3) Rinse off the shower chair, shower walls, and shower floor . Review of the Housekeeping policy, provided by the Administrator on 06/20/2024 indicated, .Procedure . Housekeeping staff will strive to keep the facility free from offensive odors,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-11-09 · tag F0577 — widespread
    Allow 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 post the results of the most recent survey in a location where individuals wishing to examine survey results do not have to ask to see them. The findings are: On 11/08/2023 at 9:19 AM, the Director of Nursing (DON) was asked to provide the location of the survey results. The DON stated the results should be located on the entryway table, but the results could not be located. On 11/08/2023 at 11:19 AM, the DON provided the survey results binder and stated that the binder had been located in the kitchen. It had been found in the drawer used to store clothing protectors for the residents. The binder was coated in various dried substances that appeared to be food. On 11/08/2023 at 3:32 PM, five members of the Resident Council (Residents #10, #15, #29, #33, and #68) were asked if they were aware of the location of the survey results binder. All five residents stated they had not been informed of the location of the binder and had not seen it in the facility. On 11/09/2023 at 9:09 AM, the Administrator acknowledged that the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-11-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure foods stored in in the dry storage areas were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; floor was free of water standing and staff washed their hands between dirty and clean tasks and before handling clean equipment or contamination to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 85 residents who receive meals from the kitchen (Total census:85) as documented on a list provided by Dietary Supervisor on 11/09/2023 at 08:07 AM. The findings are: 1. On 11/06/23 at 9:13 AM, there were puddles of water on the floor leaking out from the steam table. Dietary Supervisor stated, We have had the maintenance man sealed it one time, but it started to leak again. 2. On 11/06/23 at09:15 AM, a container of sherbets on a shelf in the freezer had popsicles on it. The surveyor asked the Dietary Supervisor to describe the appearance of the sherbets.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-09 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents living in the facility were provided a safe, clean, and comfortable homelike environment by maintaining walls in good condition for 3 (Rooms 101, 308, 407) rooms in the facility. The findings are: 1. On 11/06/23, during initial rounds the following was observed: a. On 11/06/23 at 10:07 AM in room [ROOM NUMBER] on secured unit surveyor observed 3 areas on the long wall with white spackled areas on wall and on the adjoining wall had area where wall had sheetrock exposed at the bottom of wall. Spackled areas measure 6.5x7, 4x9 and 5x3 inches. b. On 11/08/23 at 3:33 PM, room [ROOM NUMBER] B, surveyor observed wallpaper pulled away from the wall at the head of the bed in 3 areas. Areas measured 15x22, 9x12, and 14x17 inches. c. On 11/08/23 at 03:48 PM, the surveyor asked the Director of Nurses (DON), should a resident ' s room have wallpaper peeled off and hanging from the wall? [NAME] stated, No, however, we are starting…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-09 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to update a Minimum Data Set [MDS] for 2 [Residents #16 and #23] residents. This failed practice had the potential to affect all 75 residents. The findings are: 1. Resident #16 Physician's Order Summary dated 1/1/23 thru 11/30/23 showed, Seroquel (an antipsychotic medication) Oral Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime related to other frontotemporal neurocognitive disorder Discontinued 01/23/2023. Seroquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 0.5 tablet by mouth at bedtime related to other frontotemporal neurocognitive disorder give 0.5 tab to = 12.5mg every night [QHS] Discontinued 07/17/2023. 1a. MDS with an Assessment Reference Date [ARD] of 10/4/23 showed, Resident is taking an antipsychotic and has taken it in the last 7 days. 1b. On 11/9/23 at 12:35 PM, the Surveyor asked the MDS Coordinator [MC], Can you pull up the orders for Resident #16 ' s antipsychotic? Is Resident #16 on an antipsychotic. No. The Surveyor asked, can you see where Resident #16 was taking an antipsychotic 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to (1) ensure residents were bathed with a frequency that maintained good personal hygiene for 1 (Resident #38) of 19 (Residents #11, #13, #16, #17, #23, #24, #27, #28, #30, #34, #35, #36, #37, #38, #40, #41, #42, #47, #52, #57, #62, #65, #67, #73, #280 ) sampled residents that were dependent on staff for assistance with activities of daily living, (2) ensure fingernails were clean, groomed, and free from jagged edges to promote good personal hygiene and grooming for 1 [Resident #23] [Resident's #11, #13, #16, #17, #23, #24, #27, #28, #30, #34, #35, #36, #37, #38, #40, #41, #42, #47, #52, #57, #62, #65, #67, #73, #280} sample mixed residents, and (3) ensure that residents (Resident #28 ,#42, and #65) of 9 sampled residents that had not been shaved and nails cleaned and trimmed to promote good hygiene, cleanliness, and sense of wellbeing. The findings are: 1. Resident #23's diagnoses showed pyogenic arthritis, unspecified, cerebral infarction, unspecified. The Minimum Data Set [MDS] with an Assessment Reference…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-09 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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 offer activities to meet the physical needs of 1 (Resident #38) of 2 (Residents #38, #57) sampled residents residing on 400 Hall that required 2 person physical assist to leave their beds, and to ensure activities were provided to the residents on the secured unit, which had the potential to affect 17 residents residing there. The findings are: 1. On 11/07/2023 at 9:39 AM, Resident #38 was observed alone in their room, lying in bed with the television off. Resident #38 was asked if staff included them in facility activities. Resident #38 said that they were bedbound and unable to join group activities. Resident #38 was asked if staff offered activities that the resident could perform in their room. Resident #38 said that staff had not offered to supply them with any activities during their time in the facility. a. On 11/08/2023 at 2:11 PM, Resident #38 was observed lying in bed with the television off and was asked if staff had offered to provide or include them in activities since the previous day. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-09 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets as provided by the Dietary Supervisor. The findings are: 1. On 11/07/23 at 5:07 PM Dietary Employee used a #8 scoop to place 5 servings of tuna salad into a blender, added a carton of whole milk and pureed. She poured the pureed tuna salad into a pan and placed it on a pan of ice. The consistency was runny. 2. On 11/07/23 at 5:48 PM Dietary Employee (DE) #2 placed 18 crackers into a blender, added whole milk, and pureed. At 5:53 PM, he poured the pureed crackers into a pan and placed them on ice. The consistency of the pureed crackers were runny and not formed. On 11/08/23 at 2:36 PM the surveyor asked the Dietary Employee (DE) #2 to describe the consistency of the pureed tuna salad and pureed crackers served to the residents on pureed diets at 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff washed and/or sanitized their hands during meal service on the facility's special secured unit to prevent cross-contamination which had the potential to affect 17 residents residing on the secured unit as documented on the resident list by hall provided by the Administrator on 11/06/23. The findings are: 1. On 11/06/23 at 12:27 PM, the Surveyor observed Certified Nursing Assistant (CNA)#2, passing out trays to several residents without sanitizing hands in between residents. After passing out the last tray CNA #2 sat down and began to feed Resident #28 without ever sanitizing her hands. a. On 11/06/23 at 12:48 PM, the Surveyor observed CNA #1 serve a resident lunch, placed the tray to the side, and then picked up a chair placing it beside a different resident and assisted this resident to eat without sanitizing hands. 2. On 11/07/2023 at 12:26 PM, CNA #2 was observed standing between two residents feeding one, after passing out trays, and never sanitized her hands. Then she moved to another…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 perform a Neurological Assessment after an unwitnessed fall. This failed practice had the potential to affect 1 [Resident #24] resident of 7 [Residents #11, #24, #28, #33, #37, #42, #73] sample mixed residents who had an unwitnessed fall in the past 3 month according to a list provided by the Administrator on 11/9/23 at 12:11 PM. The findings are: Resident #24's Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 8/20/23 showed a Brief Interview for Mental Status [BIMS] of 00 [0-7 severe cognitive impairment] requiring extensive assistance with 1-person physical assistance for transfers. Resident's diagnoses showed Alzheimer's disease with early onset; other Alzheimer's disease; restlessness and agitation, Agitation with potential harm to other(s). Care Plan dated 8/20/23 documented: Focus: 1/24/2023 The resident has had an actual fall with no injury, 1/29/3023 The resident had a fall without injury. 1/31/2023 The resident had a fall with minor injury 4/18/23 actual fall no injury. Goals: 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to 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 →

RatingThis homeChain avg
Overall 2 of 53.6-1.6 vs chain
Health inspection 2 of 53.2-1.2 vs chain
Staffing 3 of 53.3-0.3 vs chain
Quality measures 3 of 54.2-1.2 vs chain
The other 37 homes this chain runs (chain average 3.6★, per CMS)
1 of 5Alma Nursing and RehabAlma, AR 1 of 5Jamestown Nursing And Rehab, LLCRogers, AR 2 of 5Apple Creek Health And Rehab, LLCCenterton, AR 2 of 5Belvedere Nursing And Rehabilitation Center, LLCHot Springs, AR 2 of 5Colonel Glenn Health And Rehab, LLCLittle Rock, AR 2 of 5Highlands Of Bella Vista Health & Rehab, LLCBella Vista, AR 2 of 5Innisfree Health And Rehab, LLCRogers, AR 3 of 5Aspen Health and RehabBroken Arrow, OK 3 of 5Bradford House Nursing and Rehab, LLCBentonville, AR 3 of 5Briarwood Nursing And Rehabilitation Center, INCLittle Rock, AR 3 of 5Brooken Hill Health And Rehab, LlcFort Smith, AR 3 of 5Eufaula Manor Nursing And Rehabilitation CenterEufaula, OK 3 of 5Hickory Heights Health And Rehab, LlcLittle Rock, AR 3 of 5Lake Hamilton Health And RehabHot Springs, AR 3 of 5Quapaw Care And Rehabilitation Center LLCHot Springs, AR 3 of 5Russellville Nursing And Rehabilitation CenterRussellville, AR 3 of 5Sherwood Nursing & Rehabilitation Center, IncSherwood, AR 4 of 5Ashton Place Health And Rehab, LLCBarling, AR 4 of 5Cabot Health And Rehab, LLCCabot, AR 4 of 5Chapel Ridge Health And RehabFort Smith, AR 4 of 5Cherokee County Nursing CenterTahlequah, OK 4 of 5Dardanelle Nursing And Rehabilitation Center,incDardanelle, AR 4 of 5Heather Manor Nursing And Rehabilitation CenterHope, AR 4 of 5Johnson County Health And Rehab, LLCClarksville, AR 4 of 5Lakewood Health And Rehab, LLCNorth Little Rock, AR 5 of 5Atkins Nursing And Rehabilitation CenterAtkins, AR 5 of 5Greenbrier Nursing And Rehabilitation CenterGreenbrier, AR 5 of 5Greystone Nursing And Rehab, LLCCabot, AR 5 of 5Hampton Place Healthcare, LLCRogers, AR 5 of 5Legacy Heights Nursing And Rehab, LLCRussellville, AR 5 of 5Lonoke Health And Rehab Center, LLCLonoke, AR 5 of 5Nursing And Rehabilitation Center At Good ShepherdLittle Rock, AR 5 of 5Oak Manor Nursing And Rehabilitation Center INCBooneville, AR 5 of 5Perry County Nursing And Rehabilitation CenterPerryville, AR 5 of 5Salem Place Nursing And Rehabilitation Center, INCConway, AR 5 of 5Shiloh Nursing And Rehab, LLCSpringdale, AR 5 of 5Superior Health & Rehab, LLCConway, AR

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
MORTON, MICHAELIndividualCORPORATE OFFICERsince 12/12/2024
GUYNES, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/20/2024
CENTRAL ARKANSAS NURSING CENTERS INCOrganizationADP OF THE SNFsince 01/01/2025
NURSING CONSULTANTS INCOrganizationADP OF THE SNFsince 01/01/2025
TRINITY COURT INCOrganizationADP OF THE SNFsince 12/12/2024
TENNYSON, JOSHUAIndividualADP OF THE SNFsince 12/10/2024

CMS files one row per role, so the 7 rows in the source record cover these 6 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.

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.

$9.3M
Net patient revenuemost recent cost report
+11.3%
Operating marginrevenue minus expenses
$1.3M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 75%Medicare 6%Other / private 20%

About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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

$298per resident / day
operating cost
$9,064per month
≈ monthly operating cost
$336per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in AR

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arkansas Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045374. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next