The Green House Cottages Of Belle Meade
2200 Chateau Boulevard, Paragould, AR 72450 · For profit - Partnership · 167 certified beds · (870) 236-7104 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,870 in federal fines (most recent 2024-12-19)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 69% 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.
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 | 8.6% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.1% | 4.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 11.5% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.1% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.6% | 21.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.2% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.2% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.9% | 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 | 93.6% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 9.9% | 24.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 2.6% | 12.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.63 | 2.01 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.00 | 2.13 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
45.6% 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 184 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 75.9% 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 112 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 45.6%CMS range 39.2–52.3 | 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 | 10.7%CMS range 7.2–13.9 | 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 | 75.9% | 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 | 66.1% | 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 | 68.8% | 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 | 97.3% | 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 | 100.0% | 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 | 3.4% | 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 | 6.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.6%CMS range 3.1–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.26 | 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 167 beds and averages 127.4 residents a day — about 76% occupied, or roughly 40 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 5.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.60 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.49 hrs/resident/day on weekends vs 5.32 on weekdays — 16% thinner on weekends. RN hours go from 0.48 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-12-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, document review, and interviews, the facility failed to ensure staff followed a resident's care plan, as evidenced by Resident #1 sliding off the side of the bed while 1 staff assisted with dressing, despite the care plan indicating the need for 2 staff, for 1 (Resident # 1) sampled resident. The failed practice resulted in noncompliance at the level of immediate jeopardy (IJ), which caused major injury to Resident # 1, who was at high risk for falls. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 Accidents and Hazards (to provide appropriate and sufficient supervision to each resident to prevent an avoidable accidents) at a scope and severity of J. The IJ began on 12/12/2024 at 7:15am, when Resident #1 was being assisted with getting dressed by 1…
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 before2025-08-01 · 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 observations, interviews, and record reviews, the facility failed to ensure hands were washed between residents while serving dinner, and to ensure utensils were not used after contamination during meal preparation for one of one puree meal observed. The findings include: 1) During an observation on 07/28/2025 at 4:55 PM, Certified Nurse Aide (CNA) #5 and CNA #6 were observed passing trays with gloves on. CNA #5 retrieved a plate from a resident room while wearing gloves. She then took a plate to another resident room without removing gloves or performing hand hygiene. CNA #5 came out of this room, again without performing hand hygiene or removing gloves, and went to the dining room. In the dining room, CNA #5 removed her gloves and started feeding a resident without washing or sanitizing her hands. During an observation on 07/28/2025 at 5:10 PM, CNA #4 touched a coffee cup a resident had drank from with her gloved hands. She did not remove her gloves or sanitize her hands before continuing to pass out dinner plates. During an interview on 07/30/2025 at 4:15 PM, CNA #4…
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 · D2025-08-01 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure an as needed psychotropic medication was reviewed and updated every 14 days for one (Resident #137) of five residents reviewed. The findings include: A review of Resident #137's Order Summary Report revealed the facility admitted the resident on 02/28/2024. Resident #137 had an order for an antianxiety medication to be given every 24 hours as needed for anxiety, ordered on 04/05/2024. A review of Resident #137's quarterly Minimum Data Set, with an Assessment Reference Date of 06/17/2025, revealed the resident had a Brief Interview for Mental Status score of 06, which indicated the resident had severe cognitive impairment. A review of Resident #137's Care Plan initiated 02/20/2025, indicated to administer an anti-anxiety medication as ordered by the physician. A review of Resident # 137's Medication Administration Record dated 08/01/2025 - 08/31/2025, indicated an as needed antianxiety medication was started on 04/05/2024, and discontinued 08/01/2025. A review of Resident #137's Pharmacy MRR [Medication Regimen…
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 before2025-08-01 · 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 record reviews, observation, interviews, and facility policy review, the facility failed to ensure personal protective equipment (PPE) was disposed of before walking out of one (Resident #4) of one resident’s room that was on Enhanced Barrier Precautions (EBP). The findings include: A review of Resident #4’s Order Listing Report revealed a revised order dated 07/19/2025, for an IV [intravenous] antibiotic related to a right hip incision infection. A review of Resident #4’s admission Minimum Data Set, with an Assessment Reference Date of 07/10/2025, revealed the resident had a Brief Interview for Mental Status score of 14, which indicated Resident #4 was cognitively intact. A review of Resident #4’s Care Plan revised 07/22/2025, indicated EBP were required related to a medical device used to drain urine directly from the kidney. The Care Plan also indicated to wear disposable gloves and gowns when providing high contact care. During an observation on 07/30/2025 at 2:12 PM, Registered Nurse (RN) #8, and RN #9 put on gowns, sanitized their hands, and put on gloves. A bandage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-25 · tag F0679 — failed to provide activities — patternProvide 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 provide a meaningful program of activities for 5 (Residents #4, #10, #66, #80, and #120) sampled residents and failed to ensure the activity program was designed to meet the individual activity needs, interests, and abilities of each resident. The findings are: 1. On 04/22/2024 at 11:15 AM, the Surveyor entered Cottage 2 and observed that there were no activities taking place. There was no activity calendar observed in the common area or in the resident rooms. 2. On 04/22/2024 at 1:00 AM, the Surveyor entered Cottage 900 as the residents were having lunch. There was no activity calendar observed in the common area. Resident #66 and Resident #10 were observed at the head of the table. Resident #66 identified a lack of activities as her area of dissatisfaction. Resident #10 concurred that activities are not held on a regular basis and that boredom is a daily burden. 3. On 04/22/2024 at 2:08 PM, the Surveyor observed in Cottage #2, no activities were being conducted. 4. On 04/22/2024 at 2:17 PM, the Surveyor…
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 before2024-04-25 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the nurse completed hand sanitation before and after giving a resident medication and before giving another resident medication. The findings are: 1. On 04/23/2024 at 8:25 am, observed Licensed Practical Nurse (LPN) #1 begin to administer medication to a resident without sanitizing hands, come out of the resident's room to the medication cart and began to pull medications and administer medications to the next resident. There was a medication missing for the resident and LPN #1 had to go to another cottage to the e-kit and get the medication. LPN #1 returned to the cottage and administered the medication without sanitizing hands. 2. On 04/23/2024 at 8:48 am, LPN #1 was asked to explain what should be done before starting to give a resident medication. LPN #1 said, sanitize my hands. LPN #1 was asked what should be done after giving medication to a resident and before giving another resident medication. LPN #1 said, sanitize hands. LPN #1 was asked what should be done after leaving this cottage and going 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.
- Potential for harm · D2024-04-25 · 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, interview, and record review, the facility failed to ensure a resident who required assistance with personal hygiene was regularly offered to have fingernails cleaned to maintain good grooming and hygiene for 1 (Resident #47) sampled resident. The findings are: 1. On 04/22/2024 at 11:08 am, observed Resident #47 with 0.5 inch long fingernails with a brown substance under the nails on both hands. 2. On 04/23/2024 at 9:18 am, observed Resident #47 with 0.5 inch long painted nails with brown substance under nails on both hands. 3. On 04/24/2024 at 3:31 pm, Certified Nursing Assistant (CNA) #4 was asked who was responsible for making sure fingernails were cleaned and trimmed. CNA #4 replied, The CNA is, unless they are diabetic or on blood thinner, then the nurses do it. The Surveyor asked, When do you perform nailcare. CNA #4 replied, On their shower days or whenever we see that they need them cleaned or trimmed. 4. During record review, Resident #47's Care Plan with an initiated date of 03/09/2024 noted Resident #47 required supervision with bathing. The care…
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 before2024-04-25 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure 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 was smooth 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. The findings are: On 04/24/2024 at 11:10 AM, a divided plate containing pureed chicken fettucine, pureed bread and peaches was observed on the counter in the kitchen. Each item was observed to contain particles of food that had not been completely blended. Certified Nursing Assistant (CNA) #1 who prepared the meal was asked to describe the consistency of the items on the plate. CNA #1 described how she could see the particles of food, however despite continuing to blend the items for an extended period of time the processor would not provide a smooth consistency. The peaches were described as runny; however, CNA #1 verbalized her expectations that they would thicken as they sat because thickener had been added. On 04/23/2024 at 8:30 AM, the plate contained pureed eggs, pureed sausage/biscuit combination and pureed super…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-02-03 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure food items stored in the refrigerator, freezer and dry storage areas, were sealed or covered and stored in accordance with the manufacturer's instructions; expired food items were promptly removed from stock; staff washed their hands between dirty and clean tasks and before handling clean dishes or food items; ice machines were maintained in clean and sanitary condition; and hot foods were maintained at or above 135 degrees Fahrenheit (F.) while awaiting service to prevent potential food borne illness for residents who received meals from 11 (Cottages #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) of 11 kitchens. These failed practices had the potential to affect 118 residents who received meals from the 11 affected kitchens (total census:119), as documented on a list provided by the Dietary Supervisor on 02/02/23. The findings are: 1. On 01/30/23 at 10:57 AM, the following observations were made in Cottage #6: a. The following items were on a shelf in the refrigerator: i) One opened container 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.
- Potential for harm · F2023-02-03 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
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 Quality Assessment and Assurance (QAA) committee put forth good faith attempts to correct, monitor, and reassess its own quality deficiencies for proper respiratory care for residents who were on oxygen therapy. The findings are: 1. The Quality Assurance and Performance Improvement (QAPI) Plan undated, the Facility assessment dated [DATE], and the Quality Assessment and Assurance (QAA) Committee list provided by the Assistant Administrator on 01/30/23 at 1:04 PM documented, .Those in attendance varies occasionally but normally includes the Administrator, Director of Nursing, the Infection Control/Wound Nurse, the Campus Educator, The Assistant Director of Nursing, the MDS [Minimum Data Set] Coordinators, and the Medical Director at least Quarterly . a. On 02/01/23 at 10:30 AM, the Surveyor asked the Administrator if the facility had an updated Facility Assessment as the one provided to the Surveyors was dated 12/31/21. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-02-03 · tag F0641 — patternEnsure 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 observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected an active diagnosis for 1 (Resident #27) of 10 (Residents #3, #11, #16 #27, #30, #57, #60, #69, #108 and #109) sampled residents who had Physician Orders for Insulin; 1 (Resident #59) of 12 (Residents #21, #27, #34, #37, #59, #66, #69, #70, #81, #95, #170 and #370) sampled residents who had Physician Orders for oxygen therapy and 1 (Resident #74) of 1 sampled resident who had Physician Orders for Hospice services. This failed practice had the potential to affect all 117 residents according to the Census and Conditions of Residents provided by the Administrator on 01/31/22 at 10:03 am. The findings are: 1. Resident #27 had diagnoses of Vascular Dementia, Chronic Pain, Presence of Prosthetic Heart Valve and Atherosclerotic Heart Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/22 documented the resident scored 14 (13-15 indicates…
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 10 citations
- Potential for harm · E2023-02-03 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 observation, record review, and interview, the facility failed to ensure individualized comprehensive Care Plans were implemented to meet the resident's medical and nursing needs, to promote continuity of care for 2 (Residents #27 and #69) of 10 (Residents #3, #11, #16, #27, #30, #57, #60, #69, #108 and #109) sampled residents on Insulin and 1 (Resident #69) of 12 (Residents #21, #27, #34, #37, #59, #66, #69, #70, #81, #95, #170 and #370) sampled residents who had Physician Orders for oxygen (O2) therapy. This failed practice had the potential to affect all 117 residents according to the Census List provided by the Administrator on 01/30/23 at 10:15 am. The findings are: 1. Resident #27 had diagnoses of Vascular Dementia, Chronic Pain, Presence of Prosthetic Heart Valve and Atherosclerotic Heart Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS)…
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 before2023-02-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the doors to the laundry rooms in 6 (Cottages #2, #3, #4, #5, #9 and #11) cottages were locked to prevent the potential of an injury to residents/elders, failed to ensure electrical cords were safely secured out of water for 1 (Cottage #1) to prevent the potential of injury and/or fire and failed to ensure dryer lint traps were appropriately maintained in 6 (Cottages #2, #3, #4, #9, #10 and #11) of 11 (Cottages #1, 2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) cottages to prevent the potential for a fire. The findings are: 1. On 01/30/23 at 11:56 AM, the following were in Cottage #2: a. The door to the Laundry Room was unlocked. b. The dryer contained a load of white towels and in and around the lint trap there was ¼ to ½ inch thick grey and pink lint buildup in and under the lint trap. c. The Surveyor asked Certified Nursing Assistant (CNA) #3 if the door should be locked. CNA #3 stated it should have been. The Surveyor asked CNA #3 how often the dryer lint traps were cleaned. CNA #3 stated, Umm, we are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-02-03 · 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 oxygen (O2) was administered at the physician ordered flow rate for 4 (Residents #21, #34, #59 and #66); failed to obtain a Physicians Order for 2 (Resident #170 and #370) who received oxygen therapy; failed to ensure oxygen tubing was dated for 1 (Resident #170), and failed to ensure CPAP (Continuous Positive Airway Pressure) mask, updraft masks and nebulizer mouthpieces were properly stored when not in use to prevent the potential for cross contamination and respiratory infections for 3 (Residents #21, #37 and #370) of 13 (Residents #21, #27, #34, #37, #59, #66, #69, #70, #81, #95, #170, #370 and #371) sampled residents who received updrafts and/or oxygen therapy or used a CPAP machine as documented on a list provided by the Assistant Director of Nursing (ADON) on 02/03/23 at 8:32 AM. The findings are: 1. Resident #59 had diagnoses of Unspecified Dementia and Immunodeficiency. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/22 documented the resident scored 6…
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 · E2023-02-03 · 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 in accordance with the planned, written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets, 22 residents who received mechanical soft diets, and 74 residents who received regular diets (total census:117), according to the Diet List provided by the Dietary Supervisor on 02/01/23. The findings are: 1. On 02/01/23 the facility's menu for breakfast provided by the Dietary Supervisor at 4:52 PM documented the residents on mechanical soft diets and on regular diets were to receive ¾ cup of cereal. The residents on pureed diets were to receive a #8 scoop of pureed french toast. 2.On 02/01/23, the following observations were made during breakfast in Cottage #6: a. At 7:43 AM, Certified Nursing Assistant (CNA) #13 used a #10 scoop, (equivalent to 2/5 cup) to serve oatmeal to the residents who received mechanical soft diets and regular diets, instead of ¾ cup 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 · E2023-02-03 · 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 to ensure food was prepared by methods that maintained the flavor and encouraged good nutritional intake for residents who received regular diets, mechanical soft diets, and pureed diets for 1 of 1 meal observed. This failed practice had the potential to affect 5 residents who received regular diets and 5 residents who required mechanical soft diets in Cottage #2 according to lists provided by the Dietary Supervisor on 02/01/23. The findings are: 1. On 01/30/23 at12:31 PM, in Cottage #2, the bottom of the cornbread was burnt. Certified Nursing Assistant (CNA) #11 removed the burnt area and served the top part of the cornbread to the residents. At 1:37 PM, the Surveyor asked CNA #11 to describe the appearance of the cornbread served to the residents. She stated, It was baked from another cottage and sent to us. The bottom was burnt. I had to remove the bottom part of the cornbread and I served the top part to the residents. 2. On 02/01/23 at 7:36 AM, CNA #13 placed one sausage patty into a blender, added whole milk and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-02-03 · 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. The failed practice had the potential to affect 5 residents who received pureed diets in Cottage #1, #2, #5 and #6 as documented on a list provided by the Dietary Supervisor on 02/02/23 at 4:52 PM. The findings are: 1. On 1/30/2023 at 12:05 PM in Cottage #5, the following pureed food items were served to the resident on a pureed diet: a. Pureed cornbread was served to the resident. The consistency of the pureed cornbread was not smooth. There were pieces of cornbread visible in the mixture. b. Pureed seasoned cut green beans served to the resident were runny and the pureed chicken and dumplings was not smooth. There were pieces of chicken in the mixture. The Surveyor asked the Dietary Supervisor to describe the consistency of the food items served to the resident. She stated, Pureed cut green beans were too runny. Pureed chicken and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-02-03 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure standard infection control precautions were followed for 1 (Resident #60) of 10 (Residents #11, #27, #57, #60, #66, #69, #75, #95, #96 and #108) sampled residents who had Physician Orders for Accucheck Glucose Monitoring and failed to ensure transmission-based precautions were followed for 1 (Resident #78) of 1 sampled resident who was on contact and droplet precautions. This failed practice had the potential to affect all 117 residents according to the Census and Conditions of Residents provided by the Administrator on 01/31/22 at 10:03 AM. The findings are: 1. On 02/01/22 at 11:29 AM, Licensed Practical Nurse (LPN) #6 obtained an accucheck glucose reading on Resident #76. LPN #6 then entered Resident #60's room and obtained an accucheck glucose reading using the same glucometer used on Resident #76 without cleaning the glucometer between residents. a. The Surveyor asked LPN #6 if the same glucometer was used for multiple…
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 · D2023-02-03 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure an individualized comprehensive Care Plan was implemented to meet the resident's medical and nursing needs and promote continuity of care for 1 (Resident #69) of 12 (Residents #21, #27, #34, #37, #59, #66, #69, #70, #81, #95, #170 and #370) sampled residents whose Care Plan was reviewed. This failed practice had the potential to affect all 117 residents who had Care Plans according to the Census list provided by the Administrator on 01/30/23 at 10:15 am. The findings are: 1. Resident #69 had diagnoses of Atherosclerotic Heart Disease, Personal History of Transient Ischemic Attack and Cerebral Infarction without Residual Deficits and Dependence on Supplemental Oxygen (O2). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/22 documented the resident scored 8 (8-12 indicates moderately cognitively intact) on a Brief Interview of Mental Status (BIMS) and received oxygen therapy. a. The January 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 · D2023-02-03 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 COVID-19 vaccinations were provided to eligible residents in a timely manner who consented to the immunization for 1 (Resident #67) and documented accurately in the immunization records consents and declinations for COVID-19 vaccinations for 1 (Resident #75) of 5 (Residents #14, #32, #67, #75 and #108) sampled residents whose COVID-19 immunizations were reviewed. This failed practice had the potential to affect all 117 residents who resided in the facility as documented on the Resident Matrix provided by the Minimum Data Set (MDS) Coordinator #2 on 01/30/23. The findings are: 1.On 02/01/23 at 9:25 PM, a review of the COVID-19 Consents and Immunization records showed Resident #67 had a signed consent for the COVID-19 vaccination dated 8/15/22. There was no documentation that Resident #67 received the vaccination. a. On 02/02/23 at 3:10 PM, the Surveyor asked the Human Resource Assistant (HRA) to pull up the Immunization Consent Form for Resident #67 to see which vaccines Resident #67 had consent to. The HRA stated,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-02-03 · tag F0888 — widespreadEnsure staff are vaccinated for COVID-19
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 interview, and record review, the facility failed to ensure all staff received complete primary COVID-19 vaccinations, had an approved or pending medical or religious exemption, or a temporary delay per the Center for Disease Control (CDC) per the Centers for Medicare and Medicaid Services (CMS) COVID-19 Health Care Staff Vaccination Regulations Quality Service and Oversight (QSO). The findings are: 1. The Facility Staff COVID Vaccination List provided by the Administrator on 01/30/23 at 4:16 PM and the Current Week Staff Schedule provided by the Administrator on 02/01/23 at 8:30 AM documented, Certified Nursing Assistants (CNAs) #21 and CNA #22 were on the current week staff schedule and were not on the COVID-19 vaccination list. 2. On 02/01/23 at 10:30 AM, the Surveyor asked the Administrator who was responsible for Facility Staff COVID-19 Vaccination Tracking. The Administrator stated, Human Resources (HR), Infection Control Preventionists (ICPs), and ultimately myself. 3. The updated Facility 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.
“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
$13,870 in federal fines across 1 penalty.
- $13,870 — penalty dated 2024-12-19
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to SOUTHERN ADMINISTRATIVE SERVICES — 35 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.8 | -0.8 vs chain |
| Health inspection | 2 of 5 | 3.2 | -1.2 vs chain |
| Staffing | 4 of 5 | 3.9 | +0.1 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 34 homes this chain runs (chain average 3.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| 4P2T1 OPS HOLDING LP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/01/2019 |
| ALEXARK1 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| JEJ ASSETS LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| JEJ MANAGEMENT, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| PONTHIE, SHARLOT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| HARTLEY, MATT | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2024 |
| PONTHIE, JOHN | Individual | CORPORATE DIRECTOR | — | since 01/01/2022 |
CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $9.7M paid to related parties — landlords or management companies under common ownership — equal to about 69% 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 045170. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-01, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.