Pocahontas Healthcare And Rehabilitation Center
105 Country Club Road, Pocahontas, AR 72455 · For profit - Limited Liability company · 97 certified beds · (870) 892-2523 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0569)
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- 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 $9,307 in federal fines (most recent 2025-06-20)
- about 54% 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 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 | 5.3% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.3% | 4.3% | 5.4% | better |
| 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 | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.6% | 1.4% | 6.5% | better than state‡ — see note marked double-dagger 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 | 15.8% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 1.6% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 40.0% | 21.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.2% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 8.7% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.5% | 10.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 5.3% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 86.0% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 35.1% | 24.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.4% | 12.5% | 12.0% | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
51.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 43 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 79.2% 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 24 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% 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
| 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 | 51.1%CMS range 34.2–69.8 | 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 | 15.3%CMS range 10.6–20.0 | 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 | 79.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 66.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 54.2% | 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 | 92.3% | 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 | not 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 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 | 2.6% | 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 | 2.6% | 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 | 7.7%CMS range 3.9–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.10 | 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 97 beds and averages 48.1 residents a day — about 50% occupied, or roughly 49 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 is below 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 2.99 hrs/resident/day on weekends vs 4.02 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.62 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% 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.
- Actual harm · G2025-06-20 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility document review, the facility failed to ensure that nursing staff responded appropriately to an unwitnessed fall, specifically failing to notify the appropriate parties and initiate neurological checks for an unwitnessed fall for one (Resident #1) of three residents reviewed for falls. Following the incident and prior to the surveyors entry into the facility, the facility terminated LPN #1 and initiated and completed a corrective action plan, thus these findings indicate past non-compliance. The findings include: A review of the admission Record indicated that Resident #1 was admitted [DATE] with diagnoses that included hypertensive encephalopathy (brain dysfunction) and hypertensive emergency. A review of the admission Minimum Data Set with an Assessment Reference Date of 02/14/2025 revealed Resident #1 had a Brief Interview for Mental Status score of 8, which indicated moderate cognitive impairment. The MDS also indicated Resident #1 required partial or moderate…
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 before2024-12-31 · 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, interviews, and facility policy review, it was determined that the facility failed to ensure a portable oxygen cylinder was secured to prevent an accident or injury. The findings include: A review of the facility's undated policy titled Accident Hazards prevention indicated The environment will be free from an accident hazards as is possible .An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents . A review of the facility's undated policy titled Handling of oxygen and flammable gas, indicated Oxygen cylinders will be stored in a designated ventilated area and stored in a safe manner to prevent cylinder from fall over. During an observation on 12/31/2024 at 2:04 PM, an unsecured portable oxygen cylinder was standing in front of the nursing station with residents and staff present. Two nurses were sitting behind the nursing station documenting. Three staff members were standing on the opposite side of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-31 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to promote the dignity of a resident who was observed with staff shaving in the dining room for 1 (Resident #6) 1 residents reviewed for dignity. The findings include: A review of the facility's undated policy titled resident rights and responsibility indicated The nursing facility protects and promotes the rights of each Resident/Elder admitted in order to provide a dignified existence, self-determination and communication with and access to persons and services inside and outside the nursing facility. A review of the facility's undated policy titled accident hazard prevention indicated .The facility is responsible for providing care to residents in a manner that helps promote quality of life. This includes respecting residents' rights to privacy, dignity and self-determination, and their right to make choices about significant aspects of their life in the facility. A review of the admission Record indicated the facility admitted…
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 before2024-12-31 · 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 observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by failure to wear personal protective equipment (PPE) in a contact isolation room for 1 (Resident #7) of 1 resident reviewed for infection control. The findings include: A review of the facility's undated policy titled Transmission based precautions categories, indicated Contact precaution: a. Personal protective equipment: Gloves and gown. B. Wear PPE [personal protective equipment] for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. C. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens. A review of the admission record indicated the facility admitted Resident #7 with diagnosis that included extended spectrum beta lactamase resistance (an enzyme that some bacteria produce to break down…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-08-22 · 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, record review and interviews, the facility failed to ensure cross contamination during lunch service did not occur for one of one kitchen. The findings are: On 08/20/2024 at 12:05 PM, the surveyor observed Dietary Aide #6 take a stack of plates to put inside the lunch cart for 100 Hall. Dietary Aide #6 had their hand on top of the stack as they slid it on a tray inside the cart. On 08/20/2024 at 12:08 PM, the surveyor observed Dietary Aide #6 touch the inside of a divided plate intended to serve the puree diet for the 100 Hall. On 08/20/2024 at 12:09 PM, Surveyor observed Dietary Aide #6 picked up a bowl, put their finger inside of the bowl where food would rest and serve gravy for 100 Hall. On 08/20/2024 at 12:15 PM, Surveyor observed Dietary Aide #6 removing the aluminum foil off the regular meatloaf, when a piece fell onto the steam table pan. Dietary Aide #6 then reached in with bare hands to grab the piece of aluminum foil touching the regular meatloaf. On 08/21/2024 at 3:00 PM, during an interview the Dietary Manager confirmed they are not supposed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-22 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to provide an environment that promoted the maintenance or enhancement of the resident's quality of life, denying self-determination, and adequate communication for 1 (Resident #29) of 1 resident reviewed for resident rights. The findings are: On 08/19/24 at 11:01 AM, the surveyor attempted to interview Resident #29. Resident #29 spoke a few words in English but responded to the majority of the surveyor's inquiries by smiling and nodding their head. Review of the Care Plan dated 6/17/2024 revealed Resident #29 has an impaired cognitive function related to a language barrier. The intervention was to observe/report as needed any changes in cognitive function. Noted food preferences were not listed. On 8/21/2024 at 9:30 AM, Certified Nursing Assistant (CNA) #1 was asked to identify Resident #29's native language. CNA #1 was unsure. CNA #1 stated the resident can understand some things and understands how to use his/her call light, but there are some language barriers. CNA #1 states she points to things to determine what 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 · Ecited before2024-08-22 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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, record review, and interview, the facility failed to ensure a safe, clean, homelike environment was provided for the 100-hall secured unit. On 08/19/2024 at 11:28 AM, the surveyor observed in room [ROOM NUMBER], on side B, the wall was scratched with paint removed exposing bare drywall. The baseboard by the bathroom was coming away from the wall and was warped, and right above the baseboard paint was peeling back. In the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER], to the right and behind the toilet the baseboard was coming away from the wall and warped. In the right-hand corner, the paint was peeling, and the drywall was crumbling. On the baseboard right behind the toilet is what appears to be a black substance, and the surveyor noted the bathroom had a musty, stagnant odor. On 08/19/2024 at 11:34 AM, Surveyor noted in room [ROOM NUMBER] the baseboard next the bed on side B had indentions in the wall with the paint peeling and bare drywall exposed. On 08/21/2024 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-22 · 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 observations, record review, and interview, the facility failed to a smoking apron was utilized for 1 (Resident #20) of 1 sampled resident. The findings are: A review of the Order Summary revealed Resident #20 had diagnoses of cognitive communication deficit, dementia, and chronic obstructive pulmonary disorder. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/07/2024 revealed Resident #20 scored a 13 (cognitively intact) on the Brief Interview for Mental Status (BIMS). A review of the Care Plan reveals Approaches/Tasks: Resident #20 requires a smoking apron while smoking. A review of the Smoking Safety Screen completed on 05/31/2024, reveals that Resident #20 required adaptive equipment in the form of a smoking apron. On 08/21/2024 at 11:30 AM, the surveyor observed Resident #20 going outside off the end of the 100-Hall secured unit with Certified Nursing Assistant (CNA) #2 to smoke. The surveyor observed Resident #20 was not wearing a smoking apron. On 08/21/2024 at 11:45 AM, during an interview CNA #2 stated they did not know…
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 · E2024-08-22 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, it was determined the facility failed to ensure refrigerated narcotics were stored in a permanently affixed storage box to ensure no misappropriation of resident medications affecting all 51 residents in the facility. The findings are: On 8/20/2024 at 9:30 AM, during an observation of the medication storage area inside the medication refrigerator, observed a small (approximately 4x 6), clear, medication box with a red temporary cable tie lock. The box contained a controlled medication (lorazepam) and was not secured inside the refrigerator. On 8/20/2024 at 11:45 AM, during an interview Licensed Practical Nurse #7 was asked why it is important to secure the box inside the refrigerator and stated, Because of the size, it would be very easy to remove the box with the medication. On 8/20/2024 at 11:45 AM, during an interview the Administrator confirmed the controlled medication box should be affixed inside the refrigerator. Reviewed the facility's undated policy (received on 8/20/24 PM from Administrator) on Pharmaceutical Services…
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 · E2024-08-22 · 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 observations, record review, and interview, the facility failed to ensure mechanical soft diets and puree diets were in the proper form for 2 of 2 observed meals provided by the facility kitchen. The findings are: On 08/19/2024 at 12:00 PM, the surveyor observed lunch service on the 100-hall unit, it is done in family style where the Certified Nursing Assistants (CNA) serve lunch for the residents according to the Dietary Manager. CNA #5 began serving the residents, the surveyor observed both regular and mechanical soft diets were getting diced ham and beans. Surveyor observed Resident #40 was spitting out the ham and laying it on a napkin. A review of the menu card revealed Resident #40's diet was Mechanical Soft, thin liquids, Supercal/High kcal. Surveyor observed Resident #39 was spitting ham out and putting it on the table. A review of the menu card revealed that Resident #39's diet was Mechanical Soft, regular diet, thin liquids. On 08/19/2024 at 12:15 PM, Resident #36's family member stated this is not an unusual occurrence they get food they cannot chew often.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-22 · 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 record review, observations, and interviews, the facility failed to ensure infection control measures, including hand hygiene, were implemented during incontinent care for 1 (Resident #5) of 1 sampled resident to prevent potential infection and or the spread of infections. The findings are: 1. Review of a procedure guide titled, PERI-CARE PROCEDURE, updated 04/29/2024 and provided by the Director of Nursing on 08/20/2024, indicated, Pat dry using clean, dry wash cloth, remove gloves, place in trash bag, put on clean gloves, apply sin barrier as needed. A review of an admission Record indicated the facility admitted Resident #5 with a diagnosis of congestive heart failure (CHF) that included emphysema. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident was severely impaired for their daily decision making. Review of Resident #5's Care Plan, revised on 10/11/2023, revealed the resident had an activities of daily living (ADL)…
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 · Dcited before2024-08-22 · tag F0641 — isolatedEnsure 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, interviews, record review and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 1 (Resident #29) of 1 resident reviewed for MDS accuracy. The findings are: Upon record review, the admission MDS with an Assessment Reference Date of 6/25/2024, in section A1110, noted that English is the resident's preferred language, and no interpreter is needed. On 8/19/2024 at 11:01 AM, the surveyor attempted to interview Resident #29. The resident spoke a few words in English, but most of the surveyor's inquiries were answered with head nodding and smiling. On 8/21/2024 at 9:30 AM, CNA #1 was asked what language the resident spoke, CNA #1 was unsure of the resident's native language. CNA #1 stated the resident can understand some things and understands how to use his/her call light, but there are some language barriers. The CNA stated she points to things to determine what the resident might need. On 8/21/2024 at 2:30 PM, the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to reflect the residents needs and preferences, and to properly assess a resident's fluency in English, to obtain all preferences to provide a diet consisting of resident's preferences, and to provide communication assistant devices, which affected the resident's physical, mental, and psychosocial well-being for 1 (Resident #29) of 1 resident reviewed for care plans. The findings are: On 08/19/2024 at 11:01 AM, the surveyor attempted to interview Resident #29, but realized some of the responses were not appropriate to the questions. It was noticed mostly with the open-ended questions such as, how long does it take staff to respond to the call light, where Resident #29 responded with a smile while nodding yes. Resident #29 spoke a few words in English, but most inquires were responded to with head nodding. The care plan dated 6/17/2024 stated Resident #29 has an impaired cognitive function related to language barrier.…
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 before2023-09-15 · 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, interview and record review, the facility failed to ensure food items stored in the freezer were dated to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; dented cans were removed from stock, and the dishwashing machine temperature reached the necessary, recommended minimum temperature specified by the manufacturer's instructions to destroy food borne illnesses for the residents who received meals from 1 of 1 kitchen and detergent levels in the low temperature dishwasher were consistently monitored to ensure there was detergent going through. This failed practice had the potential to affect 38 residents who received meals from the kitchen according to a list provided by the Administrator on 09/14/23 at 9:04 AM. The findings are: 1. On 09/13/23 at 11:50 AM, in the Freezer #1 were 3 bags of chicken, the bags were not dated. The Surveyor asked the Dietary Manager about the 3 bags of undated chicken observed in the freezer. The Dietary Manager stated that the chicken was received on 09/04/23 and the Dietary Manager put 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 · E2023-09-15 · 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, record review and interview, the facility failed to ensure a Physician's Order was obtained prior to administering a Trilogy unit for 1 (Resident #5) of 1 sampled resident and Physician Orders were obtained prior to administering oxygen for 1 (Resident #21) of 1 sampled resident and Physician Orders were followed for 2 (Residents #1 and #5) of 4 (Resident #1, #5, #11 and #37) sampled residents. The findings are: 1. On 09/11/23 at 11:00 AM, Resident #1 was lying in bed receiving oxygen at 1 liter per minute by nasal cannula. a. On 09/12/23 at 8:52 AM, Resident #1 was lying in bed receiving oxygen at 1 liter per minute by nasal cannula. b. On 09/12/23 at 2:48 PM, Resident #1's oxygen tubing was lying on the bed wrapped in dirty linen. c. A Physicians Order dated 07/25/23 noted Resident #1 was to receive oxygen at 2 liters per minute via nasal cannula as needed. d. A Care Plan with a revision date of 08/14/23 did not address oxygen therapy. e. On 09/12/23 at 2:55 PM, the Surveyor asked Certified Nursing Assistant (CNA) # to check the flow meter on Resident #1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-15 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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 resident funds were refunded within 30 days after the resident was discharged /expired and had a remaining balance in the facilities resident trust fund account for 1 (Resident #140) of sampled resident per a list provided by the Administrator on [DATE] on 8:45 AM. The findings are: 1. Resident #140's closed record noted the resident expired on [DATE]. 2. The Trust Transaction History for [DATE] to [DATE] documented, Resident #140 had a closing balance of $675.82. 3. On [DATE] at 11:17 AM, the Surveyor asked the Business Office Manager (BOM) to identify the date Resident #140 had expired. The BOM verified Resident #140 expired on [DATE]. The Surveyor asked what the timeline was for the facility to convey remaining funds in the trust accounts to the resident's family upon expiration. The BOM stated, Thirty days, but we try to do it in two weeks. The Surveyor asked if an attempt had been made to contact Resident #140's representative to arrange…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 walls in 2 (rooms [ROOM NUMBERS]) resident rooms were not damaged and cracked floor tiles were replaced on the 300 Hall. The findings are: 1. On 09/13/23 at 11:41 AM, observed an 11.5 inch by 2.5 inch cracked tile in the floor of the 300 Hall. 2. On 09/14/23 at 8:27 AM, Resident room [ROOM NUMBER] had a 10 inch by 82 inch damaged area to the wall extending past the length of the resident ' s bed. The area had been partially repaired with white spackling and had a rough appearance and contrasted with the surrounding wall. 3. On 09/13/23 at 1:02 PM, the Surveyor accompanied Register Nurse (RN) #1 to Resident room [ROOM NUMBER]. RN #1 identified three visible scrapes measuring 26 inches, 19.5 inches, and 13.5 inches, located to the far left wall from the door. 4. On 09/13/2023 at 3:37 PM, the Surveyor pointed out to the Maintenance Supervisor the cracked floor tile on the 300 Hall, and the scratches on the wall in Resident room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the Comprehensive Care Plan addressed the use of a Trilogy unit (a ventilator that provides respiratory support) for 1 (Resident #5) of 1 sampled resident. The findings are: 1. On 09/11/23 at 1:26 PM, observed a Trilogy unit at Resident #5's bedside. Resident #5 stated, I wear the Trilogy at night. 2. On 09/11/23 at 1:45 PM, Resident #5's Comprehensive Care Plan with a revision date of 09/08/23 did not address care and interventions for the use of the Trilogy. 3. On 09/13/23 at 11:30 AM, the Minimum Data Set (MDS) Nurse confirmed Resident #5's Trilogy unit was not on the care plan. 4. A Comprehensive Care Plan policy provided by the Administrator on 09/14/23 at 9:04 AM stated, .It is the Guidance of this facility is to develop and implement a comprehensive person-centered care plan for each resident . Guidance Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural…
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 · D2023-09-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure nebulizer treatments were administered as ordered for 1 (Resident #15) of 2 (Resident #15 and #21) sampled residents. The findings are: 1. On 09/11/23 at 11:14 AM, Resident #15 was lying in bed. A nebulizer machine was on the bedside table. There was a clear liquid in the nebulizer chamber with crystalized sediment around the top of the clear liquid. a. On 09/11/23 at 2:30 PM, Resident #15 was lying in bed. A nebulizer machine was on the bedside table with approximately 2 millimeters of clear liquid in the nebulizer chamber. The liquid had a slight odor. b. On 09/12/23 at 2:55 PM, observed a nebulizer machine sitting on Resident #15 ' s bedside table with approximately 1.5 millimeters of clear liquid in the nebulizer chamber, the liquid had a slight odor. The Surveyor asked Resident #15 if she used the Nebulizer. Resident #15 stated, Yes, three times a day. c. A Physicians Order dated 04/09/23 noted Resident #15 was to receive a nebulizer treatment three times a day. d. The September 2023 Medication…
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 · D2023-09-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 thickened water was provided at the bedside for 1 (Resident #6) of 1 sampled resident and tray cards were followed for likes and dislikes, substitutions were offered, food tray was set up with all foods opened. The findings are: 1. On 09/11/23 at 1:30 PM, Resident #6 had no fluids at the bedside. a. On 09/12/23 at 9:29 AM, Resident #6 had no fluids at the bedside. b. On 09/12/23 at 1:20 PM, Resident #6 had no fluids in her room. c. On 09/12/23 at 3:00 PM, the Surveyor asked Certified Nursing Assistant (CNA) #4 if there were any residents that do not get fluids at the bedside. CNA #4 said, There is a resident that gets nutrition by peg (percutaneous endoscopic gastrostomy) tube. Everyone else gets fluids. d. On 09/13/23 at 8:50 AM, Resident #6 had no fluids or at the bedside. e. The Care Plan with a revision date of 08/16/21 noted Resident #6 staff were to encourage hydration to minimize risk of constipation. f. On 09/13/23 at 12:30 PM, observed the Speech Therapist feeding Resident #6. 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.
- No harm found · Bcited before2023-09-15 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of the Centers for Medicare and Medicaid Services Resident Assessment Instrument Manual 3.0, the facility failed to accurately record the assessment for 1 (Resident #12) of 1 sampled resident. The findings are: 1. Resident #12 ' s admission Minimum Data Set (MDS) with an Assessment Reference Data (ARD) of 05/05/23 documented the resident required extensive, two plus person assistance with transfers, and limited one person assistance with eating. 2. A Care Plan with an initiated and a revision date 05/29/23 noted Resident #12 required a Mechanical Lift with two staff assistance for transfers. 3. A Physicians Order dated 07/07/23 noted Resident #12 was to receive nothing by mouth. 4. A Physicians Order date 07/20/23 noted Resident #12 was to receive 1422 calories of Nutren 1.5 per 24 hours and 1080 milliliters of fluids per day per feeding tube. 5. A Care Plan with a revision date 07/20/23 noted Resident #12 received nothing by mouth and received all nutrients and fluids through a feeding tube. 6. Resident #12's Quarterly MDS with an ARD 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.
“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
$9,307 in federal fines across 1 penalty.
- $9,307 — penalty dated 2025-06-20
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 | 3 of 5 | 3.2 | -0.2 vs chain |
| Staffing | 3 of 5 | 3.9 | -0.9 vs chain |
| Quality measures | 3 of 5 | 4.7 | -1.7 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 09/01/2019 |
| JEJ ASSETS LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 01/01/2022 |
| PONTHIE, SHARLOT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| FORT, JEANNIE | Individual | W-2 MANAGING EMPLOYEE | — | since 09/01/2019 |
| HICKS, DEBORAH | Individual | W-2 MANAGING EMPLOYEE | — | since 08/01/2023 |
| PONTHIE, JOHN | Individual | CORPORATE OFFICER | — | since 09/01/2019 |
| ALEXARK1 LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2022 |
| JEJ MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2022 |
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 54% 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 045284. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, 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.