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Ashley Rehabilitation and Health Care Center

2600 N 22Nd Street, Rogers, AR 72756 · For profit - Limited Liability company · 100 certified beds · (479) 899-6778 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Special Focus Facility (federal watch list)Abuse/neglect citation on record (F0600) — cited Nov 20242 immediate-jeopardy citations$65,473 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it’s on the federal Special Focus watch list for a persistent pattern of problems
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $65,473 in federal fines (most recent 2024-11-01)
  • nursing-staff turnover (71%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

/5
CMS overall
Not rated — CMS suppresses ratings for Special Focus Facilities
Health inspectionSurveyor-assigned, ranked within your stateInspector-verifiedNot rated — CMS suppresses ratings for Special Focus Facilities
StaffingFrom payroll records (PBJ)Not rated — CMS suppresses ratings for Special Focus Facilities
Quality measuresSelf-reported by the facilityNot rated — CMS suppresses ratings for Special Focus Facilities

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1615 W Persimmon St Ste B · (479) 636-7192 · Call to confirm hours
Pharmacy
2252 N 8th St · (479) 273-4000 · Call to confirm hours
Grocery
2505 N 17th St · (479) 616-1478 · Call to confirm hours
Park
2150 N Dixieland Rd · (479) 621-1117 · Typically dawn to dusk
Place of worship
2805 N Dixieland Rd

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 measuresNot rated — CMS suppresses ratings for Special Focus Facilities

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 2025-09, this home’s CMS overall rating held steady at 2 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.

CMS has published no overall rating for this home since 2025-09 — most often because it is a Special Focus Facility, whose rating CMS withholds. The line above is where the record stops; we do not carry the last star forward, and it is not this home’s rating today.

Overall ratingnot rated now
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased23.3%9.5%15.4%worse
Long-stay residents who lose too much weight4.2%4.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection1.2%1.2%2.0%better
Long-stay residents with depressive symptoms3.9%1.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.3%3.9%3.3%worse
Long-stay residents whose ability to walk worsened21.5%10.1%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.9%21.7%18.9%typical
Long-stay residents given the seasonal flu vaccine85.7%96.1%95.3%worse
Long-stay residents with pressure ulcers4.7%4.2%4.7%typical
Long-stay residents with worsening bladder/bowel control16.8%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.6%10.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine89.9%77.7%79.4%better

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.

54.8% 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 44 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.8%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
0.23U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.8%CMS range 41.7–67.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 7.0–16.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 3.1–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.46
RN hours/ resident / day
0.91
LPN hours/ resident / day
2.42
Aide hours/ resident / day
3.79
Total nurse hours/ resident / day
0.21
RN hoursweekends
71.0%
Total nursing turnover
85.7%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 52.9 residents a day — about 53% occupied, or roughly 47 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 3.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 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 3.06 hrs/resident/day on weekends vs 4.08 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.56 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 71% is well above the national median of 45%. 1 administrator has left in the past year.

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

2
deficiencies at the latest standard inspection (2026-05-14)
1
at the previous standard inspection (2025-12-12)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.

  • Immediate jeopardy · J2024-11-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure a resident was free from abuse for 1 (Resident #5) of 3 sampled residents reviewed for abuse. Specifically, the facility failed to ensure Resident #5 was free emotional abuse. The Immediate Jeopardy began on 09/02/2024, when CNA #4 made inappropriate statements to Resident #5 when she walked into the shower room while Resident #5 was taking a shower with help of CNA #4. CNA #4 and showed an inappropriate picture to Resident #5. The facility failed to investigate this incident until 09/09/2024. The facility had failed to train staff in abuse and neglect. The findings included: The Administrator became aware of the alleged abuse on 09/09/2024 and completed an Office of Long Term Care (OLTC) Incident and Accident (I&A) Report on 09/09/2024 at 11:10 AM. The report indicated that the alleged abuse occurred on 09/02/2024 and indicated that Resident #5 was taking a shower with the help of Certified Nursing Assistant (CNA) #5 when CNA #4 entered the shower room 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-11-01 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility to administer Cardiopulmonary Resuscitation (CPR) upon discovering 1 (Resident #62) sampled resident pulseless and breathless despite the resident being a full code. The Facility notified of the Immediate Jeopardy on [DATE] at 1:40 PM. The Facility Plan of Removal (POR) noted the facility will continue CPR upon discovering a resident pulseless and breathless when the resident is a full code signed [DATE]. The findings include: According to the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] Resident #62 had a Brief Interview of Mental Status of 15 indicating cognitively intact. Resident #62 had diagnoses of heart failure and morbid obesity. A review of the plan of care for Resident #62 (initiate date: [DATE]) noted Resident #62 was full code if found pulseless and breathless imitate CPR until emergency medical services (EMS) arrive to take over. Resident #62's family signed a Physician Order for Life…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-05-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and facility document review, the facility failed to ensure that the food preparation equipment and environment were maintained in a clean and sanitary condition to prevent contamination and potential development of foodborne pathogens in one of one kitchen observed. The findings include: During an observation of the lunch meal preparation on 05/13/2026 at 10:45 AM, [NAME] #6 was observed pureeing rice. [NAME] #6 took the lid off the chicken base put it upside down on the preparation table, obtained the needed amount of chicken base in the container with a plastic spoon and mixed it in a container of water. [NAME] #6 then put the lid on the container of chicken base and placed the spoon on the lid of the closed container, which touched the un-sanitized preparation table. [NAME] #6 then took the dirty blender, used for pureeing the rice to the dishwasher, ran it through the dishwasher, carried the blender back to the preparation table, and started pureeing the tortillas without washing her hands, or wearing gloves. [NAME] #6 opened the lid of the same…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-28 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to provide wound care in a manner to prevent infection for two (Resident #4 and Resident #5) of five residents reviewed for wound care. Specifically, staff performing wound care did not perform hand hygiene after contaminating their hands and before touching wound care supplies or applying ointments and dressings, and an impervious barrier was not used to prevent the contamination of wound care supplies. The findings include:Resident #4Review of Resident #4's Face Sheet, indicated the facility admitted Resident #4 on 03/19/2026 with diagnoses that included cellulitis, type 2 diabetes mellitus, protein-calorie malnutrition, venous insufficiency of the bilateral lower extremities, cognitive communication deficit, chronic venous hypertension with inflammation of bilateral lower extremities and candidiasis (fungal infection) of skin and nail.Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/21/2026, revealed Resident #4 had a…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-12 · tag F0605 — failed to not use drugs as a restraint — pattern
    Prevent 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

    Number of residents sampled:5Number of residents cited:3Based on interviews, facility record and policy reviews the facility failed to ensure consistent behavior monitoring with antipsychotic medications; failed to ensure antipsychotic medications were prescribed for an indicated diagnosis; failed to gradually reduce or eliminate antipsychotic medications with no documented behaviors for 3 (Residents #4, #7 and #41) of 5 residents reviewed for unnecessary medications. The Findings are:Based on record review, interviews, and facility policy reviews, the facility failed to ensure antipsychotic medications were prescribed for an appropriate indicated diagnosis and failed to gradually reduce or eliminate antipsychotic medications for residents with no documented behaviors for two (Resident #4 and Resident #41) of five residents reviewed for unnecessary medications. The findings include: Resident #4 Review of a quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 10/28/2025 revealed, Resident #4 had a Brief Interview for Mental Status [BIMS] score of 00, which…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-09 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility document review, the facility failed to ensure the privacy and confidentiality of residents' protected health information (PHI) was maintained for 1 (200 hall) of 1 hall of the facility. The findings include: During an observation on 06/06/2025 at 8:45 AM, Registered Nurse (RN) #5 was in room [ROOM NUMBER]. An unattended medication cart was on the 200 hall. A computer was sitting on top of the medication cart with the screen open to an electronic medication administration screen for Resident #6. During an observation on 06/06/2025 at 8:56 AM, RN #5 prepared a medication for Resident #8, locked the medication cart, entered a resident ' s room and left the computer screen open to Residents #8 ' s medication administration screen. During the observation, residents and staff were ambulating on the hall past the medication cart. During an interview on 06/06/2025 at 8:59 AM, RN # 5 stated they had been a nurse for 13 years, and began working in this facility one year…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, it was determined the facility failed to ensure staff performed hand hygiene after care of a resident and before and after medication administration for three (Resident #6, #8, and #9) of three residents observed. The findings include: During an observation on 06/06/2025 at 8:45 AM, Registered Nurse (RN) #5 was in a resident's room and placed a call light in reach of Resident #9. RN #5 exited the room, with no hand hygiene, and returned to the medication cart. RN #5 removed a medication card from the cart and placed medication into a medication cup, then provided it to Resident #6. During an observation on 06/06/2025 at 8:52 AM, RN #5 removed a clean medication cup, opened a bottle of vitamin D, poured one pill into the palm of their right ungloved hand, and placed the pill into the medication cup. RN #5 completed placing additional medications into the cup, then provided the medication cup to Resident #8. No hand hygiene was performed between residents. During an interview on 06/06/2025 at 8:59 AM, RN #5 stated they had…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-01 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to ensure required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents. The findings are: On 11/01/2024, the Administrator was asked to provide the in-services for the past 12 months conducted in the facility. The Administrator provided a binder which included in-services for the year of 2023 and 2024. In-services from 09/30/2023 to 10/27/2024 were reviewed and there were no in-services completed for dementia care. The Administrator provided a statement which was reviewed and indicated he was only able to provide an in-service completed on resident rights. On 11/01/2024 at 6:55 PM, the Director of Nursing was interviewed, and she stated the Administrator was responsible for conducting the mandatory in-services for staff and was unaware why some had not been completed. She stated she had been working on completing the in-services since she had been there.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-01 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 there was sufficient nursing staff to meet the residents' needs for 7 shifts reviewed from 09/01/2024 through 09/30/2024. On 10/28/2024 at 3:42 PM, Resident #29 was interviewed and stated the resident believed the daytime [shift] was understaffed because residents do not receive showers as they should. Resident #29 stated the resident's scheduled bath/shower days were Tuesday, Thursday, and Saturday. Resident #29 stated the resident did not receive a shower on Saturday, 10/26/24, due to the facility only had one Certified Nursing Assistant (CNA) working the hall the resident resided. The resident alleged the facility has two CNAs working in the building some nights. The grievance logs, provided by the Administrator on 10/28/2024, were reviewed and indicated multiple grievances were filed in August 2024, September 2024 and October 2024 concerning residents not receiving baths/showers on their scheduled days. The nursing staffs' schedules and timecards, provided by the Administrator, were reviewed and indicated the…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-01 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to post the daily nurse staffing information, to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. The deficient practice had the potential to affect all residents. The total census was 60. A Shift Staffing Schedule, dated 10/28/2024 for the 7:00 AM to 3:00 PM shift, was reviewed and did not have the facility's name, the number and actual hours worked by staff, the resident census or the licensed staff scheduled to work. The shift staffing schedule, dated 10/28/2024 for the 11:00 PM to 7:00 AM shift, was reviewed and only one Certified Nursing Assistant's (CNA's) name was listed on the sheet. On 11/01/2024 at 6:40 PM, the Director of Nursing (DON) was interviewed by another surveyor about the nurse staffing. The surveyor indicated the DON stated the staffing sheets, which included the facility name, date, census and total and actual number of hours worked per shift for nursing staff, were no longer required and therefore were not done.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-11-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to ensure food items stored in the freezer, refrigerator and dry storage areas were covered or sealed; expired food items were promptly removed/discard by the expiration or use by dates as when it was delivered,; 1 of 1 ice machines was maintained in clean and sanitary condition, staff washed their hands, and dietary staff washed their hands and between clean tasks when contaminated. The findings are: 1. On 10/28/24 at 10:54 AM, the following observations were made on a shelf in the walk-in freezer. a. An opened box of cookie dough. The box was not covered or sealed. b. An opened box of garlic bread sticks. The box was not covered or sealed. c. An opened box of Salisbury steak. The box was not covered or sealed. d. An opened container of sugar was under the food preparation counter with no lid on it. e. An opened container of flour was under the food preparation counter. There was no lid on it. The Dietary Manager…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-01 · tag F0837 — widespread
    Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to ensure a policy was developed and implemented pertaining to the governing body and failed to ensure the governing body was active in the development and implementation of the facility assessment. The findings are: The Facility Assessment, provided by the Administrator on 10/28/2024, was reviewed and missing necessary components. On 11/01/2024, the Administrator was interviewed, and stated no member of the governing body assisted with the completion of the facility assessment. He was asked to provide a policy for the governing body and documented on an extended survey list the facility did not have a policy for the governing body.

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 21 citations
  • Potential for harm · F2024-11-01 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the facility assessment contained pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents. This deficient practice had the potential to affect all residents of the facility. The total census was 60. The findings are: The Facility Assessment, dated as approved on 08/08/2024 and provided by the Administrator on 10/28/2024, was reviewed and indicated the purpose of the assessment was to determine what resources were necessary to care for the residents competently during day-to-day operations and emergencies. The facility assessment was missing the following components: -resident population -facility resources - facility-based and community risk assessment with an all-hazards approach - staff responsible for completing the assessment - staffing needs to ensure sufficient staff was available to meet the residents' needs - staff training/education and competencies - policies and procedures for provision of care - physical environment and building information -…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-01 · tag F0847 — widespread
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, interviews, record review and facility document review, it was deterred that the facility failed to ensure the Arbitration agreement contained all necessary components including the right to resend the agreement within the first 30 days of admission. The failed practice had the ability to affect all the residents who had signed the arbitration agreement. Findings include: A review of a facility admission agreement on 10/30/2024 at 3:30 PM, revealed, Arbitration, on page 5 section f, This provision for arbitration may be revoked by written notice delivered to the other parties within twenty-one (21) days of signature. The Administrator was provided a copy of the admission packet, on 11/01/2024 at 4:50 PM. The Administrator was asked to locate within the document the right to resend within 30 days. Administrator indicated the Arbitration Agreement may be revoked within 21 days. Administrator indicated the facility did not have a policy for arbitration.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-01 · tag F0848 — widespread
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    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 the arbitration documentation includes the selection of a neutral arbitrator and a location that is convenient for all. The failed practice had the ability to affect all 47 residents who currently reside in the facility. The findings are: During an interview on 11/01/2024 at 4:50 PM, the Administrator was asked to identify the language in the admission Agreement, page 5, section f, of the admission agreement that describes the process for selecting an arbitrator and the neutral location where the arbitration will take place. After examination the Administrator stated, I don't see it. During an interview the Administrator indicated that they did not have a policy for Arbitration. On 10/30/24 at 3:30 PM, a review of the facility arbitration agreement revealed that the facility's admission agreement, section f, pertains to Arbitration. During an interview on 11/01/24 at 4:50 PM, the admission Director (AD) was asked to identify the language in section f. of the admission agreement that describes the process for…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-11-01 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and facility policy review the facility failed to implement consistent infection surveillance to prevent the spread of possible communicable diseases. The facility also failed to develop and implement a water management plan to prevent the growth and/or spread of waterborne pathogens. The findings include: On 10/30/2024 at 9:00 AM, a review of forms in the binder provided by the facility revealed incomplete forms title Infection Control data Source: infection Control Log analysis should include Trends & Root cause Analysis and blank diagram of the facility for each month. On 10/30/2024 at 3:00 PM, the Surveyor requested any material the facility had on its' water management plan for Legionella. On 10/30/2024 at 3:10 PM, the Administrator stated the facility does not have any policy, procedures, preventions, or management for legionella in place. On 10/30/24 at 03:20 PM, The Infection Control Nurse stated I remember learning about legionella, but I do not know if we have anything in place for it. The Infection Control Nurse stated there was not an…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-01 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and facility policy review the facility failed ensure there was a consistent antibiotic stewardship to determine if the antibiotic is indicated or adjustments to the therapy should be made. The findings include: According to the admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 7/12/2024 Resident #215 had a Brief Interview of Mental Status (BIMS) score of 15 indication cognitively intact. A review of the order summary report Resident #215 had a diagnosis of cutaneous abscess of right foot and an order for an antibiotic to be given intravenous every 24 hours On 10/30/24 at 9:00 AM, a review of the forms in the binder provided by the facility revealed infection control assessment tools not completed for the months of August, September, and October. On 10/30/24 at 03:20 PM, the Infection Control Nurse stated the infection control assessment are not completed for the months August, September, and October. Infection Control Nurse stated I have no paper evidence that the facility has ensure the antibiotic was indicated or if…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-01 · tag F0941 — widespread
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    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 required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents. The findings are: On 11/01/2024, the Administrator was asked to provide the in-services for the past 12 months conducted in the facility. The Administrator provided a binder which included in-services for the year of 2023 and 2024. In-services from 09/30/2023 to 10/27/2024 were reviewed and there were no in-services completed for communication. The Administrator provided a statement which was reviewed and indicated he was only able to provide an in-service completed on resident rights. On 11/01/2024 at 6:55 PM, the Director of Nursing (DON) was interviewed, and she stated the Administrator was responsible for conducting the mandatory in-services for staff and was unaware why some had not been completed. She stated she had been working on completing the in-services since she had been there. The DON provided a monthly all staff in-service, dated 10/16/2024, which was reviewed…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-01 · tag F0946 — widespread
    Provide training in compliance and ethics.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to ensure required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents. The findings are: On 11/01/2024, the Administrator was asked to provide the in-services for the past 12 months conducted in the facility. The Administrator provided a binder which included in-services for the year of 2023 and 2024. In-services from 09/30/2023 to 10/27/2024 were reviewed and there were no in-services completed for compliance and ethics. The Administrator provided a statement which was reviewed and indicated he was only able to provide an in-service completed on resident rights. On 11/01/2024 at 6:55 PM, the Director of Nursing (DON) was interviewed, and she stated the Administrator was responsible for conducting the mandatory in-services for staff and was unaware why some had not been completed. She stated she had been working on completing the in-services since she has been there.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-01 · tag F0949 — failed to train staff on dementia and abuse — widespread
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents. The findings are: The Facility Assessment, provided by the Administrator on 10/28/2024 and dated 08/08/2024, was reviewed and included no information on ow staff was prepared to care residents who required behavioral health services. On 11/01/2024, the Administrator provided a binder which included in-services for the year of 2023 and 2024. In-services from 09/30/2023 to 10/27/2024 were reviewed and there were no in-services completed for behavioral health. The Administrator provided a statement which was reviewed and indicated he was only able to provide an in-service completed on resident rights. On 11/01/2024 at 6:55 PM, the Director of Nursing (DON) was interviewed, and she stated the Administrator was responsible for conducting the mandatory in-services for staff and was unaware why some had not been completed. She stated she had been working on completing the in-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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews the facility failed to ensure lint traps were free from excessive lint build up. The findings include: On 10/30/2024 at 08:34 AM, the Surveyor did an inspection of the clothes dryer and found all three with excessive lint build up. The Surveyor noted a clip board hanging on the wall next to the clothes dryer last entry dated 10/29/24. On 10/30/24 at 08:45 AM, the Housekeeping Supervisor stated the lint was removed from the lint traps after every 3 loads of laundry and documented on the clipboard hanging on the wall. The Housekeeping Supervisor stated there was two shifts morning and evening, and the last entry was done by the morning on the previous day. The Housekeeping Supervisor stated the lint traps looked like they have not had the lint removed which could cause a fire. On 10/31/24 at 1:38 PM, the Housekeeping Supervisor stated she had spoken to the employee who worked the evening shift on 10/29/24 and the employee stated she did enter an entry because she did not remove the lint from the lint traps. The facility provide a policy titled Fire…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews, it was determined that the facility failed to ensure established abuse policies and procedures were implemented after receiving an allegation of abuse for 1 (Resident #5) of 3 sampled residents for the implementation of abuse prohibition policies and procedures, that resulted in facility and contract staff, involved in allegations of abuse, to remain in the facility and to have continued contact with residents. Findings include: A review of a facility document titled, Abuse & Neglect Policy and Procedure, revision date 11/20/2017, indicated, The facility will implement procedures and TRAIN staff to PROTECT, RESPOND, REPORT & INVESTIGATE any allegations, suspicions or witnessed abuse. Guidelines will be established to protect residents from individuals that have allegedly committed abuse or have shown indication that would case abuse. A review of the Abuse and Neglect in-service dated 09/09/2024 showed that seven (7) people were in-serviced, and none were Certified Nursing Assistants (CNA), direct care staff. A review 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure a written discharge summary (dc) included a condensed summary of the stay in the facility and course of treatment, a reconciliation of medications, and resident status at discharge for 1 (Resident #61) sampled resident reviewed for a discharge. The findings are: On 10/29/2024, Resident #61's Discharge summary, dated [DATE], was reviewed and and indicated the resident was admitted on [DATE] and discharged home with family on 08/10/2024. The summary of stay indicated the resident attended physical, occupational, and speech therapy and a wound dressing on the right foot was changed accordingly. There was no indication of the resident's pre- and post- discharge medications, or the resident's status at discharge. There was no physician's signature on the form. On 11/01/2024 at 6:55 PM, the Director of Nursing was interviewed with concurrent observations, and she stated the nurses were responsible for completing the dc summary…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview, and record review, the facility failed to ensure baths/showers were provided to residents on their scheduled days to promote good personal hygiene and grooming for 1 (Resident #29) sampled resident reviewed for personal hygiene and grooming. The findings are: On 10/28/2024 at 3:42 PM, Resident #29 was interviewed and stated the resident believed the daytime [shift] was understaffed because residents do not receive showers as they should. Resident #29 stated the resident's scheduled bath/shower days were Tuesday, Thursday, and Saturday. Resident #29 stated the resident did not receive a shower on Saturday, 10/26/24, due to the facility only had one Certified Nursing Assistant (CNA) working the hall the resident resided. The resident alleged the facility only two CNAs working in the building some nights. A review of Resident #29's medical diagnoses indicated a lung condition which caused difficulty breathing (chronic obstructive pulmonary disease) and a condition which caused the muscles on one side of the body to be contracted (spastic hemiplegia…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and facility policy review the facility failed to ensure 1 (Resident #57) sampled resident received proper incontinence care and the incontinence care was done in a timely manner. The findings include: A review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 9/10/2024 revealed Resident #57 had memory problems and was frequent incontinent of bowel and bladder. Resident #57 had diagnoses of Alzheimer's disease and non-Alzheimer's dementia. A plan of care for Resident #57 (revision on: 3/07/2024) revealed Resident #57 had (urge, stress) bladder incontinence related to r/t activity intolerance, Alzheimer's disease, confusion, dementia, and impaired mobility. An intervention in place noted ensure the resident has unobstructed path to the bathroom. On 10/30/24 at 08:20 AM, the Surveyor observed Resident #57 sitting in wheelchair in hallway common. On 10/30/24 at 10:08 AM, the Surveyor observed Resident #57 sitting in wheelchair in hallway common area. On 10/30/24 at 11:45 AM, the Surveyor observed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review the facility failed to ensure bed rails were in use only after an assessment for risk of entrapment was completed for 1 (Resident #57) sample resident. The findings include: A review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 9/10/2024 revealed Resident #57 had memory problems and was frequent incontinent of bowel and bladder. Resident #57 had a diagnoses of Alzheimer's disease and non-Alzheimer's dementia. Resident #57 did not use side rails. A plan of care for Resident #57 (revision on: 3/07/2024) revealed Resident #57 had (urge, stress) bladder incontinence related to r/t activity intolerance, Alzheimer's disease, confusion, dementia, and impaired mobility. An intervention in place noted ensure the resident has unobstructed path to the bathroom. On 10/30/24 at 02:15 PM, the Surveyor observed Certified Nursing Assistant #7 lower the left side rail between the resident and the bathroom after care was done. CNA #7 stated to CNA #4 Resident #57 get up on the left side of the bed. On 10/31/24…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 medication was available during a medication administration observation for 1 (Resident #46) of 11 residents who received medications from 3 Licensed Practical Nurses (LPNs) and 2 Registered Nurses (RNs). The findings are: On 10/31/2024 at 8:03 AM, LPN #8, was retrieving Resident #46's medications from hall 100 medication cart. She looked through the medication cart and stated there was no Lactulose and she would need to call the pharmacy. On 10/31/2024 at 4:50 PM, RN #9 was at the medication cart for hall 100 and he was asked to check if lactulose was on the cart for Resident #46. He looked through the medication cart and retrieved a small bottle of lactulose but stated the bottle was for another resident and there was no lactulose in the cart for Resident #46. He stated Lactulose was not in a stock bottle and each resident would have an individual bottle. Resident #46's Order Summary Report was reviewed and indicated Lactulose oral solution 20 grams (GM)/30 milliliters (ML) and to give 20 ml by mouth…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5 percent (%) during the medication administration observation of 2 (Residents #7 and #46) of 11 residents who received medications from 2 Registered Nurses (RNs) and 3 Licensed Practical Nurses (LPN). 27 opportunities of medication administration were observed and 2 of the 27 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 7.41%. The findings are: On 10/31/2024 at 8:03 AM, LPN #8, was retrieving Resident #46's medications from hall 100 medication cart. She looked through the medication cart and stated there was no Lactulose and she would need to call the pharmacy. At 4:50 PM, RN #9 was at the medication cart for hall 100 and he was asked to check if lactulose was on the cart for Resident #46. He looked through the medication cart and retrieved a small bottle of lactulose but stated the bottle was for another resident and there was no lactulose in the cart for Resident #46. He was asked if 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-01 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure 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 — the official record, unedited, may be distressing

    Based on observation, record review and interview, the facility failed to ensure food items were prepared and served according to planned written menu for 1 of 2 meals observed. The findings are: 1. On 10/28/2024, the menu for noon meal indicated residents Minced Moist Soft diets were to receive 2#8 scoops (1cup) of chicken spaghetti, ½ cup of mash soft vegetables and residents on pureed diets were to receive 2#8 scoops (1 Cup) of pureed chicken spaghetti 2. On 10/28/24 at 12:34 PM, the following observations were made during the noon meal service. a. The DC #1 used a 6-ounce ladle (3/4 cup) to serve chicken spaghetti to the residents on Minced Moist soft diets, instead 2 #8 scoops which is equivalent to 1 cup. b. Residents on Minced Moist Soft diets were served pureed vegetable blend, instead of soft mash vegetables. c. The DC #1 used a #6 scoop (2/3 cup) to serve pureed chicken spaghetti to the residents on pureed diets, instead of 2#8 scoops which is equivalent to 1 cup.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-09 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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, interview and record review, the facility failed to keep medications secured by leaving it unattended on the resident's over the bed table in the resident's rooms, this failed practice had the potential to 4 of 4 Residents (Resident #4, #5, #6, and #7 case mix residents who had medication left on their over the bed table. The findings are: 1. On 1/09/24 at 8:17 AM during observation Resident #4 had eleven medication pills at bed side sitting on the over the bed table. The medications included Acetaminophen 350 mg(milligram), Ferrous Sulfate 325 mg, Amiodarone 200 mg, Aspirin 81 mg, Decubi- Vite, Furosemide 80 mg, Loratadine 10 mg, Vitamin D3 125 mcg(micrograms), Metolazone 5 mg, Potassium ER 20 mEq(milliEquivalent) and Preservision. a. The care plan dated 12/07/20 has not assessed and addressed self-medicating for Resident #4. The physician orders for January 2024 does not have an order for self-medicating for Resident #4 b. Resident #4 has a diagnosis of bipolar disorder, unspecified. 2. On 1/09/24 at 8:20 AM during observation Resident #5 had crushed…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy and procedure review and interview, the facility failed to report all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property for 1 (Resident #1) sampled resident. This failed practice had the potential to affect all 60 residents in the facility as documented by the Daily Census Report which was provided by the Director of Nursing on 8/11/23 at 7:42 a.m. The findings are: 1. A Policy titled, Abuse and Neglect Policy and Procedure which was provided by the DON with a revision date of 11/20/17 showed, . Protect and Respond Procedure . 1, The facility will act immediately upon notification when an individual(s) has been witnessed, suspected, or alleged to have caused abuse. 2. Unwitnessed, suspected, alleged statements of abuse, will be reported by the Administrator, DON or Designee to the local law officials, attending physician, resident's representative of record, Office of Long-Term Care and appropriate state agencies as required by law . Reporting Procedure . The Administrator, DON, or Designee…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-11 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and policy and procedure review, the facility failed to investigate all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property for 1 (Resident #1) sampled resident. This failed practice had the potential to affect all 60 residents in the facility as documented by the Daily Census Report which was provided by the Director of Nursing on 8/11/23 at 7:42 a.m. The findings are: 1.On 8/11/23 at 7:20 a.m., the Surveyor asked the Director of Nursing (DON) if she was aware of any recent abuse allegations. She stated, There was a complaint and the Administrator investigated it. One of the aides said it was a lie. The Surveyor requested all documentation of the investigation. 2. On 8/11/23 at 8:21 a.m., the Surveyor asked the Assistant Director of Nursing (ADON), if she was aware of any abuse allegations in the facility. The ADON stated, Earlier this week we had a shower situation. I was not in on the investigation. I know an aide was suspended. It was unfounded and they returned to work yesterday. 3.…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2026-05-14 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure 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 observations, interviews, facility policy, and record reviews, it was determined the facility did not consistently follow the supplied menu for 57 of 57 residents who received meals from the facility. The findings include: Review of the Spring/Summer 2026 menu revealed that on week one, day three, milk (1 cup) was to be served during breakfast, lunch, and dinner. During an observation of the lunch meal service on 05/13/2026 at 12:10 PM, it was observed that milk was not served to the residents. During an observation on 05/13/2026 at 23:30 PM, the refrigerator was observed to contain individual servings of milk. The refrigerator also contained seven gallons of 2% milk, four gallons of whole milk and four cases containing 25 individual chocolate milk cartons. Review of a detailed food order with a delivery date of Friday 05/08/2026 revealed the following milk was ordered for 57 residents to last until Monday 05/11/26. -2 cases which contained 25 containers of 8-ounce 1% chocolate milks. -2 cases which contained 25 containers of 8-ounce Homogenized fresh milks. -2 cases which…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$65,473 in federal fines across 1 penalty.

  • $65,473 — penalty dated 2024-11-01

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.

Who owns this facility

Owner / managerTypeRoleShareSince
LINCOLN, JAMESIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 07/01/2018
LINCOLN, JUDYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 07/01/2018
DRAKE, TIMOTHYIndividualCONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICERsince 03/22/2022
LTC MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2018

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$6.8M
Net patient revenuemost recent cost report
+5.2%
Operating marginrevenue minus expenses
$882K
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 70%Medicare 3%Other / private 27%

This home reported $882K paid to related parties — landlords or management companies under common ownership — equal to about 14% 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 2024. 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

$296per resident / day
operating cost
$9,010per month
≈ monthly operating cost
$312per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in AR

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045421. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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.

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