Rogers Health And Rehabilitation Center
1149 W New Hope Rd, Rogers, AR 72758 · For profit - Limited Liability company · 118 certified beds · (479) 636-6290 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 66% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
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 | 9.4% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.1% | 4.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.9% | 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 | 3.4% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 5.7% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.4% | 21.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.7% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.3% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.8% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.2% | 10.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.9% | 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.
38.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 55 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 38.7%CMS range 30.2–50.1 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.7%CMS range 10.3–21.0 | 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 | not 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 discharge | not 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 discharge | not 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 identified | 90.0% | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 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 118 beds and averages 60.5 residents a day — about 51% occupied, or roughly 58 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 4.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.59 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.54 hrs/resident/day on weekends vs 4.37 on weekdays — 19% thinner on weekends. RN hours go from 0.37 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% 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.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · Ecited before2025-01-24 · 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, record review, interview, and facility policy review, the facility failed to ensure the rear casters on the mechanical lift remained unlocked during lifting a resident to allow for stabilization, and to prevent injuries or tipping affecting 1 (Resident #41) of 1 sampled resident reviewed for lift. The findings include: A review of Medical Diagnoses revealed Resident #41 had diagnoses of stroke, diabetes, and kidney disease. The significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/2024 suggested a Staff Assessment for Mental Status (SAMS) indicated short- and long-term memory problems. Section H0400 indicated the resident was always incontinent of stool, and section H0100 indicated Resident #41 had a catheter. a. On 01/21/2025 at 02:12 PM, Resident #41 returned to the room to be transferred to the bed using a mechanical lift. Certified Nursing Assistant (CNA) #4 placed the open mechanical lift legs around Resident #41's chair with the rear casters in the locked position. The resident was raised using a purple lift pad and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-24 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, record review, and facility policy review, the facility failed to ensure the kitchen walls, tiles, air vents, and door frames were maintained in good repair and were free of chips, stains and rust; baseboards were secured and were maintained in clean sanitary conditions; and dietary staff washed their hands before handling clean equipment for 2 of 2 meals observed. The findings are: 1. On 1/21/25 at11:51 AM, the following observations were made in the kitchen areas: a. The florescent light above the steam table had no cover over it, electrical wires were exposed. b. The ceiling tiles around the emergency window by the steam table had brown stains on it. c. The kitchen floor by the steam table was chipped, in three (3) different areas exposing the concrete. d. The baseboard tile below the steam table was missing. e. The wall by the pipe connected to the switch attached to the plate warmer was cracked and the concrete was exposed. f. The wall leading to the Dietary Manager's office from the kitchen was cracked and the concrete was exposed. g. 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 · E2023-12-01 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 Advance Directive documents were maintained in a section of the resident's medical record readily retrievable by facility staff for 4 (Residents #9, #26, #27 and #32) of 18 sampled residents. The findings are: 1. On 11/28/23 at 9:45 AM, a review of Resident #9's medical record revealed there was no advance directive in the clinical record. On 11/28/23 at 03:20 PM, the Surveyor asked the Marketing Director, Does [Resident #9] have an advance directive? She looked in the electronic system for Resident #9's advance directive. She stated, I don't see one. 2. On 11/28/23 at 9:19 AM, a review of Resident #26's medical record revealed there was no advance directive in the clinical record. On 11/28/23 at 3:16 PM, the Surveyor asked the Marketing Director, Does Resident #26 have an advance directive? She looked in the electronic system for Resident #26 advance directive. She stated, I don't see it unless I'm overlooking it. On 11/28/23 at 1:10 AM, the Director of Nursing (DON) was asked, When should an advance directive be…
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 · E2023-12-01 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to protect the privacy of 2 (Residents #12 and #32) of 8 (Residents #1, #12, #18, #27, #32, #39, #43 and #46) sampled residents who resided on C Hall. The findings are: 1. On 11/28/2023 at 11:31 AM, a medication cart was observed positioned against a wall in the hallway on the C Unit with no nurse present. The laptop on the medication cart was open and unlocked. The Medication Administration Record (MAR) for Resident #12 was opened and easily visible on the screen. There were two staff members and one resident present in the hallway on C Unit and were able to see the personal health information (PHI) of Resident #12. On 11/28/2023 at 11:39 AM, Licensed Practical Nurse (LPN) #2 said she should have locked the laptop to protect the PHI of Resident #12 before leaving the medication cart unattended. On 11/30/2023 at 09:15 AM, the Director of Nursing (DON) said that laptops with PHI should be locked or closed when a nurse is not actively using it to protect resident privacy. On 11/30/2023 at 09:31 AM, 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 · E2023-12-01 · 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 and interview, the facility failed to ensure 3 (rooms [ROOM NUMBER]) of 12 rooms on the E Hall were free of damage. The findings are: 1. On 11/27/23 at 1:08 PM, the sheetrock on the wall behind the bed in room [ROOM NUMBER] was peeling. Splashes of brown spots were observed on the wall behind the bed. On 11/29/23 at 3:02 PM, the sheetrock on the wall behind the bed in room [ROOM NUMBER] was peeling. Splashes of brown spots were observed on the wall behind the bed. On 11/30/23 at 3:30 PM, the sheetrock on the wall behind the bed in room [ROOM NUMBER] was peeling. Splashes of brown spots were observed on the wall behind the bed. 2. On 11/29/23 at 8:14 AM, the sheetrock behind the bed in room [ROOM NUMBER] was peeling. On 11/30/23 at 8:55 AM, the sheetrock behind the bed in room [ROOM NUMBER] was peeling. On 11/30/23 at 3:50 PM, the sheetrock behind the bed in room [ROOM NUMBER] was peeling. 3. On11/28/23 at 9:39 AM, the sheetrock was peeling on the wall behind the bed in room [ROOM NUMBER],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-01 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure fingernails were maintained to promote good hygiene for 1 (Resident #22) of 15 (Residents #1, #7, #9, #12, #22, #26, #27, #32, #33, #35, #36, #46, #47, #52 and #211) sample mixed residents. The findings are: Resident #22 had diagnoses of unspecified lack of coordination; chronic respiratory failure and chronic diastolic (congestive) heart failure. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/23 documented a Brief Interview for Mental Status (BIMS) of 14 (13-15 indicates cognitively intact); required supervision with personal hygiene and one-person physical assistance with bathing. The Care Plan with an initiated date of 02/23/21 and a revision date of 09/13/23 noted Resident #22 had an ADL (Activities of Daily Living) self-care performance deficit and was to have nail length checked and trimmed and cleaned as necessary. The Care Plan with initiated date of 02/23/21 and a revision date of 02/24/21 noted Resident #22 was at risk for impaired skin integrity related 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 · E2023-12-01 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 physician's orders were followed when administering medication and enteral nutrition for 1 (Resident #32) of 2 (Residents #32 and #47) sampled residents with percutaneous endoscopic gastrostomy (PEG) tubes, and failed to ensure medications were given in the recommended time frame for 2 (Residents #29 and #37) of 31 residents that had medications administered by Licensed Practical Nurse #3. The findings are: 1. On 11/28/2023 at 11:34 AM, LPN #2 administered to Resident #32 - one medication, Oxybutynin Chloride (overactive bladder medication) Tablet 5 MG (milligrams) and provided enteral nutrition. The enteral feeding order dated 10/20/23 documented Enteral feed order noted Resident #32 was to receive bolus tube feedings four times a day of TwoCal HN (a nutritionally complete, high-calorie formula) 1 can (8 ounces) with 60 milliliters water flush before and after feedings. Licensed Practical Nurse (LPN) #2 did not incline the head of Resident #32's bed before administering the medication and enteral…
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 · E2023-12-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician to minimize the potential for hypoxia or other respiratory complications for 1 (Resident #22) of 9 (Residents #1, #6, #8, #20, #21, #22, #27, #39 and #52) sample residents according to a list provided by the Administrator on 11/30/23 at 10:52 AM. The findings are: Resident #22 had diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), and shortness of breath. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/23 documented a Brief Interview for Mental Status (BIMS) of 14 (13-15 indicate cognitively intact) and received oxygen therapy. A Physician's Order dated 04/06/23 documented Resident #22 may have O2 (Oxygen) at 2 LPM (liters per minute) via N/C (nasal cannula) as needed for shortness of breath every shift. Review of the Care Plan with a revision date of 08/01/22 revealed Resident #22 had COPD and receives oxygen via nasal prongs at 2 Liters as needed to keep sats (oxygen…
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 · E2023-12-01 · tag F0725 — failed to have enough nursing staff — patternProvide 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 sufficient qualified nursing staff were available at all times to meet the needs of the residents in a timely manner. This failed practice had the potential to affect all 58 Residents. The findings are: On 11/27/23 at 12:30 PM, the Surveyor asked Resident #211's family how they felt about the care the resident was receiving. The family member said the resident came the last part of September, and the care was great. Then there seemed to be a big turnover right after they got here. The family member said the resident said that they will push and push the call light to be changed and nobody would show up. This happened a lot at night. On 11/27/23 at 01:09 PM, the Surveyor asked Resident #6, How would you describe the care you are receiving? Resident #6 said part of care is not very good. The Surveyor asked, Could you explain in depth? Resident #6 said making sure that we get changed. I know they're shorthanded, but I've gone hours and hours without being changed. The Surveyor asked, Is there any specific shift that is…
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 · E2023-12-01 · tag F0728 — failed to protect against nurse-aide misconduct — patternEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
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 full-time nursing assistants have become certified within 4 months of nurse aide training. The findings are: On 11/30/23 at 2:47 PM, a document provided by the Administrator on 11/29/23 at 3:54 PM revealed, Nurse's Aide (NA) #1's hire date was 4/3/2023 and NA class was completed on 8/4/23. On 11/30/23 at 2:00 PM, a document provided by Human Resources (HR) revealed NA #3 attended class from 7/11/23 to 8/4/23 and graduated. A second document provided at the same time revealed a Job Title dated 11/30/23, Nurse Aide in Training. On 11/30/23 at 03:05 PM, the Surveyor asked the Director of Nursing (DON) when does a Nurses Aide start working on the floor? The DON said that varies because they have to do a lot of onboarding and they don't always start immediately. The Surveyor asked how long is an NA allowed to work from their hire date until Certified by the State? The DON said, Four months, I believe. The Surveyor asked if they get to the 4-month mark before testing, what do they do? The DON said, they are usually put 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.
Show the remaining 14 citations
- Potential for harm · E2023-12-01 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
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 facility was free of significant medication errors for 1 (Resident #35) of 2 (Residents #35 and #57) residents that were observed during the 8:00 AM medication administration pass. The findings are: Resident #35 had a diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (nerve damage). A Quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 11/21/23 documented a score of 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. A review of a November 2023 Physicians Order dated 06/01/20 documented, .[Brand Name - rapid acting insulin] Solution 100 UNIT/ML [milliliter] (Insulin Aspart) Inject 5 unit subcutaneously with meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. HOLD blood sugar less than 150 . A review of Resident #35's Medication Administration Record indicated Resident #35 received 5 units of Novolog Solution 100 UNIT/ML (Insulin Aspart) 54 times from November 1 to November 29 when his blood sugar was below 150. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-01 · tag F0865 — failed to run a quality-improvement (QAPI) program — patternHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with the provision of nail care and ensuring call devices were readily available for residents. These failed practices had the potential to affect all 58 residents who resided in the facility as identified on a Census Report provided by the Administrator on 11/30/2023 at 03:45 PM. The findings are: 1. A Recertification and Complaint survey was conducted on 09/02/2022 at the facility. During the survey, the team identified concerns with ensuring a call light was kept within residents' reach and ensuring fingernails were maintained to promote good hygiene. 2. A review of the facility's Plan of Correction for call lights with a completion date of 10/02/2022 indicated the Director of Nursing (DON)/Designee observed call light placement for residents to ensure call light was kept in within residents' reach to allow resident to request assistance to accommodate…
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 · E2023-12-01 · tag F0882 — patternDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain a designated Infection Preventionist who was responsible for the facility's Infection Prevention and Control Plan. The findings are: On 11/29/23 at 11:10 AM, the Administrator was asked, Who's the infection control nurse? She stated, His name is [Licensed Practical Nurse (LPN) #5], and he's off. He had a family emergency and had to go out of town. On 11/29/2023 at 1:52 PM, LPN #4 was asked, Who's the Infection Preventionist? He stated, I assume it's the Director of Nursing (DON). I really don't know. On 11/29/2023 at 1:56 PM, Certified Nursing Assistant (CNA) #7 was asked, Who's the Infection Preventionist? She stated, I don't know who the infection control nurse is. The last one quit not too long ago. On 11/29/2023 at 2:03 PM, LPN #1 was asked, Who's the Infection Preventionist? She stated, I'm not sure. This is my third day. On 11/29/2023 at 2:06 PM, Nurse Assistant (NA) #1 was asked, Who's the Infection Preventionist? She stated, I don't know. On 11/29/2023 at 2:13 PM, CNA #3 was asked, Who's the Infection…
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 · E2023-12-01 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
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 call light was kept within the residents' reach to allow residents to request assistance for 1 (Resident #33) of 21 (Residents #1, #2, #6, #7, #8, #9, #12, #18, #20, #22, #26, #27, #32, #33, #35, #36, #39, #46, #47, #52, and #211) sampled residents who were capable of utilizing the call light system. The findings are: Resident #33 had diagnoses of unsteadiness on feet; dementia; muscle weakness; and diastolic (congestive) heart failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/6/23 documented a Brief Interview for Mental Status (BIMS) of 8 (8-12 indicates moderately cognitively impaired) and required limited physical assistance of one person with dressing and personal hygiene and supervision of one person locomotion on and off the unit and toilet use. The Care Plan with a revision date of 11/02/23 noted Resident #33 was at risk for falls and had had a fall and was to be encouraged and educated to use her call light or ask for assistance as needed. On 11/27/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-01 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure 3 (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 12 Rooms on the E Hall were free of damage. The findings are: 1. On 11/27/23 at 1:08 PM, the sheetrock on the wall behind the bed in room [ROOM NUMBER] was peeling. Splashes of brown spots were observed on the wall behind the bed. On 11/29/23 at 3:02 PM, the sheetrock on the wall behind the bed in room [ROOM NUMBER] was peeling. Splashes of brown spots were observed on the wall behind the bed. On 11/30/23 at 3:30 PM, the sheetrock on the wall behind the bed in room [ROOM NUMBER] was peeling. Splashes of brown spots were observed on the wall behind the bed. 2. On 11/29/23 at 8:14 AM, the sheetrock behind the bed in room [ROOM NUMBER] was peeling. On 11/30/23 at 8:55 AM, the sheetrock behind the bed in room [ROOM NUMBER] was peeling. On 11/30/23 at 3:50 PM, the sheetrock behind the bed in room [ROOM NUMBER] was peeling. 3. On11/28/23 at 9:39 AM, the sheetrock was peeling on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure the laundry room was free from standing water and trash for 1 of 1 laundry room. The findings are: On 11/20/ at 1:15 PM, in the Laundry Room beside the washer was approximately 3/4 inches of standing water and trash. The Maintenance Supervisor was asked, Can you tell me why there's water and trash beside the washer? He stated, They came and fixed the washer on Monday, but it's still leaking, and I'm not sure why there's trash in the water. On 11/30/23 at 1:26 PM, the Surveyor asked Laundry Staff #1, How long has water been standing on the floor beside the washer? She stated, Since Monday. She was asked, How long has the glove and trash been in the water? She stated, I don't know. She picked up the glove and threw it in the trash.
- Potential for harm · D2023-09-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement the individualized plan of care on 1 (Resident #2) of 1 Resident. The finding include: The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 required two plus persons physical assist with bed mobility. Review of Resident #2's care plan dated 05/31/2022 showed a care plan for activity of daily living performance deficit, with an intervention requiring extensive assistance by 2 staff to turn and reposition in bed. On 09/25/2023 at 8:35AM a phone interview with Certified Nursing Assistant (CNA) #1. I said on 08/03/2023 she was changing Resident #2, when the resident rolled off the bed. DNA #1 said she was not aware Resident #2 required 2 staff to assist with care. CNA #1 stated No one told me. I work night shift and I work the hall by myself. On 09/25/2023 at 9:17AM the administrator presented an in-service dated 8/21/23 which had signatures of certified nursing assistance from the day shift. CNA #1 signature was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility staff failed to prevent a resident from falling out of bed during a bed bath, for 1(Resident #2) of 4 (Resident #1, #2, #3 and #4) sampled case mix residents reviewed for accidents. Findings included: Review of Resident #2's medical diagnosis form showed diagnoses of dementia, severe agitation, muscle wasting, and arthritis. Record review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed severe cognitive impairment and required two plus persons physical assist with bed mobility. Review of Resident #2's care plan dated 05/31/2022 showed the following: a. At risk for fall related injury with the goal to be free of all falls. Ensure bolster mattress is secure over the air mattress and you use a flat sheet instead of a fitted. b. Activity of daily living self care performance deficit with bed mobility requiring extensive assistance by 2 staff to turn and reposition in bed with an initiated date of 07/19/2018. Review Resident #2'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 before2023-09-25 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and inteview, the facility failed to provide a sanitary environment for staff and residents, by failing to clean and eliminate black substances, replace ceiling tiles, and clean the air vent in a Resident's room and the nurses' station. This failed practice has the potential to affect all residents. The findings include: On 09/25/2023 at 10:45 AM during observation, the vent over the nurses' station was covered with a black substance. Sitting on the counter under the vent, were two basins holding water dripping from the vents. LPN #1 said every time it rains it pours through. The Surveyor asked LPN #2 has the facility fixed this issue? She stated, I have been here 5 years and they keep painting over it. On 09/25/2023 at 10:46 AM, during observation room [ROOM NUMBER] had a hole in the ceiling. LPN #1 said when it rains it falls in, and this is not the first time it has happened. The hole was right above the head of the bed, but she was told the resident was not in bed at the time it fell.
- Potential for harm · Fcited before2022-09-02 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness; failed to ensure 1 of 1 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages; failed to ensure leftover food items were used properly to maintain food quality, and failed to ensure meal trays were served using proper hand hygiene for residents who received meals and meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 68 residents who receive meals from the kitchen per NPO (no food by mouth) list provided by Administrator#1 8/29/22. The findings are: 1. On 8/29/22 at 10:05, during the initial tour of the kitchen with the Dietary Manager (DM) the following items located in the Dry Storage Room had no dates that indicated when they were received or opened: a. Bread crumbs 8/2/22 b. Elbow noodles 8/28/22 c. Spiral noodles 6/30/22 d. Kiwi lime sauce 7/22 e. Powdered…
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 · E2022-09-02 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set [MDS] assessments were completed accurately to reflect necessary care and services for 2 (Resident's #40 and #71) of 2 sampled residents to provide accurate information for developing a plan of care to meet the residents' needs. This failed practice had the potential to affect 73 residents, according to the Resident Matrix provided by Administrator #2 on 08/29/22. The findings are: 1. Resident #40 had diagnoses of Unspecified Fracture of Left Femur, Fracture of Unspecified Part of Left Clavicle and Periprosthetic Fracture around another Internal Prosthetic Joint. An admission five-day Medicare Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 07/21/22 documented the resident scored 03 90-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status [BIMS] and required Total assistance of 1 for bathing, Extensive assistance of 2 for bed mobility, transfer and toilet use,…
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 before2022-09-02 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure fingernails were maintained to promote good hygiene for 1 (R# 30) of 16 (R #6, #8, #14, #15, #16, #22, #28, #30, #35, #36, #37, #47, #53, #55, #58, #63) of the sampled case mix residents who were dependent on staff for Diabetic Nail Care according to a list provided by the Administrator on 09/02/22 at 07:30am and failed to ensure bathing was provided as scheduled for 1 (R#41) of 10 (R #14, #15, #36, #50, #55, #57, #62, #66, & #71) who were dependent on staff for bathing according to a list provided by the Administrator on 9/1/22 at 12:35 PM. The findings are: 1. Resident #30 had diagnoses of Parkinson's Disease, Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. A Quarterly Minimum Data Set [MDS] with a Assessment Reference Date [ARD] of 07/03/22 documented the resident received a score of 09 (8-12 moderately impaired) on the Brief Interview for Mental Status [BIMS]. Resident required…
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 · D2022-09-02 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview the facility failed to ensure a call light was kept within residents' reach to allow residents to request assistance to accommodate their individual care needs for 1 (Resident #72) of 12 (R #3, #15, #24, #28, #29, #30, #47, #57, #62, #66, #71, #72) sampled residents who were dependent on staff assistance and were capable of utilizing the call light system. The findings are: 1. Resident #72 had diagnoses of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Paroxysmal Atrial Fibrillation and Displaced Fracture of Medial Malleolus of Right Tibia, Closed Fracture with Routine Healing. The Annual Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 08/15/22 documented the resident scored an 11 (8-12 considered mildly impaired) on a Brief Mental Status [BIMS]; required Total assistance of 2 for transfer and bathing, Extensive assistance of 2 for bed mobility, dressing, toilet use and personal hygiene, was Independent after setting up 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.
- No harm found · C2022-09-02 · tag F0850 — failed to provide social-work services — widespreadHire a qualified full-time social worker in a facility with more than 120 beds.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews the facility failed to employ a qualified Social Worker with a minimum of a bachelor's degree, to meet the needs of the residents. This failed practice had the potential to affect all 73 residents who resided in the facility. The findings are: 1.On 09/01/22 at 1:12 PM, The Surveyor asked Administrator #1 for a copy of Social Service Director's (SSD) social worker degree and/or license. Administrator #1 stated, She does not have one. [SSD name] is signed up and scheduled to complete it. The Surveyor asked, Are you licensed for more than 120 beds? Administrator #1 stated, Yes. The Surveyor asked, Does any staff in the facility have an SSD degree and/or license that was moved to a new position? Administrator #1 stated, No, we do not have anyone that has one. 2.On 09/02/22 at 07:30 AM, Administrator #1 came to conference room and handed Behavioral Health Services Agreement to the surveyor. Administrator #1 stated, they told me this meets the social worker requirement. 3.On 09/02/22 at 09:28 AM, the Director of Social Services Job Description handed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SOUTHERN ADMINISTRATIVE SERVICES — 35 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.8 | -0.8 vs chain |
| Health inspection | 2 of 5 | 3.2 | -1.2 vs chain |
| Staffing | 4 of 5 | 3.9 | +0.1 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 34 homes this chain runs (chain average 3.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| 4P2T1 OPS HOLDING LP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/14/2020 |
| ALEXARK1 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| JEJ ASSETS LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| JEJ MANAGEMENT, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| PONTHIE, SHARLOT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2022 |
| HYATT, KATHY | Individual | W-2 MANAGING EMPLOYEE | — | since 08/16/2023 |
| PONTHIE, JOHN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 01/01/2022 |
CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $5.5M paid to related parties — landlords or management companies under common ownership — equal to about 66% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 045070. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-24, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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