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Sheridan Healthcare And Rehabilitation Center

113 South Briarwood Drive, Sheridan, AR 72150 · For profit - Limited Liability company · 121 certified beds · (870) 942-2183 Medicare & Medicaid certified

Call the home — (870) 942-2183 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Apr 2025
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Apr 2025
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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 55% 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.

3/5
CMS overall
3 of 5
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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
(870) 942-3000 · Call to confirm hours
Pharmacy
Grocery
815 N Rock St · (870) 942-3400 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased2.0%9.5%15.4%better
Long-stay residents who lose too much weight2.3%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 infection0.4%1.2%2.0%better
Long-stay residents with depressive symptoms0.5%1.4%6.5%better 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 injury1.7%3.9%3.3%better
Long-stay residents whose ability to walk worsened8.7%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.6%21.7%18.9%typical
Long-stay residents given the seasonal flu vaccine96.8%96.1%95.3%typical
Long-stay residents with pressure ulcers5.5%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control4.8%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.2%10.9%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%1.3%1.4%typical
Short-stay residents given the seasonal flu vaccine81.0%77.7%79.4%typical
Short-stay residents rehospitalized after admission25.2%24.1%22.6%worse
Short-stay residents with an outpatient ER visit10.5%12.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.192.011.67worse
Long-stay outpatient ER visits per 1,000 resident days1.122.131.80better

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 109 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
9.0%U.S. median 10.7%
Went back to hospital
71.9%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 71.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 32 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 45.4–63.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.0%CMS range 6.1–13.110.7%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 discharge71.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge59.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge71.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge96.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.9%CMS range 6.3–14.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.251.02Oct 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

0.50
RN hours/ resident / day
0.95
LPN hours/ resident / day
2.80
Aide hours/ resident / day
4.24
Total nurse hours/ resident / day
0.15
RN hoursweekends
31.0%
Total nursing turnover
14.3%
RN turnover

How full it usually is: this home is certified for 121 beds and averages 59.1 residents a day — about 49% occupied, or roughly 62 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 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.80 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 3.68 hrs/resident/day on weekends vs 4.47 on weekdays — 18% thinner on weekends. RN hours go from 0.64 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below 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

3
deficiencies at the latest standard inspection (2025-04-04)
14
at the previous standard inspection (2024-01-26)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · F2025-04-04 · 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 minimum requirements were addressed in the facility assessment, as evidenced by, the medical director was not actively involved in the organization of the facility assessment for 1 of 1 facility. This failed practice had the potential to affect all residents in the facility (total census: 69). The findings are: On 04/04/2025, the Facility Assessment, dated as approved on 08/01/24 and reviewed with the Quality Assessment and Assurance (QAA) committee on 08/28/24, was reviewed and no signature page included. The revision history page was blank. On 04/04/205, the Administrator provided a copy of the QA & (and) A Committee Agenda/Minutes, dated 08/28/24, and no signature was observed for the Nurse Practitioner or Medical Director. The following words were written on the bottom of the minutes, Reviewed new F/A [facility assessment] plan. On 04/04/2025 at 2:46 PM, the Administrator was interviewed and stated the Medical Director was not a part of the completion of the facility assessment, but the Advanced Practice…

    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 · E2025-04-04 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and facility digital thermometer readings, the facility failed to maintain rehab resident rooms and the rehab hallway at a comfortable temperature level for residents in 1 of 5 hallways in the facility. The findings include: On 03/31/25 at 11:07 AM, this surveyor observed Resident #221 in their room, sitting in a wheelchair next to the bed. The resident stated the room was cold. On 03/31/25 at 01:39 PM, this surveyor observed Resident # 221 in their room, sitting in a wheelchair in the middle of the room. The resident stated it was still cold in the room and even the quilts were cold. This surveyor obtained a digital thermometer temperature reading of 68.4 degrees Fahrenheit (F), at resident sitting height. On 04/01/25 at 10:34 AM, Resident #221 stated it felt better in here [resident ' s room] last night. They [facility staff] shut my vent. This surveyor observed that the vent was closed at this time. Resident #221 stated it was still cold in the room. This surveyor obtained a digital thermometer temperature reading of 66.9 degrees F, near the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-04 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 interview, the facility failed to ensure the Ombudsman was notified of residents transferred from the facility and send a copy of the transfer of notification for 2 (Residents #15 and #63) of 2 sampled residents reviewed for hospitalization. The findings are: 1. Review of Nursing Note dated 12/25/2024 at 3:17 PM, indicated Resident #15 had confusion, that was gradually progressing during the shift. At 2:10 PM, the resident's blood pressure (BP) measured 110/60, heart rate (HR) 58, and was receiving oxygen (O2) at a flow rate of 2 liters, through a nasal cannula (NC). Resident #15 was given a breathing treatment (updraft) and the amount of oxygen in the resident's blood continued to stay at 88%. The on-call provider was called, and an order was given to send the resident to the hospital, for evaluation. Review of a Notice of Transfer/Discharge/LOA (leave of absence) with Bed Hold Policy form dated 12/25/2024, revealed Resident #15 was transferred to [hospital name], due to increase in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-04 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of resident ' s property, as evidenced by a medication card of [Compound Narcotic Pain Medication], 5 milligrams (mg)/325 mg which contained 43 pills, was taken from a medication cart and the empty card was located in a dumpster behind the facility, for 1 (Resident #8) of 1 sampled resident reviewed for misappropriation of property. The findings are: Review of an OLTC (Office of Long-Term Care) Incident and Accident Report (I&A), with discovery date and time of 07/12/2024 at 6:45 PM revealed during the count of the [NAME] medication cart on Friday, 07/12/24 around 6:15 PM, between former Licensed Practical Nurse (LPN) #5 [outgoing nurse] and former Registered Nurse (RN) #6 [incoming nurse], there was a discrepancy in the narcotic book count and the number of actual 5 mg [Brand name Opioid] for Resident #8. During the investigation, former LPN #5 admitted to the Director of Nursing (DON), Administrator and former Assistant Director of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-26 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    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 residents received personal mail on Saturdays. This failed practice had the potential to affect all 60 residents who resided in the facility, as documented on the Midnight Census provided by the Administrator on 1/22/2024 at 1:52 PM. The findings are: a. On 01/24/2024 at 02:50 PM, a resident council meeting was held with 6 residents. The Surveyors asked, Do you receive personal mail unopened and on Saturdays? The residents present replied, No we do not receive our mail on Saturdays, we receive it Monday through Friday. b. On 01/24/2024 at 04:07 PM, the Surveyor asked the Assistant Director of Nursing (ADON), Do residents receive their mail on Saturdays? The ADON stated, Yes, the weekend supervisor Registered Nurse (RN) receives the mail and delivers to the residents. c. On 01/24/2024 at 04:09 PM, the Surveyor asked the Business Office Manager (BOM), Do residents receive their mail on Saturday? The BOM replied, No, the mail comes late in the evening on Saturdays, so we deliver it to the residents on Monday. d. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-26 · 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 and interview, the facility failed to ensure potential frozen meat items were not stored above frozen packages of food items; cartons of pasteurized eggs were not stored above butter logs; foods stored in the refrigerator, and dry storage area were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, foods were dated the day received or opened to assure first in, first out usage to prevent potential for food bone illness, the dining floor was free of stains; door frames were free of rotten wood; the kitchen vent over the dish washing machine was free of rust stains, the clean dish machine counter was replaced, the dish washer and kitchen walls were free of paint peeling; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; the ice machine was maintained in clean and sanitary conditions; and expired beverages were promptly removed from refrigerator. The failed practices had the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-26 · 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 observation, interview, and record review, the facility failed to ensure staff used proper hand hygiene when assisting resident during meal service; laundry staff were properly trained to process contaminated linen; the folding table was free from contamination and to establish/implement a plan for Legionella to prevent the spread waterborne pathogens to reduce the potential for infections. This failed practice had the potential to affect 60 residents residing in the facility based on a list provided by the Administrator on 01/22/24 at 1:52 PM. The findings are: 1. On 01/22/24 at 02:15 PM, Certified Nursing Assistant (CNA) #1 removed soiled gloves and donned clean gloves without sanitizing her hands, while providing care to a resident. CNA #1 with ungloved hands assisted the resident with turning, tucked a soiled incontinent pad, and place a clean incontinent pad under the resident during care. CNA #1 then placed the soiled incontinent pad in a clear bag that was on the floor next to a trash container. a. On 01/22/24 at 02:15 PM, the Surveyor asked CNA #1 if it was standard…

    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 · E2024-01-26 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure care plans were reviewed and revised at least quarterly and/or when residents' care needs changed, as evidence by failure to revise the plan of care to address the use of an antidepressant, an anticoagulant and insulin injections to ensure staff were aware of the necessary care, assessments and services required for 1 (Resident #43) of 17 (Residents #6, #8, #11, #17, #18, #19, #23, #26, #27, #29, #31, #32, #43, #52, #53, #54 and #58) sampled residents who had orders for an antidepressant, 1 (Resident #43) of 6 (Residents #25, #27, #32, #43, #270 and #271) sampled residents who had orders for an anticoagulant and 1 (Residents #17) of 6 (Residents #8, #9, #17, #19, #29 and #32) sampled residents who had orders for insulin, as documented on lists provided by the Director of Nursing on 01/26/24 at 11:56 AM, and 1 (Resident #6) of 1 (Resident #6) sampled residents who had orders for an opioid. The findings are: 1. Resident #43 had diagnoses of Major Depressive Disorder and Atherosclerotic Heart Disease of Native Coronary…

    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 · E2024-01-26 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 5 residents who received pureed diets, as documented on the list provided by the Food Service Supervisor on 01/25/2024 The findings are: 1. On 01/24/24 at 11:19 AM, Dietary Employee (DE) #2 placed 6 servings of breaded chicken fried steak into a blender, added ½ cup of beef broth, thickener and pureed. She poured the pureed mixture into a pan. The mixture was not smooth and there were pieces of meat visible in the mixture. 2. On 01/24/24 at 12:25 PM, the pureed bread served to the residents on pureed diets, did not have a smooth consistency and had pieces of bread that were not completely pureed. At 12:31 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed chicken fried steak…

    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 · D2024-01-26 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure staff complied with a resident's request to use the bathroom to promote dignity for 1 (Resident #6) of 13 (Residents #6, #8, #11, #17, #23, #25, #26, #29, #31, #43, #53, #54, and #270) sampled residents who required staff assistance for toileting, as documented on a list provided by the Director of Nursing on 1/26/24 at 11:56 am. The findings are: 1. Resident #6 had diagnoses of Unspecified Osteoarthritis, Muscle Wasting and Atrophy and Cognitive Communication Deficit. a. A Care Plan with a review date of 12/28/23 documented Resident #6 had an Activities of Daily Living (ADL) self-care performance deficit related to impaired mobility and dependent assistance on one staff for toilet use. b. On 01/23/24 at 9:42 AM, Resident #6 had her call light on and Certified Nursing Assistant (CNA) #6 entered the room. The resident asked to go to the bathroom and CNA #6 told her she could not get up and that she had a brief on and she could go ahead and use it in her brief and they would change her later. The resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2024-01-26 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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 residents were invited and/or assisted to exercise their right to participate in development of their person-centered plans of care, to facilitate development of plans that would incorporate residents' goals, choices and preferences for 1 (Resident #25) of 6 (Residents #8, #17, #25, #29, #31 and #52) sampled residents whose Brief Interview for Mental Status (BIMS) scores were between 13 to 15 (13-15) which indicates the residents were cognitively intact, as documented on a list provided by the Director of Nursing (DON) on 1/26/24 at 11:56 AM. The findings are: 1. Resident # 25 had diagnoses of Paraplegia and Unspecified Injury at T1 (Thoracic 1) Level of Thoracic Spinal Cord. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/12/23 documented the resident had a BIMS score of 15. a. On 01/23/24 at 10:15 AM, Resident #25 was asked if she had been invited to participate in a care plan meeting regarding her care or any other changes regarding her care. She replied she had not been. b. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-26 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for 1 (Resident #19) of 1 sampled resident who had a diagnosis of a mental disorder. The findings are: 1. Resident #19 had diagnoses of bipolar and major depressive disorder. The Preadmission Screening and Resident Review (PASRR) was completed on 1/9/17. a. On 01/25/24 at 09:52 AM, according to Resident #19's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/8/23 noted Resident #19 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. b. On 01/25/24 at 03:37 PM, the Surveyor asked the Minimum Data Set (MDS) Coordinator if a PASRR level II screening was completed on Resident 19. The MDS Coordinator stated, Yes. The Surveyor asked how do you respond to question 1500 in section A of the Annual Minimum Data Set for a resident who had a level II screening completed? The MDS stated, Yes but you are going to tell me it says no, aren't you? c. On 01/25/24 at 03:45 PM, the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-26 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a Significant Change Minimum Data Set (MDS) assessment was completed within 14 days after a decline in activities of daily living (ADL) was noted, in order to address any potential changes in care needs for 1 (Resident #43) of 1 sampled resident who experienced an ADL decline. The findings are: 1. Resident #43 had diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. a. An admission MDS with an ARD of 9/29/23 documented the resident required extensive, one person assistance for transfers and toilet use. b. A Progress Note dated 11/07/23 at 8:40 AM documented, .i was called to dementia unit where resident was sitting in the floor hollaring [hollering] help me help me. vitals signs taken . bruise to right hip noted, large bump on right temporal area noted. resident assisted out of the floor and placed on couch in dementia unit . ambulance called . resdietn [resident] to be transfered [transferred] to [hospital] . c. A Progress Note…

    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 · D2024-01-26 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure comprehensive care plans were developed to address the resident's insulin injection order to ensure staff were aware of the required medication to promote continuity of care for 1 (Resident #32) of 6 (Residents #29, #8, #32, #9, #17, and #19) who had physician orders for insulin. The findings are: a. On 1/24/2024 at 10:27 AM, during record review the Surveyor noted on the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/2023 that Resident #32 received insulin injections the last 7 out of 7 days. The Annual MDS with an ARD of 05/09/2023 noted Resident #32 received insulin injections the last 7 out of 7 days. b. On 1/24/2024 at 10:32 AM, Resident #32's Care Plan did not address physician orders for insulin. c. On 01/26/2024 at 12:19 PM, the Surveyor asked the MDS Coordinator to review Resident #32's Annual MDS with an ARD 05/09/2023. The MDS Coordinator was also asked to review the Quarterly MDS with an ARD of 11/08/2023. The MDS Coordinator confirmed Resident #32 received insulin…

    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 · D2024-01-26 · 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 observation, record review and interview, the facility failed to ensure nail care services were regularly provided to promote good personal hygiene and grooming for 1 (Resident #6) of 16 (Residents #6, #8, #11, #17, #23, #25, #26, #29, #31, #40, #43, #52, #53, #54, #58, #270 ) sampled residents who required assistance for nail care, as documented on a list provided by the Director of Nursing on 1/26/24 at 11:56 am. The findings are: 1. Resident #6 had diagnoses of Unspecified Osteoarthritis, Muscle Wasting and Atrophy and Cognitive Communication Deficit. a. A Care Plan with a review date of 12/28/23 documented Resident #6 had an ADL (Activities of Daily Living) self-care performance deficit related to impaired mobility, preferred her nails to be long. An approach was to check nail length, trim and clean as necessary. b. On 01/22/24 at 1:42 PM, Resident #6 was resting quietly in bed awake. A dark brown substance was noted underneath the fingernails on her left hand. c. On 01/23/24 at 8:49 AM, Resident #6 was resting quietly in bed awake. The fingernails on her right hand 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-26 · 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 observation, interview and record review, the facility failed to ensure Resident #19 received proper incontinence care to prevent the potential for skin breakdown, poor hygiene, and/or infection. The findings are: 1. Resident #19 had diagnoses of paraplegia and weakness. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/6/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and was always incontinent of bowel and bladder. a. A Care Plan with an initiated and revision date of 08/05/2020 noted Resident #19 was to receive incontinence care every 2 hours and as needed by 1 staff member. b. On 01/22/24 at 02:15 PM, Certified Nursing Assistant (CNA) #1 provided incontinent care to Resident #19. CNA #1 applied gloves; removed Resident #19's covers and unfastened the brief. CNA #1 cleaned stool from the front of Resident #19 with wipes, using the wipe several times before tucking it between the resident's legs. CNA #1 removed her dirty gloves and put on clean gloves without sanitizing…

    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 · D2024-01-26 · 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, record review, and interview, the facility failed to ensure bed rails were utilized only after an assessment for entrapment risk was conducted and documented for 1 (Resident #60) of 5 (Residents #27, #8, #54, #60, and #23) sampled residents who used bed rails. The findings are: Resident #60 had a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. According to the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/23, the Resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and used bed rails daily. a. On 01/22/24 at 02:10 PM, observed Resident #60 sitting on the side of the bed with her feet on floor and the side rails up. b. On 01/25/24 at 10:15 AM, observed Resident #60's side rails were up on the bed. c. The Care Plan with an initiated date of 06/27/23 and the January 2024 Physician Orders, did not address the use of side rails. d. On 01/24/24 at 10:30 AM, the Surveyor asked Certified Nursing Assistant (CNA) #5 what type of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-26 · tag F0725 — failed to have enough nursing staff — isolated
    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 observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner to ensure resident safety and care needs were met. The findings are: 1. Resident #371 had diagnosis of difficulty walking, dizziness, and methicillin-resistant staphylococcus aureus (MRSA) of the left knee. A Care Plan dated 01/11/24 documented Resident #371 was on isolation precautions for MRSA. a. On 01/23/24 at 08:42 AM, observed the call light on outside of Resident #371's closed door and heard a beeping noise. b. On 01/23/24 at 08:56 AM, observed Licensed Practical Nurse (LPN) #2 donning Personal Protective Equipment (PPE) outside of Resident #371's closed door and then enter the room. c. On 01/23/24 from 08:42 AM to 08:56 AM, the Surveyor counted 7 staff members on the hall near Resident #371's door (3 staff members walked past Resident #371's room, 4 had a conversation near door, and 2 made multiple trips in the area near door, for a total of 10 failed opportunities by staff to respond to call light. d. On 01/23/24 at 08:56 AM, the Surveyor asked LPN…

    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 · E2022-11-03 · 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 observation and interview the facility failed to ensure that dryer lint traps were cleaned of excess buildup to minimize potential for fire. The failed practice had the ability to affect 52 residents who reside in the facility according to the Daily Census which was provided by the Administrator on 10/31/22 at 10:00 AM. The findings are: a. On 11/02/22 at 1:23 PM, The Surveyor asked Laundry Employee (LE) #1 to open the lint door of the middle dryer for observation. LE #1 opened the lint door of the middle machine. The lint screen was covered in a layer of light gray material. Toward the back of the machine a large, deposit of lint/debris was no longer attached to the lint screen and had fallen off onto the bottom of the machine. The lint door of the machine immediately to the right was opened. The lint screen was covered in a layer of light gray material. Toward the back of a machine two large deposits of multi-colored material were no longer attached to the lint screen and had fallen on to the bottom of the dryer. The Surveyor asked LE #1, How often are the lint screens…

    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 · Dcited before2022-11-03 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on Interview and record review, the facility failed to ensure that the Minimum Data Set (MDS) was coded correctly to meet the residents needs for 1 (R #22) of 15 (R #1, R #11, R #14, R #16, R #20, R #22, R #26, R #29, R #30, R #34, R #43, R #47, R #50, R #57, R #58) sampled residents whose MDS were reviewed. The findings are: Resident #22 had diagnoses of Hallucinations and Psychosis. A Quarterly MDS with an Assessment Reference Date (ARD) of 8/15/22 documented that the resident scored a 13 (13-15 Indicates Cognitively Intact) on a Brief Interview for Mental Status (BIMS); required extensive assistance with one-person physical help with bed mobility, transfers, and toileting and Independent with set up help with eating. Use of Antipsychotic Medication was not documented during the 7 day look back period. a. On 11/2/22 at 7:30PM, on the Medication Administration Record (MAR), the Antipsychotic was documented as being given during the 7 day look back period. b. On 11/2/22 at 7:40PM, The Physicians Order dated 7/14/22 documented, Seroquel 25 mg [Milligrams] give 1 tablet 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-03 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 that a Pre-admission Screening and Resident Review [PASARR] Level I and Level II was in place in the Medical Record, and in the facility for 1 (Resident #34) of 14 sample Residents (R #6, R #9, R #10, R #15, R #17, R #22, R #29, R #25, R #33, R #34, R #43, R #46, R #47, and R #110) who required PASARR's. This failed practice had the potential to affect 24 residents in the facility who required Level II PASARR's according to the list given by the Administrator on 11/03/22 at 11:30 AM. The findings are: 1. Resident #34 had diagnoses of UNSPECIFIED DEMENTIA, MILD, WITH OTHER BEHAVIORAL DISTURBANCE, ALTERED MENTAL STATUS, and UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date [ARD] of 08/10/22, documented a Brief Interview Mental Status [BIMS] of 05 (Indicated Cognition Severely Impaired), required extensive assistance with activities of daily living Self-Performance skills with one-person physical assist. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to 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 →

RatingThis homeChain avg
Overall 3 of 53.8-0.8 vs chain
Health inspection 2 of 53.2-1.2 vs chain
Staffing 4 of 53.9+0.1 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 34 homes this chain runs (chain average 3.8★, per CMS)
2 of 5Des Arc Nursing And Rehabilitation CenterDes Arc, AR 2 of 5The Green House Cottages of Southern HillsRison, AR 3 of 5Arbor Oaks Healthcare And Rehabilitation CenterMalvern, AR 3 of 5Ash Flat Healthcare And Rehabilitation CenterAsh Flat, AR 3 of 5Conway Healthcare And Rehabilitation CenterConway, AR 3 of 5Encore Healthcare And Rehabi Of MalvernMalvern, AR 3 of 5Lake Village Rehabilitation and Care CenterLake Village, AR 3 of 5Ouachita Nursing And Rehabilitation CenterCamden, AR 3 of 5Pocahontas Healthcare And Rehabilitation CenterPocahontas, AR 3 of 5River Ridge Rehabilitation And Care CenterWynne, AR 3 of 5Rogers Health And Rehabilitation CenterRogers, AR 3 of 5Southern Trace Rehabilitation And Care CenterBryant, AR 3 of 5The Cottages At TexarkanaTexarkana, AR 3 of 5The Green House Cottages Of Belle MeadeParagould, AR 3 of 5Willowbend Health And Rehabilitation, LLCMarion, AR 4 of 5Brookridge Cove Rehabilitation And Care CenterMorrilton, AR 4 of 5Pleasant Valley Rehabilitation And NursingLittle Rock, AR 4 of 5St Johns Place Of Arkansas, LLCFordyce, AR 4 of 5The Green House Cottages Of Poplar GroveLittle Rock, AR 4 of 5The Pines Nursing And Rehabilitation CenterHot Springs, AR 4 of 5Three Rivers Health And Rehabilitation CenterMarked Tree, AR 4 of 5Twin Rivers Rehabilitation And Healthcare CenterArkadelphia, AR 4 of 5Valley Springs Rehabilitation And Health CenterVan Buren, AR 5 of 5Belle View Estates Rehabilitation And Care CenterMonticello, AR 5 of 5Courtyard Rehabilitation And Health Center, LLCEl Dorado, AR 5 of 5Greenhurst Nursing CenterCharleston, AR 5 of 5Heartland Rehabilitation And Care CenterBenton, AR 5 of 5Highland Court, A Rehabilitation And Resident CareMarshall, AR 5 of 5Ozark Nursing And RehabOzark, AR 5 of 5Summit Health & Rehab CenterTaylor, AR 5 of 5The Green House Cottages Of HomewoodMena, AR 5 of 5The Green House Cottages Of Northwest ArkansasBentonville, AR 5 of 5The Green House Cottages Of Walnut RidgeWalnut Ridge, AR 5 of 5The Green House Cottages Of Wentworth PlaceMagnolia, AR

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

Who owns this facility

Owner / managerTypeRoleShareSince
4P2T1 OPS HOLDING LPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2019
JEJ ASSETS LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2022
PONTHIE, SHARLOTIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2022
LOGAN, JODIIndividualW-2 MANAGING EMPLOYEEsince 09/01/2019
PONTHIE, JOHNIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 09/01/2019
ALEXARK1 LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 01/01/2022
JEJ MANAGEMENT, LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 01/01/2022

CMS files one row per role, so the 8 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.

$7.4M
Net patient revenuemost recent cost report
+4.8%
Operating marginrevenue minus expenses
$3.9M
Related-party expense55% of expenses
Who pays — share of resident-days
Medicaid 58%Medicare 18%Other / private 24%

This home reported $3.9M paid to related parties — landlords or management companies under common ownership — equal to about 55% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$340per resident / day
operating cost
$10,329per month
≈ monthly operating cost
$357per day
avg. revenue, all payers

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

What families pay in AR

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045256. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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