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Windcrest Health And Rehab INC

2455 Lowell Road, Springdale, AR 72764 · For profit - Corporation · 70 certified beds · (479) 756-9000 Medicare & Medicaid certified

Call the home — (479) 756-9000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 26 lower-level deficiencies on record (see below)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • a high number of inspection citations overall (26) — 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 20% 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
3559 N Thompson St · (479) 231-1250 · Call to confirm hours
Pharmacy
400 W Emma Ave · (479) 750-2220 · Call to confirm hours
Grocery
2330 N Thompson St · (479) 751-4517 · Call to confirm hours
Park
2003 Fleming Dr · (818) 398-2004 · Typically dawn to dusk
Place of worship
301 W Bailey Ave · (479) 725-6024

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 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.

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 increased5.2%9.5%15.4%better
Long-stay residents who lose too much weight2.6%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 infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%1.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.5%3.9%3.3%better
Long-stay residents whose ability to walk worsened4.6%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.0%21.7%18.9%worse
Long-stay residents given the seasonal flu vaccine98.0%96.1%95.3%typical
Long-stay residents with pressure ulcers1.4%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control11.1%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table8.2%10.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine66.7%77.7%79.4%worse
Short-stay residents rehospitalized after admission26.4%24.1%22.6%worse
Short-stay residents with an outpatient ER visit4.4%12.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.552.011.67worse
Long-stay outpatient ER visits per 1,000 resident days0.992.131.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

9.2%U.S. median 10.7%
Went back to hospital
0.08U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.01hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 5.7–13.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened4.0%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 hospitalizationnot 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 SNFs1.291.02Oct 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

0.29
RN hours/ resident / day
1.23
LPN hours/ resident / day
2.76
Aide hours/ resident / day
4.27
Total nurse hours/ resident / day
0.27
RN hoursweekends
40.7%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 70 beds and averages 53.0 residents a day — about 76% occupied, or roughly 17 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.27 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.76 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 3.81 hrs/resident/day on weekends vs 4.46 on weekdays — 15% thinner on weekends. RN hours go from 0.29 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% 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

9
deficiencies at the latest standard inspection (2024-10-31)
2
at the previous standard inspection (2023-11-03)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · E2024-10-31 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, it was determined that the facility failed to ensure that residents had a clean, safe, homelike environment by not repairing water damaged ceiling, walls, light fixtures, and not keeping furniture and linens clean. The findings are: 1. On 10/28/2024 at 11:55AM, Resident #11's bedsheets were observed to have a brown, wet substance on them. Resident #11 confirmed she had an accident and needed assistance. A Certified Nursing Assistant (CNA) was called into the room to assist resident. a. On 10/29/2024 at 8:27AM, observed Resident #11 having the same bedsheets as the day before, and brown substance appeared to be dried on the sheets. 2. On 10/29/2024 at 8:31AM, in the hall of the secure unit, two ceiling tiles and a light covering appeared to have been wet by the appearance of brown ring stains, and a spot in the light covering that looked like liquid. 3. On 10/29/2024 at 8:48AM, rubber stripping that connects the floor with the wall in the dining room was peeled…

    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 · E2024-10-31 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure medications were not pre-popped prior to administering medications to residents for 7 (Resident #5, #11, #15, #16, #26, #28, and #49) of 7 residents reviewed for preparation of medication administration. Findings include: A review of facility policy titled, Pharmacy Services Overview, revised in April 2007, stated pharmacy services were to provide feedback about performance and practices related to medication administration and medication errors. Services will collaborate with staff and practitioners to address and resolve medication problems. A review of facility policy titled, Administering Medications, revised April 2019, stated that medications will be administered in a safe, timely manner and as prescribed. Medications administered are to be verified with the resident ' s identity before administering medication and the person administering the medication must check the medication label three times to verify the correct…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-31 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure hot foods were served hot and cold dairy products were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed. The findings are: 1. On 10/28/24 at 11:48 AM, Resident #30 stated the food was cold when served in the dining room and even colder if served in the resident's room. 2. On 10/30/24 at 12:38 PM, an unheated food cart was in the main dining room by the kitchen window. The first lunch tray for the unit was placed on a shelf in the unheated food cart by the Certified Nursing Assistant (CNA) #3. While CNA #3 was loading food trays in the unheated food cart, she left the door open. At 12:29 PM, as CNA #3 finished loading food trays onto the left side shelf of the food cart, she closed the door. The right side of the door remained open while she continued loading food cart. Once the right side was filled, she closed that door and delivered the food cart to the unit. The door was left open as the CNA #3 removed food trays from the food cart and served…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-31 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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, record review, interview, and facility policy review, the facility failed to ensure dish washing machine air vent was cleaned; floors, base boards, dish washer and kitchen walls were free of dirt; chipped floor tiles were replaced; a sanitary environment for food preparation was provided, and expired spices and leftover fruit items were promptly removed from stock for 1 meal observed. The findings are: 1. On 10/30/24 at 8:06 AM, the scoop holder on a wall by the ice machine in the kitchen had a gray, wet residue at the bottom of it. The scoop was directly touching the residue. The Lead Dietary [NAME] (LDC) was asked to wipe the gray residue at the bottom of the scoop holder. He did so, and the substance easily transferred to the paper towel. The LDC, when interviewed, stated, it [the residue] was gray in color. They use it [the ice machine] to fill beverages served to the residents at mealtimes, the CNAs (certified nursing assistants) use the ice for the water pitchers in the residents' rooms, and it is cleaned once a week. 2. On 10/30/24 at 8:07 AM, one…

    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 · D2024-10-31 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to shave, clean the hands and face, and change clothing for 1 (Resident #2) of 1 resident reviewed for dignity. Findings include: A review of a facility policy titled, Resident Rights, revised on 12/01/2016, indicated residents would have their existence dignified and would be treated with respect kindness and dignity. A review of Resident #2 ' s admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain, and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed supervision or touching assistance with personal hygiene; and partial to moderate assistance with upper body dressing. A review of Resident #2 ' s Care…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-31 · tag F0641 — isolated
    Ensure 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 observations, interviews, record review, facility document review, and facility policy review it was determined that the facility failed to ensure accuracy of the assessments required for the Minimum Data Set (MDS) for 1 (Resident #2) of 2 residents reviewed for accuracy and assessment completion of the MDS. Findings include: A review of a facility policy titled, Certifying Accuracy of the Resident Assessment, revised on December 2009 indicated, any personnel completing any section of the MDS must sign and certify accuracy of that assessment portion. A review of the admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed set up or clean up assistance with eating and oral care,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-31 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure care plans were updated with accurate information and failed to resolve care plans that were no longer needed for 1 (Resident #2) of 3 residents reviewed for Care Plans. The findings are: 1. A review of a facility policy titled, Resident Rights, revised December 2016, indicated residents have the right to be informed of and participate in care planning and treatment. 2. A review of Resident #2 ' s admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed set up or clean up assistance with eating and oral care, supervision or touching assistance…

    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 · Dcited before2024-10-31 · tag F0657 — failed to keep the care plan current — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure the care plans were updated within the appropriate time frame with accurate information and failed to resolve care plans that were no longer needed for 3 (Resident #2, #14, and #23) of 3 residents reviewed for Care Plans. The findings are: 1. A review of a facility policy titled, Resident Rights, revised December 2016, indicated, residents have the right to be informed of and participate in care planning and treatment. 2. A review of Resident #2 ' s admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain, and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed set up or clean up assistance with…

    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 · Dcited before2024-10-31 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure resident was shaved, failed to clean resident ' s face and hands after meals and failed to assist resident with changing clothing after being soiled during meals for 1 (Resident #2) of 1 resident reviewed for activities of daily living. Findings include: A review of a facility policy titled, Activities of Daily Living (ADLs), Supporting, revised in March 2018, indicated, residents who were unable to independently carry out ADLs would receive services to maintain good nutrition, grooming and personal and oral hygiene. A review of Resident #2 ' s admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain, and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13…

    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 · Ecited before2023-11-03 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the environment was free of potential hazards as possible, as evidenced by failure to ensure medications were stored and contained for 1 (Resident #41) of 1 sampled resident; and failed to ensure mattress's fit the bed frame to prevent potential accidental injury for 1 (Resident#53) of 1 sampled resident. The findings are: 1. Resident #41 had a diagnosis of diabetes mellitus and chronic kidney disease. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident required limited to extensive assistance with activities of daily living (ADL's). A review of Resident #41 electronic health record revealed no order to self-administer medications and was not care planned to self-administer medications. On 10/30/23 11:55 AM Resident #41 lying in bed watching tv. A bottle of rubbing alcohol (green)…

    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
Show the remaining 16 citations
  • Potential for harm · E2023-11-03 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make 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, record review and interview, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior and improve the quality of life for 2 (Resident #18 and #40) of 2 sample residents. The findings are: 1. Resident #40 had a diagnosis of dementia and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe impairment. The resident required extensive to dependent assistance for activities of daily living (ADL's). On 10/30/23 12:13 PM, Resident #40 in bed an area behind Resident #40 bed is an area peeling. A hole in the wall approximately 2 centimeters (cm) in diameter was observed on the wall behind Resident #40 bed. On 10/31/23 10:05 AM, Resident #40 observed in bed. The wall area behind the resident's bed was torn and peeling. A hole in the wall approximately 2 cm in diameter was observed on the wall…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-07-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foods stored in the refrigerators, freezers, and dry storage were consistently dated & labeled of when received, opened and/or prepared, failed to ensure foods stored in refrigerators, freezers, and shelves were sealed/closed completely, failed to ensure left-over food products were used or discarded within 3 days, failed to ensure foods being prepared were kept free of contamination by insects to ensure foods were distributed in sanitary conditions, and failed to ensure dish washer sanitizer level was checked with test strips each shift to ensure dishes were washed in sanitary conditions to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen in facility. These failed practices had the potential to affect 57 residents who received meals from the kitchen, as documented by list of 1 resident NPO (nothing by mouth) 7/29/22 received from Assistant Director of Nursing. The findings are: 1. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-07-29 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have 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 observation, record review and interview, the facility failed to follow and implement an appropriate plan of action to correct an identified quality deficiency cited on the 2021 Annual Survey to monitor, track, and evaluate the effectiveness of accurately coding the Minimum Data Set (MDS) Plan for their Quality Assurance Corrective Action/Performance Improvement Activities/Plan (QACAPIAP). This failed practice had the potential to affect 58 Residents residing in the facility according to the Resident Census and Condition of Residents provided by the Nurse Consultant on 7/25/22 at 11:02 AM. The findings are: a. The 2567 dated 5/7/21 showed, Based on observation, interview and record review the facility failed to ensure the Minimum Data Set was coded correctly for 1 (Resident #36) of 5 (Residents #10, 32, 35, 36 and 43) final sampled residents who wandered in the facility. b. On 7/29/22: Based on observation, record review and interview the facility failed to ensure the MDS was completed in a timely manner for 1 (Resident #1). The facility failed to ensure the MDS 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-29 · 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

    Based on record review and interview, the facility failed to notify the Resident and/or Resident Representative in writing of the reason for transfer to hospital in a language they understand for 3 (Resident #8, 34 and 156) of 8 (Resident #34, 8, 56, 38, 5, 42, 156 and 16) sampled residents who were transferred/discharged to the hospital in the last 120 days. This failed practice had the potential to affect 11 residents who were transferred/discharged to the hospital in the last 120 days as documented on a list provided by the Administrator on 7/27/22 at 8:07 AM. The findings are: 1. R #8 had diagnoses of VASCULAR DEMENTIA WITH BEHAVIORAL DISTURBANCE, ANXIETY DISORDER, UNSPECIFIED, OTHER RECURRENT DEPRESSIVE DISORDERS, and RESTLESSNESS AND AGITATION. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/22 showed a Staff Assessment of Mental Status (SAMS) score of 3 (a score of 3 indicates severe cognitive impairment). a. The Progress Note dated 6/11/2022 at 11:26 AM showed, Orders Administration Note Text: resident sent to hospital on 6/10/2022 b. 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 · E2022-07-29 · tag F0636 — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure that the Resident Assessment Instrument (RAI) was used and coded correctly, to comprehensively assess the resident's physical, mental and psychosocial needs to ensure the residents received their necessary care and services for 1 (R #31) of 2 (R#31, R#46) sampled residents according to a list provided by the Assistant Director of Nursing (ADON) on 7/29/22 at 7:25 AM. The failed practices had the potential to affect 2 residents who wander, and the facility also failed to ensure the Minimum Data Set (MDS) assessment accurately reflected medication use based upon pharmaceutical category for 1 (Resident #50) of sampled residents who had a Physician Order for Plavix an antiplatelet. This failed practice had the potential to affect 3 (Resident #50, #9 and #15) sampled residents who had Physician orders for antiplatelets per list provided by the ADON on 7/29/22. The findings are: 1. R #31 has Diagnoses of Unspecified Dementia with…

    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 · Ecited before2022-07-29 · tag F0641 — pattern
    Ensure 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 record review and interview, The facility failed to ensure the Minimum Data Set accurately documented weight loss of 5% or more in 1 mo. and 10% or more in 6 months for 1 (Resident #8) of 20 (#25, 21, 43, 49, 47, 18, 16, 39, 23, 22, 24, 156, 34, 35, 40, 7, 37, 1, 8 and 3) Sampled Selected residents who had weight loss in last 6 months. This failed practice had the potential to affect 22 Residents with weight loss in the last 6 months according to a list provided by the Assistant Director of Nurses on 7/29/22 at 8:49 AM and failed to ensure the Minimum Data Set (MDS) assessment accurately reflected medication use based upon pharmaceutical category for 1 (Resident #50) of sampled residents who had a Physician order for Plavix antiplatelet. This failed practice had the potential to affect 3(Resident #50, #9 and #15) sampled residents who had Physician orders for antiplatelets per list provided by the ADON on 7/29/22 and failed to ensure MDS (Minimum Data Set) was accurately coded to reflect resident's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-07-29 · 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 person centered comprehensive care plans were updated to address specific, identified care needs to prevent potential inadequate care for 1(#34) of 3 (Residents #34, #38, and #49) sample selected residents. The failed practice had the potential to affect 58 residents according to the Resident Census and Condition of Resident's provided by Nurse Consultant on 7/25/22 at 11:02am, and failed to ensure the Resident Plan of Care was updated with Aftercare Instructions post Hip Surgery and fall interventions for 1 (Resident #156) of the Sampled Selected Residents with falls with major injury for the last 6 months according to a list provided by the Assistant Director of Nurses (ADON) on 7/29/22 at 8:49 AM. The findings are: 1. R #34 had Diagnosis of Other Sequela Following Unspecified Cerebrovascular Disease and Dysphagia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/6/22 documented a Staff Assessment of Mental Status (SAMS) of .Not Assessed .MDS with an ARD of 3/6/22 documented a SAMS 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-29 · tag F0660 — pattern
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, facility failed to ensure residents and resident representatives were asked about their interest in receiving information about returning to the community for 2 of 2 (Resident #48 & R #106) sample selected closed record review residents. This failed practice had the potential to affect 59 residents not admitted to the facility since the facility's last annual recertification on 05/7/21 per the list of admissions provided by the Assistant Director of Nursing (ADON) on 07/29/22. The findings are: 1. Resident #48 had a Diagnosis of Acute Respiratory Failure, Chronic Obstructive Pulmonary Disorder (COPD), and Cognitive Communication Deficit. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/1/22 showed, the resident scored 11 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS). 2. Resident #106 had diagnoses of Aftercare for Joint Replacement, Diabetes Mellitus, and Cognitive Communication Deficit. The Quarterly MDS with an ARD of 02/16/22 showed, the resident scored 15 (13-15…

    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 · Ecited before2022-07-29 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to ensure residents were supervised when smoking for 2 of 2 (Resident #1, #5) sample selected residents that were assessed, and care planned for supervision while smoking and failed to ensure environment was free of hazards for 12 self-mobile residents that had moderate to severe cognitive impairment per list provided by Administrator 7/27/22 and for 9 residents that smoke per list provided by Administrator 7/25/22. The findings are: 1. Resident #1 had a diagnosis of Acute on Chronic Diastolic (Congestive Heart Failure), Chronic Obstructive Pulmonary Disease with (Acute Exacerbation), and Respiratory Failure. Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/14/22 scored a 15 (13-15 intact cognition). 2. R #5 had a diagnosis of Metabolic Encephalopathy, Other Specified Disorders Due to Known Physiologic Condition, Alcohol Dependence with Alcohol-Induced Persisting Dementia, and Post Traumatic Seizure. The admission (MDS)…

    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 · E2022-07-29 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 Pharmacist's documented Monthly Medication Reviews were placed in Resident Medical Records of Sampled Mix Residents (R#15, R#52, R#22, R#8, R#38). This failed practice had the potential to affect the 58 Residents who resided in the facility as documented on the Resident Census and Condition of Residents provided by the ADON [Assistant Director of Nursing] on 7/28/22 at 11:20 AM. The findings are: 1. On 7/28/22, a review of the resident's electronic charts showed, the Pharmacist's Monthly Medication Reviews were not found. 2. On 7/28/22 at 11:20 AM, The Surveyor asked the ADON, Where are the Pharmacist's Monthly Medication Reviews kept? She stated that they were kept in a binder behind the Director of Nursing (DON)'s desk. 3. On 7/29/22 a policy titled Medication Regimen Reviews showed .The Consultant Pharmacist shall review the medication regimen of each resident at least monthly .10. Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-29 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    In accordance with State and Federal laws, the facility failed to ensure all drugs were stored under proper temperature controls. This failed practice had the potential to affect 58 residents per census and conditions provided by the Nurse Consultant on 7/25/22. The findings are: 1. On 7/27/22 at 8:22 AM, the Assistant Director of Nursing (ADON) was asked to accompany the surveyors to review the facility's medication storage room. 2. On 7/27/22 at 8:25 AM, a small black refrigerator sitting on the floor on the left side of the room that contained medications and there was no thermometer in the refrigerator. The Surveyor asked the ADON if she saw a thermometer in the medication refrigerator. The ADON looked in the refrigerator and stated, I actually don't see one. The Surveyor asked who is responsible for monitoring this refrigerator temperatures? The ADON stated, The night shift nurses. The Surveyor asked, Where is this monitoring log? The ADON stated, I think in the DON's (Director of Nursing) office. I'm (I am) not sure. The Surveyor asked, How often is this refrigerator'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-29 · 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 residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 7 residents who received pureed diets documented on the Diet Order Report provided by the Registered Nurse (RN) Consultant 7/27/22. The findings are: 1. On 07/27/22 at 10:45 AM, the Surveyor entered kitchen to watch puree and line service. The Surveyor obtained plastic spoons from the Dietary Manager (DM). Dietary Staff (DS)#1 asked the to check the puree. The Surveyor informed DS#1 that the Surveyor would check the puree once he was completed and was ready to cover the containers for service. DS#1 began puree process stating he had 8 puree and 20 mechanical soft but he typically made enough for 10 and 24 respectively. DS#1 pureed spaghetti noodles from colander resting on edges of sink, with cold water running over it. When the Spaghetti puree was completed, it was put in pan and left…

    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 · D2022-07-29 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 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 ensure each resident was assessed using the standardized Quarterly Review Assessment Tool no less than once every 3 months between comprehensive assessments for 1 (R #1) of 31 (R #21, 19, 53, 43, 51, 20, 13, 49, 12, 18, 16, 53, 4, 32, 39, 30, 23, 22, 24, 34, 9, 40, 7, 11, 37, 15, 1, 31, 8, 33, 38, and 29) sampled residents who had a Minimum Data Set (MDS) due in the last 120 days according to a list provided by the Assistant Director of Nursing (ADON) on 7/29/22 at 09:26 AM. The failed practice had the potential to affect 31 residents who had a MDS due in the last 120 days. The findings are: 1. On 07/26/22 at 07:21 PM, Resident #1's Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/14/2022 was completed on 3/21/2022 but no MDS has been completed since. a. On 07/28/22 at 10:00 AM, the MDS Coordinator was asked, What checks are in place to make sure MDS's are completed in a timely manner? She said, We don't have checks. She was then asked, Do you know why the quarterly for [R1] has not been completed…

    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 · Dcited before2022-07-29 · 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 a comprehensive plan of care was developed for a resident who was on anticoagulant therapy to assure that the resident's individual needs were met and maintained for 1 (Resident #15) of 8 (Resident #15, #25, #19, #51, #4, #35, #11 and #38) of the sampled case mix residents who were receiving anticoagulants. The failed practice had the potential to affect 8 (Resident #15, #25, #19, #51, #4, #35, #11 and #38) who required anticoagulant therapy per the list provided by the Assistant Director of Nursing (ADON) on 7/29/22. The findings are: 1. Resident #36 had Diagnoses of Chronic Embolism and Thrombosis of unspecified Deep Veins of the Right Lower Extremity, Tachycardia, and Cerebral Infarction Due to Unspecified Occlusion of Stenosis of Unspecified Cerebral Artery. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/11/22 documented the resident scored 11 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS) and required ADL [Activities of Daily Living]…

    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 · Dcited before2022-07-29 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure residents were regularly assisted with shaving or grooming of facial hair to ensure good grooming and hygiene for 1 (Resident #30) of 17 (R #64, 43, 20, 13, 47, 12, 4, 22, 34, 9, 44, 37, 31, 30, 21, 42, and 11) and failed to ensure hair was regularly shampooed to ensure good personal hygiene for 1 (Resident #30) of 41 (Residents #25, 157, 42, 21, 19, 53, 17, 14, 43, 20, 13, 49, 47, 12, 18, 55, 52, 4, 32, 39, 30, 23, 50, 22, 156, 34, 35, 9, 44, 40, 7, 11, 37, 15, 26, 1, 31, 8, 33, 38, and 29) sampled residents who required assistance with personal hygiene and shaving. The failed practices had the potential to affect 41 residents who required assistance with personal hygiene and 17 who required assistance with shaving according to a list provided by ADON (Assistant Director of Nursing) on 7/29/22 at 7:25 AM. The findings are: 1. R #30 had diagnoses of Cerebral Infarction, Unspecified, Weakness, Cerebrovascular Disease, Unspecified,…

    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 · D2022-07-29 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for 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 that an oral surgeon's referral was made per the Doctor's recommendation on 2/10/22, for a severely cognitively impaired resident, without documentation of the resident's family and/or representative being informed about risks, benefits and treatment options and involved in the decision-making process for 1 (Resident #37) resident. This failed practice had the potential to affect 6 sample residents (R #37, #49, #17, #55, #9, and #7) who had dental issues according to the list provided by the Assistant Director of Nursing [ADON] on 7/29/22. The findings are: 1. Resident #37 had diagnoses of Alzheimer's Disease, Dementia, Cognitive Communication Deficit, Unspecified Protein-Calorie Malnutrition Muscle Wasting and Atrophy, Bipolar Disorder, Centrilobular Emphysema, and Dysphagia, Oropharyngeal Phase. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 6/14/22 showed a Staff Assessment for Mental Status score of 3 (Severely impaired), required limited to extensive assistance 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.

    Quality of Life and Care 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 ANTHONY & BRYAN ADAMS — 38 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 53.5-1.5 vs chain
Staffing 4 of 53.0+1.0 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 37 homes this chain runs (chain average 3.8★, per CMS)
1 of 5Ridgecrest Health And RehabilitationJonesboro, AR 2 of 5Bailey Creek Health And RehabTexarkana, AR 2 of 5Magnolia Square Nursing And RehabSpringfield, MO 2 of 5St. Elizabeth's PlaceJonesboro, AR 2 of 5Twin Lakes Therapy And LivingFlippin, AR 2 of 5Westwood Health And Rehab, INCSpringdale, AR 3 of 5Alcoa Pines Health And RehabilitationBenton, AR 3 of 5Birch Pointe Health And RehabilitationSpringfield, MO 3 of 5James River Nursing And RehabilitationSpringfield, MO 3 of 5The Lakes At Maumelle Health And RehabilitationMaumelle, AR 3 of 5Timberlane Health & RehabilitationEl Dorado, AR 4 of 5Beebe Retirement Center, Inc.Beebe, AR 4 of 5Chapel Woods Health And RehabilitationWarren, AR 4 of 5Evergreen Living Center At StagecoachBryant, AR 4 of 5Gassville Therapy And LivingGassville, AR 4 of 5Heritage Living CenterConway, AR 4 of 5Hiram Shaddox Health And RehabMountain Home, AR 4 of 5Katherine's Place at WedingtonFayetteville, AR 4 of 5Maples Health And Rehabilitation, TheSpringfield, MO 4 of 5Mountain Meadows Health And RehabilitationBatesville, AR 4 of 5Oak Ridge Health And RehabilitationEl Dorado, AR 4 of 5Silver Oaks Health And RehabilitationCamden, AR 4 of 5Southridge Village Nursing And RehabHeber Springs, AR 5 of 5Amberwood Health And RehabilitationBenton, AR 5 of 5Care Manor Nursing And RehabMountain Home, AR 5 of 5Chambers Health And RehabilitationCarlisle, AR 5 of 5Corning Therapy And Living CenterCorning, AR 5 of 5Eaglecrest Nursing And RehabAsh Flat, AR 5 of 5Edgewood Health And RehabSpringdale, AR 5 of 5North Hills Life Care and RehabFayetteville, AR 5 of 5Pioneer Therapy And LivingMelbourne, AR 5 of 5Rector Nursing And RehabRector, AR 5 of 5Southfork River Therapy And LivingSalem, AR 5 of 5Spring Creek Health & RehabCabot, AR 5 of 5The Crossing At Riverside Health And RehabilitatioSearcy, AR 5 of 5The Maples At Har-Ber MeadowsSpringdale, ARNot ratedQuail Run Health And RehabTrumann, 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
3B HOLDINGS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 07/01/2004
DAVIS, CHARLESIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/20/2021
JACK, NACOLEIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 04/01/2025
THOMAS, DARRYLIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2010
ADAMS, ANTHONYIndividualCORPORATE OFFICER; ADP OF THE SNFsince 06/02/2004
ADAMS, BRYANIndividualCORPORATE OFFICER; ADP OF THE SNFsince 06/02/2004
ELLIS, JOHNIndividualCORPORATE OFFICER; ADP OF THE SNFsince 07/01/2004
KOEHLER, TOBEYIndividualCORPORATE OFFICER; ADP OF THE SNFsince 07/01/2004
LTC SYSTEMS/RX, LLCOrganizationADP OF THE SNFsince 07/01/2004
PHARMACY CONSULTS, LLCOrganizationADP OF THE SNFsince 07/01/2004
RELIANCE HEALTH CARE, INC.OrganizationADP OF THE SNFsince 07/01/2004
SP NORTH RE, LLCOrganizationADP OF THE SNFsince 07/01/2004
BURNER, KIMBERLYIndividualADP OF THE SNFsince 08/28/2024
MCGINNIS, LARRYIndividualADP OF THE SNFsince 07/01/2004

CMS files one row per role, so the 24 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

$6.1M
Net patient revenuemost recent cost report
+4.0%
Operating marginrevenue minus expenses
$1.2M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 9%Other / private 15%

About 77% 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 $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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

$283per resident / day
operating cost
$8,592per month
≈ monthly operating cost
$294per 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 045367. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-31, 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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