The Springs Of Waldron
1369 West 6th Street, Waldron, AR 72958 · For profit - Limited Liability company · 105 certified beds · (479) 637-3171 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
- about 26% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.2% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.6% | 4.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.6% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 10.2% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 25.5% | 21.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.3% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 14.6% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.2% | 10.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.3% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 76.8% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.5% | 24.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.4% | 12.5% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.22 | 2.01 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.07 | 2.13 | 1.80 | worse |
* 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.
36.7% 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 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.8% 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 31 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 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 36.7%CMS range 26.6–50.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.8–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 54.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 58.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 41.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 3.8–13.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 105 beds and averages 66.8 residents a day — about 64% occupied, or roughly 38 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.39 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.28 hrs/resident/day on weekends vs 3.87 on weekdays — 15% thinner on weekends. RN hours go from 0.51 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · E2024-12-11 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure that nutritionally balanced meals were provided for the residents for 1 of 1 meal observed. The findings are: 1. On 12/09/2024, the menu for the noon meal documented residents on pureed regular diets and on mechanical soft diets were to receive 4 ounces (oz) of meat balls in sauce. 2. On 12/9/24 at 12:11 PM, Dietary [NAME] (DC) #1 placed 16 meatballs into a blender and ground. DC #1 poured the ground meatballs into a pan and placed it on the steam table to be served to 17 residents who required mechanical soft diets. 3. On 12/9/24 at 12:30 PM, during the noon meal service, DC #1 used a 2-ounce spoon to serve a single portion of ground meatballs to eight (8) residents on mechanical soft diets instead of 4 ounces. At 12:51 PM, the 16 meatballs prepared to be served to 17 residents ran out after serving 8 residents 2 ounces instead of 4 ounces. 4. On 12/9/24 at 12:53 PM, DC #1 placed 21 meat balls into a pan and handed it to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-11 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure foods stored in the dry storage areas, refrigerator, and freezer were covered and sealed, expired food items were promptly removed, and dietary staff washed their hands before handling clean equipment or food items for 2 of 2 meals observed. The findings are: 1. On 12/9/24 at 11:13 AM, the following observations were made in the kitchen areas: a. An opened box of baking soda was in the cabinet above the food preparation counter. The box had an expiration date of 11/27/2024. The Dietary Manager (DM) was interviewed and was asked what she use baking soda for. The DM stated the staff used it when a recipe calls for it, but they had not used it to bake anything in a long time. b. Five (5) boxes of baking soda were in a cabinet above the food preparation counter. The boxes had an expiration date of 11/27/2024. c. An opened box of brown sugar was on a shelf above the food preparation counter. The bag was not sealed. d. An opened bag of grits was on the shelf above the food preparation counter. The bag was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff used proper hand hygiene when providing care for 2 (Residents #5, #6) of 3 (Residents #4, #5, #6) sampled residents. The finding include: 1. A review of the significant change Minimum Data Set (MDS), with the Assessment Reference Date of 9/15/2024, revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate impaired cognition. Resident #5 was frequently incontinent of bowel and bladder. a. A plan of care for Resident #5, revision date 8/15/2023, revealed Resident #5 had an Activities of Daily Living (ADL) self-care deficit related to impaired mobility, weakness, and fluctuation in mental status. b. On 12/10/2024 at 1:45 PM, this surveyor observed Certified Nursing Assistant (CNA) #2 and CNA #3 did not use proper hand hygiene while providing care to Resident #5. This surveyor observed CNA #2 apply a clean brief and place a pillow under the resident's knees with dirty gloves. c. On 12/10/2024 at 2:00PM, CNA #3 stated hand hygiene…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure incontinence care was provided to 1 (Resident #5) of 3 (Residents #4, #5, #6) sampled residents in a manner to promote cleanliness and/or prevent skin breakdown. The findings include: A review of the significant change Minimum Data Set (MDS), with the Assessment Reference Date of 9/15/2024, revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate impaired cognition. Resident #5 was frequently incontinent of bowel and bladder. A plan of care for Resident #5, revision date 8/15/2023, revealed Resident #5 had an Activities of Daily Living (ADL) self-care deficit related to impaired mobility, weakness, and fluctuation in mental status. On 12/10/2024 at 1:45 PM, this surveyor observed Certified Nursing Assistant (CNA) #2 and CNA #3 provide incontinence care to Resident #5, who had been incontinent of bladder. CNA #2 and CNA #3 did not clean all areas of the perineal and buttock areas that had been exposed to urine. On 12/10/2024 at 2:00…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-01 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to have measures in place to prevent the growth of Legionella and other opportunistic waterborne diseases in building water system. The facility failed to have staff use appropriate Personal Protective Equipment (PPE) when providing care to a resident on droplet precautions for 1 (Resident # 2) sampled resident. The findings include: 1. A review of a facility policy titled, Water Management Program dated 02/12/2024, indicated the following: a. The control measures, locations, and frequency-controlled measures shall be implemented at the location of risk areas on a weekly basis by the maintenance director or designee. Common control measures include but are not limited to the following: i. Visual inspection ii. Disinfection levels iii. Temperature checks. b. Monitor and respond- when it is determined that the control limits are not usually met, the maintenance director shall report to the water management team and corrective actions shall occur. Control measures…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-01 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Administrator was responsible for the overall operation of the facility. The findings are: 1. Resident #04 expired in the facility on [DATE]. a. A Nursing Progress Note dated [DATE] at 3:54 PM by Licensed Practical Nurse (LPN) #01 documented, This nurse went into residents room to check on her and no vitals were obtained. No respirations noted. No heart beat auscultated. Time of death was pronounced by this nurse at 1449 [2:49 PM]. Family at beside. Administrator, DON [Director of Nursing], ADON [Assistant Director of Nursing], Dr. [Name], and [Nurse Consultant Name] all notified of time of death. [Name] Funeral Home was called at 1500 [3:00 PM]. Body picked up . b. During an interview on [DATE] at 12:27 PM, the County Coroner confirmed no one from the nursing home or the Medical Director had called her office to report Resident #04 had expired and time of death needed to be called. c. During an interview on [DATE] at 04:05 PM, the Funeral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-01 · tag F0836 — isolatedEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted 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 interview and record review, the facility failed to ensure compliance with all applicable Federal, State, and local laws, regulations, and codes by failing to ensure a death was reported to the Coroner's office. The findings are: 1. Resident #04 expired in the facility on [DATE]. a. A Nursing Progress Note dated [DATE] at 3:54 PM by Licensed Practical Nurse (LPN) #01 documented, This nurse went into residents room to check on her and no vitals were obtained. No respirations noted. No heart beat auscultated. Time of death was pronounced by this nurse at 1449 [2:49 PM]. Family at beside. Administrator, DON [Director of Nursing], ADON [Assistant Director of Nursing], Dr. [Name], and [Nurse Consultant Name] all notified of time of death. [Name] Funeral Home was called at 1500 [3:00 PM]. Body picked up . b. During an interview on [DATE] at 12:27 PM, the County Coroner confirmed no one from the nursing home or the Medical Director had called her office to report Resident #04 had expired and time of death…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-01 · tag F0841 — isolatedDesignate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
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 Medical Director fulfilled his/her responsibility for the implementation of resident care policies and/or the coordination of medical care in the facility. The findings are: 1. Resident #04 expired in the facility on [DATE]. a. A Nursing Progress note dated [DATE] at 3:54 PM by Licensed Practical Nurse (LPN) #01 documented, This nurse went into residents room to check on her and no vitals were obtained. No respirations noted. No heart beat auscultated. Time of death was pronounced by this nurse at 1449 [2:49 PM]. Family at beside. Administrator, DON [Director of Nursing], ADON [Assistant Director of Nursing], Dr. [Name], and [Nurse Consultant Name] all notified of time of death. [Name] Funeral Home was called at 1500 [3:00 PM]. Body picked up . b. During an interview on [DATE] at 12:27 PM, the County Coroner confirmed no one from the nursing home or the Medical Director had called her office to report Resident #04 had expired and time 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.
- Potential for harm · Fcited before2023-08-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure opened packages of food were sealed and dated in the dry storage room to maintain food freshness and prevent the potential for infestation, and the facility failed to ensure the ice machine was clean to prevent the potential for foodborne illness. The failed practices had the potential to affect 50 residents who received a meal tray from the kitchen, as documented on a list provided by the Business Office Manager on 8/22/23 at 12:43 PM. The findings included: On 08/21/2023 with Dietary Employee #1, the following was observed: a. At 9:56 AM, there was one bag of cookie wafers unsealed and undated. b. Dietary Employee #1 at 10:07 AM, wiped the area of the ice machine where the ice is dispensed with a white napkin. Observation of the white napkin after Dietary Employee #1 completed wiping the ice machine showed dark brownish black particles on the napkin. The Surveyor asked Dietary Employee #1 to describe what is on the napkin? Dietary Employee #1 stated, I would say it's mold. During interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-25 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to serve residents in a manner that promoted dignity for 3 (Residents #2, #22, #26) of 9 (Residents #2, #22, #25, #26, #29, #31, #36, #42, #43 ) sampled residents that eat their meals in the dining room. The findings included: On 08/21/2023 at 12:06 PM the Surveyor observed Resident #2 seated at a table in the dining room with another resident. The second resident received a lunch tray at 12:08 PM, while Resident #2 did not receive a lunch tray until 12:17 PM. The second resident had completed eating their lunch before Resident #2's tray arrived. On 08/21/2023 at 12:08 PM the Surveyor observed Resident #22 seated at a table in the dining room with another resident. A lunch tray was delivered to each resident at 12:08 PM, but Resident #22 did not receive assistance with eating until 12:16 PM. On 08/21/2023 at 12:10 PM the Surveyor observed Resident #26 seated at a table in the dining room with two other residents. A lunch tray was delivered to the other two residents at 12:14 PM. Resident #26 did not receive 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.
Show the remaining 12 citations
- Potential for harm · E2023-08-25 · tag F0657 — failed to keep the care plan current — patternDevelop 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 observation, interview, and record review, the facility failed to revise Care Plans to reflect the current needs of 2 (Residents #10 and #43) of 29 (Residents #2, #4, #6, #10, #16, #17, #18, #21, #22, #25, #26, #27, #29, #30, #31, #32, #34, #39, #41, #42, #43, #44, #47, #50, #52, #53, #154, #204 and #205) sampled residents. The findings included: The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/2023 for Resident #10 showed Resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) an assessment of care needed as, extensive assistance with one-person physical assist. Review of Resident #10's Care Plan initiated on 10/30/2021 showed Resident required set-up/supervision by 1 staff with personal hygiene, nail care, and oral care. Review of the MDS with an ARD of 07/28/2023 for Resident #10 showed Resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: [NAME], [NAME] Based on observation, record review and interview, the facility failed to ensure adequate supervision for 2 of 2 Residents (Resident #6 and #39) sampled residents who desired to smoke. The findings are: During interview on 08/21/2023 at 10:23 AM, Resident #6 stated, The staff went through my stuff without permission. They took my cigarettes and lighter. I went out with a friend to smoke. Review of Resident #6's Care Plan with an initiation date of 06/09/2023 showed, Resident goes off facility property with family to smoke, and will not suffer injury from unsafe smoking/electronic smoking device practices. Resident and family educated on safe smoking. Review of Resident #6's Nursing -Tobacco/e-cigarette Assessment and Care Plan-V1 dated 08/22/2023 showed, Resident #6 smokes with supervision, requires a smoking apron, and needs facility to store smoking material. During interview on 08/22/2023 at 08:50 AM, LPN #2 stated, There is no smoking policy, administration is working on it. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-25 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: [NAME], [NAME] Based on observation, record review, and interview, the facility failed to ensure residents received an enhanced diet to meet the nutritional needs for 3 (Resident #12, #25, and #26,) of 12 (Resident #6, #44, #16, #17, #29, #21, #26, #25, #12, #27, #22 and # 47) sampled residents who had a physician's order for an enhanced diet. This failed practice had the potential to affect 19 residents who had a physician's order for an enhanced diet as documented on a list provided by Nurse Consultant #1 on 08/24/2023 at 01:01PM. The findings included: During observation of Resident #26 ' s meal tray card on 08/21/2023 at 12:47 PM showed an enhanced diet, and mashed potatoes was the enhanced food item Resident #26 received fried fish, pinto beans, buttered noodles, and cantaloupe on her tray. During the noon meal service on 08/23/2023 at 12:18 PM the following was observed: a. Resident #12 ' s tray was sitting at the dietary window ready to be served with enhanced diet written on the tray card. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0574 — isolatedThe resident has the right to receive notices in a format and a language he or she understands.
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 residents know where the Ombudsman contact information is posted, and the facility failed to ensure the residents have been informed of their rights and given information of how to file a formal complaint with the State Agency. The failed practice had the potential to affect all 52 residents in the facility as documented on the Resident Census and Conditions of Residents which was provided by the Administrator on 08/21/2023 at 1:00 PM. The findings included: During interview on 08/22/2023 at 9:30 AM, the Administrator confirmed there were three Presidents of the Resident Council Resident #7, #38, and #43. On 08/22/2023 at 1:10 PM, the Surveyors met with the Resident Council with Resident #5, #42, #31, #37, and #40 in attendance. The three Presidents were not in attendance. The Surveyor asked the Resident Council members, do you know where the Ombudsman poster with contact information is posted? The Resident Council members collectively said they did not know. The Surveyor asked the Resident Council members, have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 state inspection results are available to residents without having to ask. This failed practice had the potential to affect all 52 residents in the facility. The findings included: During interview on 08/22/2023 at 9:30 AM, the Administrator confirmed there were three Presidents of the Resident Council Resident #7, #38, and #43. On 08/22/23 at 1:10 PM, the Surveyors met with the Resident Council with Resident #5, #42, #31, #37, and #40 in attendance. The three Presidents were not in attendance. The Resident Council was asked, do you know where the results of the state inspection are posted, and can you read them without having to ask for them? The Resident Council stated collectively they did not know. During interview on 08/22/2023 at 2:00 PM, the Surveyor asked the Activity Director why did the presidents not attend the Resident Council meeting? The Activity Director said one Resident was in the shower, one Resident was getting a haircut, and one Resident said he had been interviewed by the state. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0637 — isolatedAssess 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 complete a Significant Change in Status Minimum Data Set (MDS) after a decline in two or more activities of daily living (ADL) for 1 (Resident #26) of 10 (Resident# 6, #18, #21, #26, #34, #39, #44, #47, #204 and #205) residents whose MDS were reviewed. The findings included: Review of Resident #26 ' s Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of 03/29/2023 showed Resident required limited assistance with 1-person physical assist with bed mobility and limited assistance with 1- person physical assist. Review of the Minimum Data Set a Quarterly Assessment with an Assessment Reference Date of 06/29/2023 showed the resident required extensive assistance with 2-person physical assist with bed mobility and extensive assistance with 1- person physical assist. During interview on 08/24/2023 at 3:08 PM, the MDS Coordinator (MDSC) confirmed a decline in 2 or more areas between the last 2 MDSs of Resident #26. During interview on 08/24/2023 at 3:20 PM, the Director of Nurses (DON) confirmed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 a resident with a Mental Disorder was referred for a Level II PASARR (Preadmission Screening and Resident Review) evaluation for 1 (Resident #43) out of 2 (Resident #10 and #43) sample mix. The findings included: Review of Resident #43's Care Plan showed a diagnosis of bipolar disorder, and antipsychotic medications r/t bipolar disorder with an initiated date of 11/27/2021 and revised on 07/11/2023. During interview on 08/22/2023 at 3:40 PM, the BOM confirmed Resident #43 does not have a State Designated Professional Associates letter for Level II PASARR. During an interview on 08/23/2023 at 08:29 AM 08:29 AM, with a State Designated Professional Associate regarding a PASSAR Level II for Resident # 43 who stated the resident was not being tracked. During interview on 08/23/2023 at 3:40 PM, the Director of Nursing (DON), said, we try to get the preadmission screening completed before they come in. The DON confirmed there was not a PASARR Level II for Resident #43 and confirmed a resident with a diagnosis of bipolar…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, interview, and record review, the facility failed to ensure fingernails were kept trimmed for 1 (Resident #10) of 29 (Residents #2, #4, #6, #10, #16, #17, #18, #21, #22, #25, #26, #27, #29, #30, #31, #32, #34, #39, #41, #42, #43, #44, #47, #50, #52, #53, #154, #204, #205) sampled residents who relied on the facility for nail care per a list provided by Nurse Consultant #2 on 08/24/2023 at 08:56 AM. The findings included: On 08/21/2023 at 10:38 AM the Surveyor observed Resident #10 fingernails with jagged edges extending ½ past the tips of the fingers. During interview on 08/21/2023 at 10:38 AM, the Surveyor asked Resident #10 do you like your nails that length? Resident #10 stated No, I wish they would cut them. Resident #10 said the facility staff cuts her nails and the staff is aware of the nails needing cut. On 08/23/2023 at 1:10 PM the Surveyor observed Resident #10 ' s fingernails with jagged edges extending ½ past the tips of the fingers. During interview on 08/23/2023 at 1:22 PM the Surveyor asked LPN #1 who was responsible for cutting the nails 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.
- Potential for harm · D2023-08-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide repositioning assistance for 1 (Resident #43) of 5 (Resident #10, #21, #27, #43 and #44) sampled residents that required the assistance of one or more staff members for bed repositioning per a list provided by Nurse Consultant #2 on 08/24/2023 at 8:56 AM. The findings included: On 08/21/2023 at 10:21 AM, the Surveyor observed Resident #43 lying in bed. The bed was inclined, and Resident #43 was slouched down in bed at an angle, with her head and feet extending from either side of the bed. The Surveyor asked Resident #43, are you comfortable? Resident #43 stated, No my neck and back are hurting. The Surveyor asked are you able to reposition yourself without assistance? Resident #43 stated, No please I need help. On 08/22/2023 at 7:19 AM the Surveyor observed, with LPN #1, Resident #43 lying slouched down in bed with her feet and lower legs hanging off the right side of the bed and her head hanging off the left side. The Surveyor asked Resident #43 do you need help? Resident #43 stated, Yes I'm not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a physician's order was obtained prior to administering supplemental oxygen to 1 (Resident #43) of 7 (Residents #6, #16, #26, #34, #39, #43, #205) sampled residents receiving supplemental oxygen in the facility per a list provided by Nurse Consultant #2 on 08/24/2023 at 08:56 AM. The findings included: During observation on 08/21/2023 at 10:21 AM, Resident #43 was lying in bed with a nasal cannula in place receiving oxygen from a bedside oxygen concentrator set to deliver 3 liters per minute of oxygen. During interview on 08/22/2023 at 7:19 AM Licensed Practical Nurse (LPN) #1 confirmed that Resident #43 was receiving oxygen via nasal cannula at a rate of 3 liters. The Surveyor asked LPN #1 to locate the physician's order regarding supplemental oxygen for Resident #43. LPN #1 stated I don't see one. During interview on 08/23/2023 at 3:39 PM, the Assistant Director of Nursing (ADON) stated, They were receiving oxygen when they were in the hospital, I don't know why it isn't in the chart. Review 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.
- Potential for harm · D2023-08-25 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 pain medication was provided in a timely manner for 1 (Resident #33) of 19 (Resident #33, #38, #6, #44, #16, #17, #29, #5, #39, #43, #26, #10, #37, #20, #34, #205, #27, #47, #32) sampled residents who had a physician's order for routine pain medication, as documented on a list provided by the Director of Nursing (DON) on 08/23/2023 at 3:30 PM. The findings included: 1. On 08/22/2023 during observation at 8:00 AM LPN #1 was informed Resident #33 was in pain and requesting pain medication. The Surveyor accompanied LPN #1 to Resident #33's room. The LPN asked Resident #33 to rate the pain on a scale of 1 to 10. Resident #33 said, 8. The LPN administered Hydrocodone-Acetaminophen 10-325 MG. The Surveyor asked LPN #1 is the medication scheduled or PRN (as needed)? LPN #1 replied, It's scheduled. Review of Resident #33 ' s physician ' s Order Summary Report dated 08/23/2023 showed the following: a. A diagnosis of quadriplegia, spinal cord injury, and chronic pain. b. A medication order dated 10/07/2022…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-11 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record review, the facility failed to ensure snacks were provided to meet the nutritional needs of individual residents. This deficient practice had the potential to affect 57 residents that reside in the facility according to the census provided by the Business Office Manager on 08/09/2023 at 1:28 PM. The findings included: During an interview with Resident #1 on 08/09/2023 at 1:51 PM, Resident #1 said, we do not get snacks on a regular basis around here and the snack last night was a small piece of an orange. During observations and interview on 08/09/2023 showed the following: a. At 2:10 PM the Surveyor asked CNA #1, are you passing out snacks? CNA #1 stated, No. I am passing out ice, but I can go get snacks if you want me to give them out. The Surveyor asked CNA #1, Do you pass out snacks? CNA #1 stated, Yes, if a resident asks for some. b. At 2:15 PM to 3:00 PM, no snacks were passed out to residents, and no snacks were available at the nurses' station counters. During observation on 08/10/2023 showed the following: a. At 10:00 AM to 10:30…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE SPRINGS ARKANSAS — 26 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.4 | +0.6 vs chain |
| Health inspection | 4 of 5 | 3.2 | +0.8 vs chain |
| Staffing | 4 of 5 | 3.0 | +1.0 vs chain |
| Quality measures | 2 of 5 | 3.8 | -1.8 vs chain |
The other 25 homes this chain runs (chain average 3.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| RED RIVER MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2024 |
| BOWEN, MONICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2024 |
| HERZBERG, CHAIM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2024 |
| RICHEY, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2024 |
| WALDRON REALTY HOLDINGS LLC | Organization | ADP OF THE SNF | since 08/01/2024 |
| GUTMAN, ISAAC | Individual | ADP OF THE SNF | since 08/01/2024 |
| HOFFMAN, ALEXANDER | Individual | ADP OF THE SNF | since 08/01/2024 |
| TAUB, JACOB | Individual | ADP OF THE SNF | since 08/01/2024 |
CMS files one row per role, so the 12 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 26% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AR
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arkansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045383. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.