Arbor Walk Healthcare Center
570 North Solomon Street, Greenville, MS 38703 · Non profit - Corporation · 60 certified beds · (662) 335-5863 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0606) — most recent Jan 2026
- it has a citation for mishandling residents’ money or property (F0568)
- it has 3 actual-harm citations
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,165 in federal fines (most recent 2024-07-10)
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 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 | 2 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 2 to 1 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 | 17.5% | 20.5% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.7% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.7% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.0% | 2.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 0.6% | 1.6% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.5% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 19.9% | 19.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 20.1% | 23.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 92.0% | 97.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.1% | 6.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.4% | 20.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.4% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 3.4% | 2.5% | 1.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.47 | 2.43 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 3.21 | 2.86 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 96% of this home’s weekday level — it runs therapy at close to weekday levels right through 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
| 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 | not 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 SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 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 60 beds and averages 55.3 residents a day — about 92% occupied, or roughly 5 beds typically open. It runs fairly full. 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 2.68 hrs/resident/day on weekends vs 3.73 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 0.73 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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 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.
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.
25 citations, most serious first. The 13 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gcited before2024-07-10 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review and facility policy review, the facility failed to notify the Nurse Practitioner (NP) of Registered Dietitian (RD) recommendations for a resident with significant weight loss (Resident #1) and a change in condition (Resident #2) for two (2) of six (6) residents reviewed for physician notification. Findings include: Record review of the facility policy titled, Change in a Resident's Condition or Status revealed, Policy Statement, Our facility shall promptly notify the resident, his or her Attending Physician .of changes in the resident's medical/mental condition and/or status . Resident #1 A record review of Registered Dietitian Assessment Summary for Resident #1, dated 10/16/2023, indicated that Resident #1's weight was 160 pounds (lbs.) with a weight change of 6.98 percent (%) since admission, which indicated a significant weight loss. A record review of weights documented for Resident #1 revealed: 9/29/23 weight 172 lbs (pounds)., 10/2/23 weight 160 lbs., 10/18/23 weight 151.2 lbs. and 11/3/23 weight 127.4 lbs. Record review of a Subjective,…
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.
- Actual harm · Gcited before2024-07-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview and facility policy review the facility failed to implement care plan interventions to prevent significant weight loss for one (1) of seven (7) care plans reviewed. Resident #1. Findings include: Record review of the facility policy titled, Care Plans-Comprehensive revised September 2010, revealed, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident .5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. Record review of Resident #1's summary of weights revealed: 9/29/23 weight 172 lbs, 10/2/23 weight 160 lbs, 10/18/23 weight 151.2 lbs and 11/3/23 weight 127.4 lbs. A record review of Registered Dietitian Assessment Summary for Resident #1, dated 10/16/2023, indicated that Resident #1's weight was 160 pounds (lbs) with a weight change of 6.98 percent (%) since admission, which indicated a significant…
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.
- Actual harm · G2024-07-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview and facility policy review the facility failed to put interventions in place for a resident identified as having had significant weight loss for one (1) of four (4) residents reviewed for weight loss. Resident #1. Findings include: Review of the facility policy, titled Weight Assessment and Interventions, revised September 2008, revealed Policy Statement: The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation, Weight Assessment .5. Any Registered Dietitian Recommendations will be forwarded to the resident's Physician for action as indicated. Subsequent Physician orders will be provided to the facility within 72 hours. A record review of Registered Dietitian Assessment Summary for Resident #1, dated 10/16/2023, indicated that the resident received a Renal Diet and Isosource 1.5, three (3) times a day by percutaneous endoscopic gastrostomy tube (PEG). Resident #1's weight was 160 pounds (lbs.) with a weight change of 6.98 percent (%) since…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-12 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff and resident interviews, record review, and facility policy review, the facility failed to ensure each resident's right to remain free from sexual abuse for one (1) of three (3) residents reviewed for abuse. Resident #1. Based on the implementation of corrective actions on 1/5/26, the State Agency (SA) determined the deficiency to be Past Non-Compliance and the facility was in compliance as of 1/6/26, prior to the SA entrance on 1/12/26. Findings Included: Record review of the facility policy titled, Abuse Prohibition revealed Policy Statement, To assure the prohibition of abuse, neglect, mistreatment, and the misappropriation of property of all residents . Record review of the facility investigation revealed that on 12/31/25 at 3:00 PM, the Administrator (ADM) received an allegation of sexual abuse that occurred on the afternoon of 12/27/25, when Certified Nursing Assistant (CNA) #1 observed Resident #2 in the room of Resident #1 with his hand in her brief and his mouth on her breast. Further review of the investigation revealed Resident #2 was placed on every…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-23 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from verbal abuse when a staff member engaged in a loud, profane verbal exchange with a resident in the dining room, for one (1) of four (4) resident reviewed for abuse. Resident #1.Top of Form Findings included: Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021 revealed, Policy Statement, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse . Record review of the facility investigation revealed that on 8/15/25 Resident #1 was in the dining room yelling profanities. As Housekeeper #1 walked by, staff heard her yelling the same profanities back at the resident. The incident was witnessed by four staff members: the Maintenance Director (MD) , Housekeeping Supervisor (HS), Activities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure residents were free from verbal abuse for two (2) of three (3) residents reviewed for abuse. Residents #1 and #2 Findings include: Review of the facility policy titled Resident Rights, with no revision date, revealed under Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include: the resident's right to: .c. be free from abuse . An observation and interview on 6/27/25 at 8:40 AM with Resident #1 revealed she had asked a Certified Nurse Assistant (CNA) to notify her nurse that she needed pain medication. Resident #1 stated that RN #1 came into her room and yelled at her, saying she was always asking for pain medicine and would get it when RN #1 was ready. Resident #1 stated the nurse often spoke ugly to her and others and that she had never reported it, believing other residents had not either. She said RN #1 would often say, You better be good today or else. Resident #1 confirmed another nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-19 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review, and facility policy review, the facility failed to notify the Resident Representative (RR) of changes in condition for one (1) of three (3) residents reviewed for notification of change. Resident #1. Findings Include: Record review of the facility policy titled Change in a Resident's Condition or Status with a revision date of February 2021 revealed the following policy statement: Our facility shall promptly notify the resident, his or her Attending Physician, and the resident representative of changes in the resident's medical/mental condition and/or status . In a telephone interview with Resident #1's RR on 5/19/25 at 12:19 PM, he stated that one weekend in late April 2025, he visited his brother during lunch and noticed that his diet was pureed. He said he had never been notified that his brother's diet was changed to pureed, nor was he informed of the reason for the change. A record review of the Physician Order Summary for Resident #1 revealed an order for Regular diet, Pureed texture, Regular/Thin consistency, state frozen nutritional…
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 · E2025-04-16 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and facility policy review, the facility failed to provide proper notice of a hospital transfer for one (1) of two (2) residents reviewed for hospitalizations. (Resident #41) Findings include: Review of the facility policy titled, Transfer or Discharge-Facility Initiated, last revised October 2022, revealed, Notice of Transfer or Discharge (Emergent or Therapeutic Leave)- 4.) Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term (LTC) Ombudsman when practicable (e.g. in a monthly list of residents that includes all notice content requirements). Review of a progress note dated 01/11/25 for Resident #41 revealed the resident was transferred to the hospital on 1/11/25 at 6:46 AM related to dislodgement of a gastrostomy tube. During an interview with the Interim Administrator on 4/15/25 at 2:30 PM, she revealed that the facility had not been providing any transfer notice to the residents or their…
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 · E2025-04-16 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 staff interview, record review, and facility policy review, the facility failed to provide a Bed-Hold notice of a hospital transfer/admission for one (1) of two (2) residents reviewed for hospitalizations. (Resident #41) Findings include: Review of the facility policy titled, Bed-Hold and Return, last revised October 2022, revealed the following policy statement: Policy Statement: Resident and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Record review of a progress note for Resident #41 dated 01/11/25 revealed that the resident was transferred to the hospital on 1/11/15 at 6:46 AM due to dislodgement of a gastrostomy tube. During an interview with the Interim Administrator on 4/15/25 at 2:30 PM, confirmed that the facility should be providing these notices to inform residents and their representatives of the bed-hold policy. She revealed that the facility had not been providing any written documentation regarding the per diem charges and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 resident and staff interviews, record review, and facility policy review, the facility failed to honor a resident's choice for bathing preference for one (1) of 24 sampled residents. Resident #33. Findings Include A review of the facility policy titled, Resident's Rights revealed the following: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . e. self-determination. On 4/14/25 at 9:35 AM, during an interview, Resident #33 stated that he does not like taking showers. He expressed a preference for tub baths but reported that staff would not provide him with one. A record review of the Annual Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 7/1/24, revealed under Section F - Preferences for Customary Routine and Activities, that in response to How important is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0606 — failed to not employ staff found guilty of abuse — isolatedNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review, and facility policy review, the facility failed to ensure a criminal history record was reviewed and that a criminal conviction investigation was completed for one (1) of (8) eight new hire personnel files reviewed. Maintenance Assistant (MA) Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revealed the following under Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: . 4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . A review of the facility policy titled Background Screening Investigation revealed, Our facility conducts employment background screening checks, reference checks, and criminal conviction investigation checks on all applicants…
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 · D2025-04-16 · tag F0641 — isolatedEnsure 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 staff interview, record review and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for one (1) of 24 sampled residents reviewed. (Resident #53) Findings include: Review of the facility policy titled, Certifying Accuracy of the Resident Assessment, last revised November 2019, revealed the following statement: Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. Record review of the Discharge Planning Review for Resident #53 dated 2/7/25 revealed that the resident was discharged to a nursing home (long-term care facility). Record review of Section A2105 of the Discharge MDS for Resident #53, with an Assessment Reference Date (ARD) of 2/06/25, revealed the discharge status was coded as short-term general hospital. During an interview with the MDS nurse on 4/16/25 at 9:21 AM, she confirmed that the discharge MDS for Resident #53 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a care plan related to resident preferences for baths (Resident #33) and failed to develop a care plan related to nail care (Residents #12 and #33) for two (2) of 24 sampled residents reviewed. Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered with a revision date of March 2023 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #12 On 4/14/25 at 10:39 AM, an observation of Resident #12 revealed long fingernails that measured one-half (1/2) inch in length with a brown substance underneath. The resident revealed he would like to have his nails cut. Record review of Resident #12's care plan titled, Resident has an Activities of Daily Living (ADL) Deficit r/t (related…
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 · Dcited before2025-04-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain hygiene, as evidenced by the failure to provide nail care for two (2) of 50 residents residing in the facility. Resident #12 and #33. Findings include: Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, with a revision date of March 2018, revealed Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Resident #12 An observation and interview on 4/14/25 at 10:39 AM, with Resident #12 revealed the resident's fingernails were long and dirty. They measured approximately one-half (1/2) inch in length past the tips of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 staff interview, record review, and facility policy review, the facility failed to ensure that as needed (PRN) medications with anticholinergic side effects were used only when clinically necessary and that the PRN medication had a completion time frame for one (1) of six (6) residents reviewed for psychotropic drug dosage reduction. (Resident #5) Findings include: Review of the facility's policy titled, Medication Therapy revised April 2007, revealed, .Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks . Record review of Resident #5's Order Summary Report for active orders revealed an order dated 1/8/25 for Hydroxyzine hydrochloride (HCl) Oral Tablet 25 milligrams (MG), give one (1) tablet by mouth every eight (8) hours as needed for itching related to Anxiety Disorder, Unspecified, with no stop date. Record review of Resident #5's Medication Administration Record (MAR) for 4/1/25 - 4/15/25 revealed the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-28 · 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, staff interviews, record review, and facility policy review, the facility failed to maintain clean ice machines, as evidenced by observations during the annual survey of two (2) of 2 unclean ice machines. Findings include: Review of the facility policy titled, Ice Machines and Ice Storage Chests, with a revised date of January 2012, revealed Policy Statement: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. 4. Ice machines . will be properly cleaned one (1) time per month . An observation and interview on 9/25/23 at 10:32 AM, with the Dietary Manager (DM) of the ice machine, located immediately outside of the kitchen, revealed there was an approximate 2 by one (1) and 1 half (1 1/2) inch area of black residue on the top curved right-side edge of the white plastic shield located directly over the ice on the inside of the ice machine bin. The DM was observed to use a white, wet, paper towel and removed the entire amount of small black residue on the white plastic shield. The DM revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, observation and facility policy review, the facility failed to implement a care plan for changing oxygen (O2) tubing, for call light use, and failed to develop/implement a care plan to monitor side effects for a resident taking anticoagulants for (3) three of 13 residents reviewed for care plans. Resident #35, Resident #42, and Resident #48. Findings include: A review of the facility policy titled, Care Plans -Comprehensive, revised September 2010, revealed, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Resident #42 Record review of the comprehensive care plan for Resident #42 titled, Resident experiences frequent periods of Shortness of Breath, with a start date of 7/20/23 revealed Interventions: Change Oxygen Tubing weekly on Thursday's . An observation of the O2 tubing for Resident #42 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 · D2023-09-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and record review the facility failed to change an oxygen tubing as evidenced by an oxygen (O2) humidifier bottle and tubing dated 8/24/23 and failed to store O2 tubing in a clean storage bag for one (1) of four (4) residents reviewed for oxygen therapy. Resident #42 Findings include: A review of a statement on facility letter head revealed, Arbor Walk Healthcare Center does not have a specific policy on Labeling, Storing, and/or Changing of Oxygen Tubing. An interview with Resident #42 on 9/25/23 at 1:58 PM, revealed he puts the O2 on mainly at night when he is short of breath. Resident #42 revealed the last time he used the oxygen was last night. An observation of the oxygen tubing revealed the O2 tubing laying across the oxygen concentrator and the humidifier water bottle and tubing were dated 8/24/23 with the concentrator running. Resident #42 revealed he placed the tubing on the concentrator when he took it off. Resident #42 revealed he has not seen 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.
- Potential for harm · D2023-09-28 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 staff interview, record review and facility policy review, the facility failed to ensure that residents were free from unnecessary medications as evidenced by the facilities' failure to provide adequate laboratory monitoring for anticoagulant usage for one (1) of five (5) resident's medications reviewed. Resident #35. Findings include: A record review of the facility policy, Orders for Anticoagulation, with a revision date of April 2013, revealed, Policy Statement . 2. Anticoagulants shall be prescribed only with proper clinical and laboratory monitoring . Outcomes .3. Anticoagulant use will be administered and monitored properly . A record review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/6/23, for Resident #35, revealed in Section N0410 that the resident received an anticoagulant seven (7) of the last 7 days of the look back period. Record review of the Physician's Telephone Orders revealed orders dated 7/19/23 Hold Warfarin x (times) 2 (two) days, then…
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 · D2023-09-28 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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 staff interview, record review, and facility policy review the facility failed to obtain laboratory services per physician orders for one (1) of four (4) residents reviewed for laboratory services. Resident #35. Findings include: Review of the facility policy, Orders for Anticoagulation, with a revision date of April 2013, revealed Policy Statement . 2. Anticoagulants shall be prescribed only with proper clinical and laboratory monitoring .Procedure .14. For individuals receiving long term anticoagulants, the staff and physician will periodically assess and document trends in laboratory results PT/INR (Protime and International Normalized Ratio) .by periodically checking .PT/INR . A record review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/6/23, for Resident #35, revealed in Section N0410 that the resident received an anticoagulant seven (7) of the last 7 days of the look back period. Record review of Resident #35's Physician's Telephone Orders dated 7/19/23,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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, staff interview and facility policy review the facility failed to notify the Provider of a critically high laboratory result for one (1) of four (4) residents reviewed for Provider notification of laboratory results. Resident #35. Findings include: A record review of the facility policy titled, Test Results with a revision date of April 2007, revealed, Policy Statement The resident's Attending Physician will be notified of the results of diagnostic tests .2. Should the test results be provided to the facility, the Attending Physician shall be promptly notified of the results. 3. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results . A record review of the facility policy titled Clinical Protocol for Lab and Diagnostic Test Results, with a revision date of September 2012, revealed, Identifying Situations that Warrant Immediate Notification .4 .If a test was obtained to monitor the blood level 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 · D2023-09-28 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interview, record review, and facility policy review the facility failed to ensure a resident's call light was in reach for (1) one of 47 residents observed with call lights. Resident # 48 Findings include: A review of the facility policy titled, Answering the Call Light, revised October 2010, revealed, Purpose: The purpose of this procedure is to respond to the resident's requests and needs .General Guidelines: 5.) When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . An observation and interview with Resident #48 on 9/25/23 at 12:15 PM, revealed he has a hard time calling for staff because he cannot reach his call light. Resident #48's call light was observed on the floor under the bed and not in reach of resident. Resident #48 then stated, this happens all the time and I just yell for someone to come, and they do. An observation of Resident # 48 on 9/25/23 at 2:20 PM, revealed resident asleep call light remains on the floor at the foot of the bed. An interview with Resident #48 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 · D2022-03-17 · tag F0568 — isolatedProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interviews, staff interviews, record review, and facility policy review, the facility failed to provide quarterly statements of personal funds to residents for five (5) of seventeen (17) residents attending the Resident Council meeting. Residents requested to not be identified. Findings include: Record review of the facility policy titled, Quarterly Accounting of Resident Funds dated October 2008, revealed, 1. Each resident with personal funds entrusted to the facility will receive an individual quarterly accounting of funds managed by the facility. Upon his/her request, the resident may also receive an accounting of such funds from the business office. 2. The business office will prepare separate quarterly statements to include: a. the resident's balance at the beginning of the statement period; b. the total of deposits and withdrawals by the resident for the quarter; c. any interest earned; d. the ending balance for the quarter; e. any petty cash on hand; and f. the total amount of cash on deposit and petty cash on hand. During the resident council meeting 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 · Dcited before2022-03-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review and facility policy review the facility failed to provide oral care and hair care for dependent residents for two (2) of sixteen residents. Resident #8 and Resident #15. Findings include: Resident #15 Review of the facility policy titled Mouth Care with a revision date of October 2010 revealed under Purpose, The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth An observation on 03/14/22 at 10:55 AM, revealed the resident lying in bed on her back with thick white phlegm on her lips and inside her opened mouth. An observation on 03/14/22 at 12:20 PM, revealed the resident lying in bed on her right side with thick white phlegm on her lips and inside her opened mouth. An observation on 03/14/22 at 03:17 PM, revealed the resident lying in bed on her back with thick white phlegm on her lips and inside her opened mouth. An observation on 03/14/22 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-17 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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, staff interviews, record review and facility policy review, the facility failed to prevent a significant medication error as evidenced by crushing an extended release (ER) tablet for one (1) of thirty five medication administration opportunities observed. Resident #42. Findings include: Record review of facility policy titled, Administering Medications, dated December 2012, revealed, Medications shall be administered in a safe and timely manner, and as prescribed. Record review of facility policy titled, Administering Medications through an Enteral Tube, dated March 2015, revealed, Do not crush or split medications for administration through an enteral tube unless first checking with the pharmacy or facility approved 'Do Not Crush Medication List' .Do not crush enteric coated, sustained release, bucal, sub-lingual, or enzyme-specific medications, An observation on 3/16/2022 at 9:00 AM, of Registered Nurse (RN) #1 during medication pass revealed an extended-released (ER) Potassium Chloride…
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
$8,165 in federal fines across 2 penalties.
- $4,082 — penalty dated 2024-07-10
- $4,083 — penalty dated 2024-07-10
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DASPIT, RICHARD | Individual | CORPORATE OFFICER | since 01/01/1996 |
| JOYCE, KIMBERLY | Individual | CORPORATE OFFICER | since 08/02/2021 |
| PEELER, LONNIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2014 |
| GUISE, RAQUEL | Individual | ADP OF THE SNF | since 05/27/2025 |
| HODGES, COLE | Individual | ADP OF THE SNF | since 05/27/2025 |
CMS files one row per role, so the 7 rows in the source record cover these 5 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.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 83% 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 $362K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 MS
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 Mississippi 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 255219. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-16, 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.