Cycle 1
Health 2025-08-21 · Fire 2025-08-21
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Conway, AR
Conway Healthcare And Rehabilitation Center
3-star overall rating with 2-star inspections with $25,483 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2603 Dave Ward Drive, Conway, AR
(501) 329-2149
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Southern Administrative Services
Operator or chain grouping
Approved since
1994-08-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
35 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.40 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
3.95
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.08
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.27 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 51% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,102
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0.79
Baseline 48.78% · Performance 60.47% · Measure score 0.79 · Achievement 0.79 · Improvement 0
Adjusted total nurse staffing
4.16
Baseline 4.26 hours · Performance 4.26 hours · Measure score 4.16 · Achievement 4.16 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 63.64% |
95.27%
31.6 pts worse
|
Numerator 14 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 84 |
| Staff flu vaccination coverage | 27.47% |
42%
14.5 pts worse
|
Numerator 25 · Denominator 91 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.0
0.8 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.6 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.8 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
94.9%
4.7 pts worse
|
93.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.3% · Q2 88.9% · Q3 95.2% · Q4 88.4% · 4Q avg 90.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.6% |
96.1%
3.5 pts worse
|
95.5%
2.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.9%
0.4 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.3% · Q3 4.8% · Q4 2.9% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
1.4%
1 pts worse
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 5.7% · Q3 0.0% · Q4 1.7% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
4.9%
2.3 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 7.7% · Q3 7.4% · Q4 4.8% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.7% |
21.8%
5.9 pts worse
|
19.6%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 26.4% · Q3 29.1% · Q4 34.9% · 4Q avg 27.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
12.5%
1.3 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 16.1% · Q3 5.6% · Q4 9.8% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.4% |
11.4%
1 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.8% |
10.4%
0.4 pts worse
|
14.9%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 11.4% · Q3 6.8% · Q4 1.9% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.1%
1.1 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
14.6%
5.4 pts worse
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 19.3% · Q3 17.4% · Q4 20.7% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
4.6%
1.7 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 6.9% · Q3 4.1% · Q4 4.9% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.2% |
81.8%
28.6 pts worse
|
81.7%
28.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 44.4% · Q3 61.5% · Q4 62.1% · 4Q avg 53.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
13.8%
5.5 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 10.0% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.4% |
77.9%
26.5 pts worse
|
79.7%
28.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.4% |
25.2%
6.8 pts better
|
23.9%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 20.0% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-06 · Fire 2024-05-06
10 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-03-17 · Fire 2023-03-17
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-20
F · Potential for more than minimal harm
2024-05-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-28
F · Potential for more than minimal harm
2023-03-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-17
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-20
E · Potential for more than minimal harm
2025-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-21
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-09-20
E · Potential for more than minimal harm
2024-10-31
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-22
J · Immediate jeopardy
2024-05-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-06
E · Potential for more than minimal harm
2024-05-06
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-05-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-27
E · Potential for more than minimal harm
2024-05-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-06
E · Potential for more than minimal harm
2024-05-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-05-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-05-06
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-03-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-05
E · Potential for more than minimal harm
2023-03-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-03-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-03-17
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-17
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-14
Penalties and ownership
What sits behind the stars
$25,483
2024-05-06
Fine
Fine · fine $25,483
Fine
Ownership
4p2t1 Ops Holding LP
5% Or Greater Direct Ownership Interest · Organization
Alexark1 LLC
General Partnership Interest · Organization
Jej Assets LP
5% Or Greater Indirect Ownership Interest · Organization
Jej Management, LLC
General Partnership Interest · Organization
Ponthie, John
5% Or Greater Indirect Ownership Interest · Individual
Ponthie, John
Corporate Officer · Individual
Ponthie, Sharlot
5% Or Greater Indirect Ownership Interest · Individual
Poore, Melissa
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Salem Place Nursing And Rehabilitation Center, Inc
Conway, AR
4-star overall rating with 4-star inspections with 5 fire-safety deficiencies in the latest cycle
#2
Heritage Living Center
Conway, AR
4-star overall rating with 3-star inspections with 5 recent health deficiencies
#3
The Blossoms At Conway Rehab & Nursing Center
Conway, AR
1-star overall rating with 1-star inspections with $8,021 in total fines with 6 recent health deficiencies
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