Cycle 1
Health 2025-08-07 · Fire 2025-08-07
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Marshall, AR
Highland Court, A Rehabilitation And Resident Care
5-star overall rating with 4-star inspections with 1 recent health deficiencies
942 North Highway 65, Marshall, AR
(870) 448-3577
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
78
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Southern Administrative Services
Operator or chain grouping
Approved since
1999-07-14
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.83
Registered nurse staffing · state 0.40 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.76
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.36
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
0.95
CMS adjusted RN staffing hours
Adjusted total hours
4.77
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 51% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,076
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9995
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
1.94
Baseline 6.00% · Performance 7.26% · Measure score 1.94 · Achievement 1.94 · Improvement 0
Total nurse turnover
7.73
Baseline 46.15% · Performance 32.07% · Measure score 7.73 · Achievement 7.73 · Improvement 6.11
Adjusted total nurse staffing
4.17
Baseline 3.92 hours · Performance 4.27 hours · Measure score 4.17 · Achievement 4.17 · Improvement 1.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.47% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 14.04% · Lower 95% interval 7.65% |
| Discharge to community | 44.45% |
50.57%
6.1 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 37.04% · Lower 95% interval 30.95% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.5% |
95.27%
7.8 pts worse
|
Numerator 35 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 59.09% |
53.69%
5.4 pts better
|
Numerator 13 · Denominator 22 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 11 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 1 · Denominator 40 · Adjusted rate 2.22% |
| Healthcare-associated infections requiring hospitalization | 7.26% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 7.41% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 64 |
| Staff flu vaccination coverage | 93.67% |
42%
51.7 pts better
|
Numerator 74 · Denominator 79 |
| Discharge function score | 68.18% |
56.45%
11.7 pts better
|
Numerator 15 · Denominator 22 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 1 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.0
0.9 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.2
0.3 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.9%
5.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
96.1%
2.2 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.9%
0.4 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.6% · Q3 3.3% · Q4 2.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.4%
1.4 pts better
|
11.4%
11.4 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 who lose too much weight | 6.7% |
4.9%
1.8 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 9.5% · Q3 5.9% · Q4 4.9% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.1% |
21.8%
16.3 pts worse
|
19.6%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.0% · Q2 38.1% · Q3 37.3% · Q4 38.1% · 4Q avg 38.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.9% |
12.5%
9.6 pts better
|
16.7%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.3% · Q3 2.4% · Q4 5.0% · 4Q avg 2.9% · 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 | 6.6% |
11.4%
4.8 pts better
|
16.3%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
10.4%
1.2 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 17.5% · Q3 12.5% · Q4 7.3% · 4Q avg 9.2% · 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 | 32.3% |
14.6%
17.7 pts worse
|
19.8%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 40.7% · Q3 41.1% · Q4 16.5% · 4Q avg 32.3% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
4.6%
2.3 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 5.7% · Q3 10.5% · Q4 4.3% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.8% |
81.8%
4 pts worse
|
81.7%
3.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 80.0% · Q3 72.7% · Q4 78.0% · 4Q avg 77.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
13.8%
8.2 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 5.1% · Expected 10.3% · 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 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.1% |
77.9%
9.2 pts better
|
79.7%
7.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.6% |
25.2%
6.4 pts worse
|
23.9%
7.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.6% · Observed 30.8% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
10 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-21 · Fire 2023-04-21
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-04-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-04-25
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-24
F · Potential for more than minimal harm
2023-04-21
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-06-09
F · Potential for more than minimal harm
2023-04-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-01
E · Potential for more than minimal harm
2023-04-21
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-05-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-06
E · Potential for more than minimal harm
2024-04-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-25
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 2024-05-24
E · Potential for more than minimal harm
2024-04-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-21
E · Potential for more than minimal harm
2024-04-25
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 2024-05-24
E · Potential for more than minimal harm
2024-04-25
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-05-21
E · Potential for more than minimal harm
2024-04-25
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 2024-05-24
E · Potential for more than minimal harm
2024-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-04-25
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-05-24
C · Minimal harm
2024-04-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-25
F · Potential for more than minimal harm
2023-04-21
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 2023-05-19
E · Potential for more than minimal harm
2023-04-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-04-21
F803 · Nutrition and Dietary Deficiencies
Health
Ensure 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.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-21
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 2023-05-19
D · Potential for more than minimal harm
2023-04-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-19
Penalties and ownership
What sits behind the stars
Ownership
4p2t1 Ops Holding LP
5% Or Greater Direct Ownership Interest · Organization
Ponthie, John
5% Or Greater Indirect Ownership Interest · Individual
Alexark1 LLC
5% Or Greater Indirect Ownership Interest · Organization
Jej Assets LP
5% Or Greater Indirect Ownership Interest · Organization
Jej Management, LLC
5% Or Greater Indirect Ownership Interest · Organization
Lavalle, Kimberly
W-2 Managing Employee · Individual
Patterson, Amanda
Contracted Managing Employee · Individual
Ponthie, John
Corporate Officer · Individual
Ponthie, Sharlot
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Creekside at the Springs
Yellville, AR
4-star overall rating with 3-star inspections with $15,915 in total fines with 1 recent health deficiencies
#2
Ozark Health Nursing And Rehab Center
Clinton, AR
4-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Twin Lakes Therapy And Living
Flippin, AR
2-star overall rating with 1-star inspections with $25,678 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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