Cycle 1
Health 2024-09-06 · Fire 2024-09-06
7 health deficiencies
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lake Village, AR
Lake Village Rehabilitation And Care Center
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
903 Borgognoni Drive, Lake Village, AR
(870) 265-5337
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Southern Administrative Services
Operator or chain grouping
Approved since
1992-01-01
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
0.55
Registered nurse staffing · state 0.40 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.27 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
4.66
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
33%
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
6,036
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9882
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
3.49
Baseline 66.67% · Performance 50.00% · Measure score 3.49 · Achievement 3.35 · Improvement 3.49
Adjusted total nurse staffing
3.36
Baseline 3.45 hours · Performance 4.03 hours · Measure score 3.36 · Achievement 3.36 · Improvement 2
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.18% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 21.43% · Lower 95% interval 8.36% |
| Discharge to community | 49.93% |
50.57%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 40.54% · Lower 95% interval 33.73% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.11% |
95.27%
2.8 pts better
|
Numerator 52 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 24 · Denominator 42 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 21 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 3.77% |
2.29%
1.5 pts worse
|
Numerator 2 · Denominator 53 · Adjusted rate 2.81% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · 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 74 |
| Staff flu vaccination coverage | 80% |
42%
38 pts better
|
Numerator 80 · Denominator 100 |
| Discharge function score | 59.52% |
56.45%
3.1 pts better
|
Numerator 25 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 3.85% |
25.2%
21.3 pts worse
|
Numerator 1 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 69.7% |
94.9%
25.2 pts worse
|
93.4%
23.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.2% · Q2 61.4% · Q3 49.2% · Q4 91.2% · 4Q avg 69.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.9% |
96.1%
9.2 pts worse
|
95.5%
8.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.9%
3 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.8% · 4Q avg 0.9% · 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 | 1.4% |
4.9%
3.5 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
21.8%
9.3 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 12.5% · Q3 14.0% · Q4 16.1% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.8% |
12.5%
6.7 pts better
|
16.7%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 2.6% · Q3 2.3% · Q4 8.7% · 4Q avg 5.8% · 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 | 16.9% |
11.4%
5.5 pts worse
|
16.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.7% |
10.4%
2.3 pts worse
|
14.9%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 7.8% · Q3 5.8% · Q4 9.8% · 4Q avg 12.7% · 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 | 10.2% |
14.6%
4.4 pts better
|
19.8%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 5.5% · Q3 7.0% · Q4 12.5% · 4Q avg 10.2% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.6%
0.9 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 4.4% · Q3 2.1% · Q4 2.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.3% |
81.8%
53.5 pts worse
|
81.7%
53.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 46.9% · Q2 25.0% · Q3 17.1% · Q4 25.0% · 4Q avg 28.3% |
| 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 · Q3 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 | 18.8% |
77.9%
59.1 pts worse
|
79.7%
60.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 18.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-06 · Fire 2023-10-06
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-07 · Fire 2022-07-07
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-06
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-06
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 2024-10-04
F · Potential for more than minimal harm
2024-09-06
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-04
F · Potential for more than minimal harm
2022-07-07
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 2022-08-06
F · Potential for more than minimal harm
2022-07-07
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-08-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-06
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 2024-10-04
E · Potential for more than minimal harm
2024-09-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-06
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-06
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 2024-10-04
D · Potential for more than minimal harm
2024-09-06
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 2024-10-04
D · Potential for more than minimal harm
2024-09-06
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 2024-10-04
D · Potential for more than minimal harm
2024-09-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-04
F · Potential for more than minimal harm
2023-10-06
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 2023-10-31
D · Potential for more than minimal harm
2023-10-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-31
F · Potential for more than minimal harm
2022-07-07
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 2022-08-06
B · Minimal harm
2022-07-07
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 2022-07-07
Penalties and ownership
What sits behind the stars
Ownership
4p2t1 Ops Holding LP
5% Or Greater Direct Ownership Interest · Organization
Jej Assets LP
5% Or Greater Indirect Ownership Interest · Organization
Ponthie Investments Limited Partnership
5% Or Greater Indirect Ownership 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
Russell, John
Operational/Managerial Control · Individual
Wallace, Amanda
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
River Heights Healthcare Center
Greenville, MS
1-star overall rating with 2-star inspections with abuse icon flag with $8,800 in total fines with 12 recent health deficiencies
#2
Legacy Manor Nursing And Rehabilitation Center
Greenville, MS
4-star overall rating with 3-star inspections with $27,024 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Ms Care Center Of Greenville
Greenville, MS
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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