Cycle 1
Health 2025-02-06 · Fire 2025-02-06
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Marion, AR
Willowbend Health And Rehabilitation, LLC
2-star overall rating with 2-star inspections with $30,771 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
830 Canal Street, Marion, AR
(870) 739-3268
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Southern Administrative Services
Operator or chain grouping
Approved since
2006-04-30
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
0.42
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
2.48
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.27 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 51% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,180
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9988
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.66
Baseline 21.91% · Performance 19.39% · Measure score 4.66 · Achievement 4.40 · Improvement 4.66
Healthcare-associated infections
4.14
Baseline 6.02% · Performance 6.60% · Measure score 4.14 · Achievement 4.14 · Improvement 0
Total nurse turnover
6.43
Baseline 58.06% · Performance 37.39% · Measure score 6.43 · Achievement 6.43 · Improvement 5.72
Adjusted total nurse staffing
3.01
Baseline 3.34 hours · Performance 3.93 hours · Measure score 3.01 · Achievement 3.01 · Improvement 1.93
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.13% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 9.26% · Lower 95% interval 7.01% |
| Discharge to community | 46.66% |
50.57%
3.9 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 39.76% · Lower 95% interval 39.22% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.89% |
95.27%
3.6 pts better
|
Numerator 89 · Denominator 90 |
| Falls with major injury | 2.22% |
0.77%
1.5 pts worse
|
Numerator 2 · Denominator 90 |
| Discharge self-care score | 59.62% |
53.69%
5.9 pts better
|
Numerator 31 · Denominator 52 |
| Discharge mobility score | 53.85% |
50.94%
2.9 pts better
|
Numerator 28 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 3 · Denominator 90 · Adjusted rate 2.5% |
| Healthcare-associated infections requiring hospitalization | 6.6% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 6.15% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 136 |
| Staff flu vaccination coverage | 12.31% |
42%
29.7 pts worse
|
Numerator 24 · Denominator 195 |
| Discharge function score | 61.54% |
56.45%
5.1 pts better
|
Numerator 32 · Denominator 52 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 96.67% |
96.28%
0.4 pts better
|
Numerator 29 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 1.67% |
25.2%
23.5 pts worse
|
Numerator 1 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
2.2
1.8 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 3.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
94.9%
0.5 pts worse
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 86.9% · Q2 94.4% · Q3 97.3% · Q4 99.0% · 4Q avg 94.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
96.1%
0.6 pts worse
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.9%
1.3 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.7% · Q3 1.8% · Q4 1.0% · 4Q avg 2.6% · 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 | 0.9% |
4.9%
4 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.1% · Q4 1.2% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
21.8%
1 pts better
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 21.6% · Q3 20.9% · Q4 18.8% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.5% |
12.5%
6 pts better
|
16.7%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.3% · Q3 9.1% · Q4 6.3% · 4Q avg 6.5% · 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 | 2.4% |
11.4%
9 pts better
|
16.3%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.4% · Q3 0.0% · Q4 2.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.5% |
10.4%
5.9 pts better
|
14.9%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.0% · Q3 1.2% · Q4 3.8% · 4Q avg 4.5% · 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 | 0.5% |
1.1%
0.6 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.7% |
14.6%
6.9 pts better
|
19.8%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 8.4% · Q3 5.0% · Q4 5.3% · 4Q avg 7.7% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.6%
0.3 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.2% · Q3 3.0% · Q4 3.6% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.8% |
81.8%
5 pts better
|
81.7%
5.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 70.9% · Q2 82.3% · Q3 94.3% · Q4 100.0% · 4Q avg 86.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.3% |
13.8%
1.5 pts worse
|
12.0%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 17.4% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.4%
0.1 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.7% |
77.9%
17.2 pts worse
|
79.7%
19 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
25.2%
0.6 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 30.4% · Expected 28.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-01-06 · Fire 2023-01-06
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-06
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-03-03
F · Potential for more than minimal harm
2025-02-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-03
F · Potential for more than minimal harm
2025-02-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-03
F · Potential for more than minimal harm
2024-03-28
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 2024-04-22
E · Potential for more than minimal harm
2023-01-06
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-02-03
Inspection history
Recent health citations
J · Immediate jeopardy
2025-02-06
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 2025-02-06
E · Potential for more than minimal harm
2025-02-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-02-06
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 2025-03-03
E · Potential for more than minimal harm
2025-02-06
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 2025-03-03
E · Potential for more than minimal harm
2025-02-06
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 2025-03-03
E · Potential for more than minimal harm
2025-02-06
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 2025-03-03
D · Potential for more than minimal harm
2025-02-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-03
J · Immediate jeopardy
2024-03-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-28
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 2024-04-22
E · Potential for more than minimal harm
2024-03-28
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-28
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 2024-04-22
E · Potential for more than minimal harm
2024-03-28
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 2024-04-22
E · Potential for more than minimal harm
2024-03-28
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 2024-04-22
E · Potential for more than minimal harm
2024-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-28
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-28
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 2024-05-22
D · Potential for more than minimal harm
2024-03-28
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 2024-04-22
E · Potential for more than minimal harm
2023-01-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-03
E · Potential for more than minimal harm
2023-01-06
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 2023-02-03
E · Potential for more than minimal harm
2023-01-06
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 2023-02-03
E · Potential for more than minimal harm
2023-01-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-03
E · Potential for more than minimal harm
2023-01-06
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 2023-02-03
Penalties and ownership
What sits behind the stars
$15,129
2025-02-06
Fine
Fine · fine $15,129
Fine
$15,642
2024-03-28
Fine
Fine · fine $15,642
Fine
$0
2024-03-28
Payment Denial
Payment Denial · denial start 2024-04-26 · 26 days
26 day denial
Ownership
4p2t1 Ops Holding LP
5% Or Greater Indirect Ownership Interest · Organization
Alexark1 LLC
Operational/Managerial Control · Organization
Jej Assets LP
5% Or Greater Indirect Ownership Interest · Organization
Ponthie, John
5% Or Greater Indirect Ownership Interest · Individual
Ponthie, John
General Partnership Interest · Individual
Ponthie, Sharlot
5% Or Greater Indirect Ownership Interest · Individual
Taylor, Jennifer
W-2 Managing Employee · Individual
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