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The Blossoms At Fort Smith Rehab & Nursing Center

5301 Wheeler Avenue, Fort Smith, AR 72901 · For profit - Partnership · 130 certified beds · (479) 646-3454 Medicare & Medicaid certified

Call the home — (479) 646-3454 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2024Resident-funds citation (F0567)1 actual-harm citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0567)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (57%) runs well above the national median (45%)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Mercy0.5 mi
4600 Towson Ave · (479) 274-6900 · Call to confirm hours
Pharmacy
1910 S Zero St · (479) 646-2971 · Call to confirm hours
Grocery
5309 Jenny Lind Rd · (479) 648-9477 · Call to confirm hours
Park
2920 S Zero St · (479) 222-6760 · Typically dawn to dusk
Place of worship
501 Xavier St · (479) 646-9961

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 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 held steady at 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.6%9.5%15.4%better
Long-stay residents who lose too much weight3.3%4.3%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.6%0.9%better
Long-stay residents with a urinary tract infection0.5%1.2%2.0%better
Long-stay residents with depressive symptoms1.1%1.4%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.1%3.9%3.3%better
Long-stay residents whose ability to walk worsened6.2%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication34.5%21.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers1.8%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control5.4%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.1%10.9%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine92.9%77.7%79.4%better
Short-stay residents rehospitalized after admission17.9%24.1%22.6%better
Short-stay residents with an outpatient ER visit20.3%12.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.182.011.67worse
Long-stay outpatient ER visits per 1,000 resident days2.492.131.80worse

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.

9.8%U.S. median 10.7%
Went back to hospital
56.0%U.S. median 56.6%
Met the expected recovery
0.09U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 56.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot 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 SNF9.8%CMS range 6.1–14.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge56.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge56.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge44.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization10.8%CMS range 6.4–18.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.421.02Oct 2022–Sep 2024CMS 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

0.26
RN hours/ resident / day
0.72
LPN hours/ resident / day
2.27
Aide hours/ resident / day
3.25
Total nurse hours/ resident / day
0.23
RN hoursweekends
57.0%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 130 beds and averages 119.8 residents a day — about 92% occupied, or roughly 10 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 3.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 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 2.81 hrs/resident/day on weekends vs 3.42 on weekdays — 18% thinner on weekends. RN hours go from 0.27 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%.

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

5
deficiencies at the latest standard inspection (2025-09-19)
6
at the previous standard inspection (2024-05-23)

Deficiencies are fewer than at the previous inspection — improving. 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.

ABCDEFGHIJKL

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.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · Gcited before2025-01-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure staff used safe laundry transport techniques to prevent accidents for 1 (Resident #1) of 11 residents reviewed for accidents and hazards. Findings include: A review of a facility policy titled, Resident Rights, dated 11/01/2022, indicated residents have a right to a safe environment. A review of Resident #1's admission Record, indicated the facility admitted Resident #1 with diagnoses which included generalized anxiety disorder, psychosis, schizophrenia, abnormal gait and mobility, abnormal auditory perception, lack of coordination, cognitive communication, and a history of falls. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2024, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 9 which indicated the resident was had moderate cognitive impairment. A review of Resident # 1's Care Plan, revisions as of 01/06/2025, revealed the resident was at risk for falls. Interventions…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-19 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Number of residents sampled:1Number of residents cited:1Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure a resident was not allowed to self- administer their medications for 1 (Resident #7) of 6 sampled residents (R#1, R#7, R#13, R#16 R#30 and R#72) who reside in a secure neighborhood.Findings include:Based on observations, record review, interviews, and facility policy review, it was determined that the facility failed to ensure a resident was clinically appropriate to self- administer medications for one (Resident #7) of six residents reviewed. The findings include: During an observation on 09/15/2025 at 1:30 PM, Resident #7 was lying in bed. As they talked to this surveyor they reached into their bedside table drawer and got out a box, with a prescription label on it, which contained a nasal spray, they then placed it back in the drawer. During a concurrent observation and interview on 09/16/2025 at 9:04 AM, Resident #7 was sitting on their bed as they talked with this…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Number of residents sampled:1Number of residents cited:1Based on observations, interviews, record reviews, facility records and policy review the facility failed to ensure physician orders were consistently implemented for 1 (resident #111) of 1 final sample resident reviewed for position and mobility. The findings are:Based on observations, record review, and interviews, it was determined that the facility failed to ensure Physician Orders were consistently implemented for one (Resident #111) of one resident reviewed for position and mobility. The findings include: During an observation on 09/15/2025 at 1:19 PM, this surveyor observed Resident #111 sitting up in a chair in the residents' room after lunch. Resident #111's left hand was closed tightly with their thumb between the first and second finger and the arm was held close to the body. No handroll or splint was observed in the hand. A basket sitting in the room on a shelf held both a Handroll Carrot [a carrot shaped soft fabric device held within the hand to prevent contracture] and a splint [a device with hook and loop straps…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-19 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Number of residents sampled:3Number of residents cited:2Based on observations of the 8:00 AM medication administration, interviews, record reviews and facility policy review, it was determined that the facility failed to ensure medications were administered according to the physician's orders for 2 (residents #30 and #85) of 3 residents who were observed during medication administration.The findings are:Based on observations, interviews, record reviews and facility policy reviews, it was determined that the facility failed to ensure medications were administered according to the physician's orders for two (Resident #30 and Resident #85) of three residents who were observed during medication administration, resulting in two medication errors in thirty-six opportunities, with a total error rate of 5.56%. The findings include: Resident #85 During an observation and concurrent interview on 09/17/2025 at 8:09 AM, LPN #3 gathered Resident #85's medication cards and bottles, checked them with the Electronic Medical Record (EMR), withdrew one multivitamin tablet from its bottle, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-19 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Number of residents sampled:1Number of residents cited:1Based on observation of the 8:00 AM medication administration, interviews, record reviews and facility policy review the facility failed to ensure that an insulin pen was prepared and administered according to manufacturer's instructions for 1 (resident #30) of 1 resident observed for insulin administration. The findings are: Based on observation, interviews, record reviews and facility policy review, it was determined that the facility failed to ensure that an insulin pen was prepared and administered according to manufacturer's instructions for one (Resident #30) of one resident observed for insulin administration. The findings include: During an observation of medication administration on 09/18/2025 at 8:06 AM for Resident #30, this surveyor observed Registered Nurse (RN) #4 placed a needle on the Aspart flex pen insulin. RN #4 then dialed up two units and while holding the pen horizontally, depressed the plunger toward the medication cart, nothing was observed exiting the insulin pen. RN #4 then dialed up the sliding scale…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Number of residents sampled:5Number of residents cited:1Based on observations, interviews, facility in-services, and facility policy review, it was determined that the facility failed to follow proper infection control precautions during wound care for 1 (Resident #79) of 5 residents reviewed for infection control.Findings include:Based on observations, record review, interviews, and facility policy review, it was determined that the facility failed to follow proper infection control precautions during wound care for one (Resident #79) of five residents reviewed for infection control. The findings include: During a concurrent observation and interview on 09/17/2025 at 10:31AM, signage for Enhanced Barrier Precaution (EBP) was hanging on Resident 79's door. Licensed Practical Nurse (LPN) #1 came to Resident #79's room and entered with wound care supplies on a sterile tray. LPN #1 sat the tray with supplies on the bedside table and placed a red biohazard bag at the end of the resident's bed. LPN #1 applied gloves and proceeded to take off Resident #79's shoes. LPN #1 did not wash…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-16 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 record review and interview, the facility failed to coordinate with the State Designated Authority. Specifically, the facility failed to notify the State Designated Authority when one (Resident #3) of one sampled resident was admitted on [DATE] and failed to request the level II PASARR (Pre-admission Screening and Resident Review) to ensure Resident #3 was receiving all recommended care and services. The findings include: A review of the resident ' s Medical Diagnosis revealed Resident #3 had diagnoses that included catatonic schizophrenia, anxiety, and alcohol abuse. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/2025, Section A1600 and 1805 revealed resident was admitted from a Psychiatric facility on 01/15/2025. The Staff Assessment for Mental Status (SAMS) revealed Resident #3 had long and short-term memory problems, and Section C1000 revealed Resident #3's cognitive skills for daily decision making were severely impaired. Section E0900 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-16 · tag F0850 — failed to provide social-work services — isolated
    Hire a qualified full-time social worker in a facility with more than 120 beds.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, the facility failed to hire a certified Social Worker with a bachelor ' s degree in social work or a Human Services-related field and at least one year of supervised social work experience in a healthcare setting when the number of beds in the facility exceeded 120. The findings are: During an interview on 04/16/2025 at 11:42 AM, the Administrator indicated that the facility had one hundred and thirty (130) physical beds, and one hundred and seven (107) residents. The Administrator indicated that the facility should have a certified Social Worker if there were more than one hundred and twenty (120) beds. The Administrator indicated that the Social Worker was not certified. The Administrator also indicated that the facility increased to over one hundred and twenty (120) beds in July 2024. During an interview on 04/16/25 at 11:50 AM, the Social Services staff member indicated that she had been employed at the facility for two and a half years. The Social Services staff member indicated that she did not have formal education or certification in social work. 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-18 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure staff reported allegations of verbal abuse to the Administrator within two hours of the allegation being made for 2 (Residents #2 and #3) of 3 sampled residents reviewed for abuse and/or neglect. The findings include: 1. A review of a facility policy titled, Abuse, Neglect, and exploitation revised on 12/2022 indicated, We are committed to the safety and well-being of all our residents. We believe that the resident has the right to be free from verbal abuse .The facility's goal is to prevent abuse through annual and ongoing in-service of staff .The facility has developed policies and procedures which provide essential components to an abuse prevention and intervention program. 1. Screening of potential hires .2. Training staff annually and on an ongoing basis in interventions, reporting detection, and prevention. 6. Protection for individuals from abuse during investigation of allegations. 7. Reporting/Response-assurance that incidents are…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-08 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to maintain dignity by supplying toilet paper and paper towels for 1 (Resident #10) of 1 resident reviewed for resident rights with the potential to affect all 24 residents residing on the women's secured unit. Findings include: A review of a facility policy titled, Resident Rights, dated 11/01/2022, indicated residents had a right to a dignified existence and be treated with respect, kindness, and dignity. During an observation on 01/06/2025 at 4:30 PM, neither of two stalled bathrooms on the locked women's unit had toilet paper or paper towels available. Both bathrooms had signs on the paper towel dispenser which stated, NO PAPER TOWELS. A review of Resident #10's admission Record, indicated the facility admitted Resident #10 with diagnoses that included intellectual disabilities, mental disorder due to know physiological condition, psychosis, schizophrenia, and anxiety. The quarterly Minimum Data Set (MDS), with an Assessment Reference…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-08 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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.
    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 observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure safe wheelchair transport techniques were used for 1 resident (Resident #6) and cigarettes were stored out of residents access for 1 resident (Resident #11) of 11 residents reviewed; the facility failed to ensure the women's secure unit shower was clean, sanitary, and decluttered; failed to repair broken tile in the doorway of room [ROOM NUMBER]; and the facility failed to ensure an employee's cigarettes were not securely stored away from residents of the 200 Hall and 300 Hall for 4 halls reviewed; and failed to provide adequate number of fitted sheets for resident beds in the men's secured unit when reviewed for a safe, clean, comfortable, homelike environment. Findings include: 1. A review of a facility policy titled, Resident Rights, dated 11/01/2022, indicated residents had a right to a safe, clean, homelike environment including but not limited to…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2025-01-08 · tag F0567 — failed to protect residents' money held by the home — isolated
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to obtain written authorization to manage personal funds, ensure a resident was aware of process to access personal funds, and had knowledge of facility charges for 1 (Resident #8) of 5 residents reviewed for personal funds. Findings include: A review of a facility policy titled, Resident Rights, dated 11/01/2022, indicated residents had a right to manage their own funds or choose to have the facility manager funds. A review of the admission Record, indicated the facility admitted Resident #8 on 08/26/2024 with diagnoses that included injury at C7 level of the cervical spine, functional quadriplegia, depression, and panic disorder. Resident #8 was their own Power of Attorney (POA) and made their own decisions. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/05/2024, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During an interview 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to provide perineal care during a soiled brief change for 1 (Resident #10), and failed to ensure physician orders were followed for medication administration, specifically not crushing and administering iron tablets labeled DO NOT CRUSH for 1 (Resident #7) of 11 residents reviewed for Quality of Care. Findings include: 1. A review of a facility policy titled, Resident Rights, dated 11/01/2022, indicated residents have a right to a dignified existence and be treated with respect, kindness, and dignity. A review of Resident #10's admission Record, indicated the facility admitted Resident #10 with diagnoses that included intellectual disabilities, mental disorder due to know physiological condition, psychosis, schizophrenia, anxiety, and lack of coordination. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/2025, revealed Resident #10 had a Staff Assessment of Mental Status (SAMS) score of 3 which…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-08 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record reviews, and review of facility policy, the facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for 2 of 3 residents (Resident #7 and Resident #9) reviewed for tube feeding. Specifically, the facility failed to appropriately check tube placement prior to administering flushes and/or medications for Resident #7 and Resident #9. The findings include: A review of facility policy titled Enteral Feeding with revision date of 11/25/2022 revealed the following, Check enteral tube placement prior to each feeding and administration of medication and if resident is not alert and able to voice symptoms of bloating, nausea or abdominal pain then nurse is to monitor gastric residual volume prior to administration of feeding or medication. A review of the Resident #7's admission Record indicated the facility initially admitted Resident #7 on 05-28-2015 with current diagnosis of metachromatic leukodystrophy, gastrostomy status, and dysphagia. A review of Resident's #9's admission Record indicated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and policy review, it was determined the facility failed to ensure an accident/hazard free environment, as evidenced by not keeping doors locked on rooms containing chemicals and hazards. The findings are: On 9/18/2024 at 5:30 am, observed the facilities hopper room door on the 300 Hall was not completely closed. When the door was pushed open, there were chemicals, sharps containers (a puncture-resistant waste container for sharp objects) that were overflowing with used razors, and the hopper had a brown substance covering the inside. The room had a foul odor. On 9/18/2024 at 5:37 am, observed the shower room door on the Administration Hall was not closed completely. When the door was pushed open, there were chemicals and razors inside. The chemicals included: rinse free body wash, deodorant, anti-perspirant, shaving cream, body oil, and skin protectant. The anti-perspirant contained alcohol, the skin protectant had a warning to contact poison control right away if ingested. All chemicals had a label with a warning to keep out of reach of children.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview, and policy review, it was determined the facility failed to ensure residents had reasonable accommodation of needs by not ensuring the residents call lights were within reach for 1 (Resident #6) sampled resident. The findings are: Review of the Medical Diagnosis portion of Resident #6's electronic health record revealed a diagnosis of hemiplegia, indicating paralysis on one side of the resident's body. Review of a 5-day Minimum Data Set with an Assessment Reference Date of 09/06/2024, Section GG, revealed Resident #6 had impaired function on one side of their body, utilized a wheelchair, and in the category Indoor mobility(ambulation) an assessment of Not Applicable was documented. On 9/17/2024 at 4:14 pm, while in Resident #6's room, the call light was observed behind the chair that the resident was sitting in, out of reach of the resident. On 9/18/2024 at 5:10 am, while in Resident #6's room, the call light was observed beside the resident's bed and under the wheel of the bedside table, out of reach of the resident. On 9/18/2024 at 5:27 am, while…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    Based on observations, interviews, and record reviews, it was determined the facility failed to ensure 1 (Resident #13) of 4 sampled residents reviewed for activities of daily living (ADL) care was kept clean and dry. The findings are: A review of an Order Summary Report, indicated Resident #13 had a diagnosis of neuromuscular dysfunction of the bladder. The quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 7/25/2024 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 09, which indicated the resident had moderate cognitive impairment and had occasional urinary incontinence. Review of Resident #13's, Care Plan, revised 7/29/2023, revealed Resident #13 was frequently incontinent of bladder and wore disposable briefs. Resident #13 required extensive assistance times one staff with toileting, check for incontinence, change brief, and provide care assistance every two hours and as needed. On 9/18/24 at 5:37 AM, Certified Nurse Aide (CNA) #4 removed the blanket from Resident #13 and placed it on the floor. Resident #13's brief, pad, and sheet…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-05-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure food items stored in the freezer were covered or sealed to prevent potential freezer burn; expired food items were promptly removed/discarded by the expiration or use by dates; one of 2 ice scoops and 1 of 2 ice machines were maintained in clean and sanitary condition to prevent food and beverages contamination; staff washed hands prior to clean tasks and before handling clean equipment or food items to minimize the potential for contaminating food items; and cold food items were maintained at or low 41 degrees Fahrenheit while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 104 residents who received meals from the kitchen. The findings are: 1. On 05/22/24 at 9:15 AM, the following observations were made on a shelf in the refrigerator. a. A gallon of 2 % milk with an expiration of 05/19/2024. b. Two of 2 gallons of 2 % milk in the milk…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-23 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observation, record review, and interview it was determined the facility failed to ensure a Resident who was lying in bed wearing only a brief, and a Resident who was receiving a brief change with perineal care, were not visually exposed from the hall in order to maintain dignity and privacy for 2 (Resident #7 and Resident #88) of 2 sampled residents reviewed who required total assistance. The findings include: 1. Resident #7 had diagnoses (dx) of Cerebral Palsy, Calorie Malnutrition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/2024 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). On 05/20/24 12:03 PM during initial rounds, Resident #7 was observed lying in bed on back, fully uncovered with only a brief on. The Resident's door was open to the hallway and the privacy curtain was not pulled closed. On 05/20/24 3:55 PM, Resident #7 was observed lying in bed on back fully…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, it was determined that the facility failed to ensure proper hand hygiene was performed during perineal care for 1 (Resident#88) of 1 Resident reviewed for perineal care; and to ensure proper hand hygiene was performed during medication pass, and meal and beverage service. Findings include: A review of a facility policy titled, Policies and Procedures, with a revised date 11/03/2022, indicated, . 7. Prevention of Infection a. Important facets of infection prevention: (3) educating staff and ensuring that they adhere to proper techniques and procedures . (7) following established general .guidelines such as those of the Centers for Disease Control (CDC) . A review of the facility's document titled, Staff In-Service Sheet, dated 05/22/2024, indicated the information provided was when performing peri-care . you must put sanitizer in a med cup to use in between dirty glove change to clean gloves. The signatures included CNA #7 and CNA #8. A review of the facility document titled, Handwashing, dated 10/31/2023, contained signatures for…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 (Resident #83) of 1 resident reviewed for abuse. Specifically, the facility failed to protect Resident #83 from a resident with known behaviors, Resident #19, which resulted in Resident #83 being hit by Resident #19 hard enough in the back of the head to move Resident #83 out of their wheelchair. Findings include: A review of the admission Record indicated the facility admitted Resident #83 with diagnoses that included cerebral infarction, vascular dementia, other speech, and language deficits following other cerebrovascular disease, lack of coordination, cognitive communication deficit, and amnesia. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/2024 revealed Resident #83 had a Staff Assessment of Mental Status (SAMS) score of 2, which indicated the resident was moderately cognitively impaired for daily decision making. Resident #83 used a wheelchair for ambulation, required setup/cleanup…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and facility document review, it was determined the facility failed to ensure supervision of a cognitively impaired resident at risk for choking for 1 (Resident #91) of 2 residents observed during in room meal service. Findings include: A review of the admission Record, indicated the facility admitted Resident #91 with diagnoses that included early onset Alzheimer's Disease, mild protein-calorie malnutrition, psychosis, dementia unspecified severity, depression, lack of coordination, cognitive communication deficit, need for assistance with personal care. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/15/2024, revealed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 1 which indicated the Resident had severe cognitive impairment. Resident rarely had feelings of social isolation, did not refuse care, requires set up and clean up assistance with eating, oral hygiene, toileting, and bathing, and had no swallowing or nutritional deficits. A review of Resident #91's Care Plan, revised…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-23 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure prescribed medications remain with the nurse for a Resident who is not assessed to self-administer medications for 1 (Resident #31) of 1 Resident reviewed for medications left at the bedside. Findings include: A review of a facility policy titled, Label/Store Drugs and Biologicals, dated 12/26/2022, indicated, Medication will not be stored in a Resident room unless the Resident has been approved for self-administration of medication. If approved, the Resident will be provided with a lockbox to safely store medications. Residents will not order and store medications without the DON (Director of Nursing) approval. A review of the Order Summary Report, indicated the facility admitted Resident #31 with diagnosis that included Chronic Obstructive Pulmonary Disease. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/22/2024, revealed Resident #31 had a Brief Interview of Mental Status (BIMS) score 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-04-28 · tag F0699 — widespread
    Provide care or services that was trauma informed and/or culturally competent.
    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, record review, and interview, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preference in order to eliminate or mitigate triggers that may cause recurring traumatization for 3 (Residents #24, #91 and #96) sampled residents of 27 (Residents #1, # 6, #15, #16, #20, #23, #24, #26, #27, #28, #33, #35, #38, #42, #50, #58, #63, #66, #71, #72, #85, #91, #95, #96, #103, #105 and #165) sampled residents with positive responses to trauma informed care assessments. The findings are: 1. Resident #24 had diagnoses of Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance and Agitation and Delusional Disorders. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/26/23 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-04-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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, record review, and interview, the facility failed to ensure hall trays were transported on food carts in a manner to prevent the potential for cross contamination for 50 residents who received meals on the 100 Hall, 16 residents who received meals on the 200 Hall and 35 residents who received meal trays on the 300 Hall; foods stored in the freezer, refrigerator and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; and dietary staff washed their hands before handling clean equipment or food items. These failed practices had the potential to affect 104 residents who received meals from the kitchen (total census: 109) as documented on a list provided by Dietary Supervisor on 04/27/23 at 12:49 PM. The findings are. 1. On 04/24/23 at 12:40 PM, a food delivery cart sitting between the 200 Hall and the 300 Hall contained meal trays for delivery to the locked Memory Unit. There were bowls of fruit, side dishes, and desserts exposed to air during transport with lids too…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-28 · tag F0641 — pattern
    Ensure 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 interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status at the time of assessment for 2 (Residents #15 and #28) of 31 (Residents #1, # 6, #15, #16, #18, #20, #23, #24, #26, #28, #33, #35, #38, #42, #48, #50, #51, #58, #63, #66, #71, #85, #91, #95, #96, #97, #103, #105, #113, #114 and #165) sampled residents whose MDS was reviewed. The findings are: 1. Resident #15 was admitted on [DATE] and had diagnoses of Severe Protein-Calorie Malnutrition, Hypomagnesemia, and Vitamin Deficiency. The Modification of Significant Change/Medicare 5 Day MDS with an Assessment Reference Date (ARD) of 03/18/23 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision with set up assistance for eating. a. The Electronic Medical Record on 09/12/22 indicated, the resident weighed 131.0 lbs [pounds]. On 03/14/23, the resident weighed 102.6 pounds,…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-28 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop 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, record review, and interview, the facility failed to ensure a comprehensive person centered Care Plan included measurable objectives and timeframes to meet the residents' psychosocial needs to include trauma informed care and the residents' goals, desired outcomes, and preferences for 3 (Residents #24, #91 and #96) of 27 (Residents #1, # 6, #15, #16, #20, #23, #24, #26, #27, #28, #33, #35, #38, #42, #50, #58, #63, #66, #71, #72, #85, #91, #95, #96, #103, #105 and #165) sampled residents with positive responses to trauma informed assessments as documented on a list provided by the Social Services Director on 04/27/23 at 8:10 AM. The findings are: 1. Resident #24 had diagnoses of Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance and Agitation and Delusional Disorders. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/26/23 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-28 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review the facility failed to ensure the Care Plan was revised for 2 (Residents #35 and #95) of (30) (Resident #1, #6, #15, #16, #18, #20, #23, #24, #26, #28, #33, #35, #38, #42, #48, #50, #51, #58, #63, #66, #71, #85, #91, #95, #96, #97, #103, #105, #113 and #114) sampled residents who was required to have a Care Plan. The findings are: 1. Resident #35 had a diagnosis of Neuromuscular Dysfunction of Bladder, Unspecified. The Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/23 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive one-person physical assistance with toilet use, and personal hygiene, was occasionally incontinent of bowel and had an indwelling catheter. a. A Care Plan with a revision date of 09/20/22 did not address Resident #35's indwelling catheter. b. A Hospital Record dated 4/05/23 - 4/10/23 documented, .urinary retention, Foley catheter was placed on 4/9 [04/09/23] . c. On 04/27/23 at 2:32 PM, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-28 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and interview, the facility failed to ensure a written Discharge Summary was completed to include a recapitulation of the resident's stay with a concise summary of the stay and course of treatment for 1 (Resident #114) of 1 sampled resident who was discharged in the past 120 days, as documented on a list provided by the Director of Nursing (DON) on 04/26/23 at 12:03 PM. The findings are: 1. Resident #114 had diagnoses of Encephalopathy, Other Pulmonary Embolism, Intervertebral Disc Disorders with Radiculopathy. The Discharge Return Not Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/12/23 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was discharged to the community. 2. The Discharge Planning Review dated 02/14/23 at 9:16 AM, contained no recapitulation of Resident #114's stay at the facility. 3. On 04/26/23 at 4:05 PM, the Surveyor asked the DON, Whose responsibility is it to complete the Discharge Summary? The DON stated, Social does it at 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the Physician was notified when 1 (Resident #35) of 1 sampled resident who had a catheter with pus-like drainage coming from the catheter insertion site. The findings are: Resident #35 had a diagnosis of Neuromuscular Dysfunction of Bladder, Unspecified. A Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/23 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview of Mental Status (BIMS) and had an indwelling catheter. a. A Care Plan with a revision date of 10/28/21 did not address Resident #35's indwelling catheter. b. An After Visit Summary from [Hospital] dated 04/10/23 documented, c. A Physicians Order dated 04/10/23 documented, Change Foley Catheter System . PRN [as needed] based on clinical indications such as infection, obstruction, or when compromised . d. A Physicians Order dated 04/26/23 documented, .U/A C&S [Urinalysis with culture and sensitivity] . e. On 04/26/23 at 9:00 AM, the Surveyor asked Licensed…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE BLOSSOMS REHAB & NURSING CENTER — 23 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.6-1.6 vs chain
Health inspection 2 of 52.7-0.7 vs chain
Staffing 1 of 52.3-1.3 vs chain
Quality measures 4 of 53.0+1.0 vs chain
The other 22 homes this chain runs (chain average 2.6★, per CMS)
1 of 5The Blossoms At Conway Rehab & Nursing CenterConway, AR 1 of 5The Blossoms At Eureka Springs Rehab & Nursing CenEureka Springs, AR 1 of 5The Blossoms At Midtown Rehab & Nursing CenterLittle Rock, AR 1 of 5The Blossoms At Van Buren Rehab And Nursing CenterVan Buren, AR 1 of 5The Blossoms at Berryville Rehab & Nursing CenterBerryville, AR 1 of 5The Blossoms at Cumberland Rehab & Nursing CenterLittle Rock, AR 1 of 5The Blossoms at Woodland Hills Rehab & Nursing CenLittle Rock, AR 2 of 5The Blossoms At Oakdale Rehab & Nursing CenterJudsonia, AR 2 of 5The Blossoms At West Dixon Rehab & Nursing CenterLittle Rock, AR 2 of 5The Blossoms At White River Rehab & Nursing CenterNewport, AR 2 of 5The Blossoms at Newport Rehab & Nursing CenterNewport, AR 2 of 5The Blossoms at White Hall Rehab & Nursing CenterWhite Hall, AR 3 of 5The Blossoms At North Little Rock Rehab & NursingNorth Little Rock, AR 3 of 5The Blossoms At Star City Rehab & Nursing CenterStar City, AR 3 of 5The Blossoms at Nashville Rehab and Nursing CenterNashville, AR 3 of 5The Blossoms at the Village Rehab & Nursing CenterHot Springs, AR 4 of 5The Blossoms At Mountain View Rehab & Nursing CenMountain View, AR 5 of 5The Blossoms At Hot Springs Rehab And Nursing CentHot Springs, AR 5 of 5The Blossoms At Prescott Rehab & Nursing CenterPrescott, AR 5 of 5The Blossoms At Rogers Rehab & Nursing CenterRogers, AR 5 of 5The Blossoms At Stamps Rehab & Nursing CenterStamps, AR 5 of 5The Blossoms at Dierks Rehab and Nursing CenterDierks, AR

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
ARKANSAS OPCO HOLDING LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/05/2021
AKS AR OPOC LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2023
SCHREIBER, ABRAHAMIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2023
BROWN, BRANDONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/05/2022

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

$11.7M
Net patient revenuemost recent cost report
+8.4%
Operating marginrevenue minus expenses
$585K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 5%Other / private 12%

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 $585K 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 2024. 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

$257per resident / day
operating cost
$7,815per month
≈ monthly operating cost
$281per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 AR

Paying with Medicaid

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 Arkansas Medicaid page.

Typical monthly cost in Arkansas
$7,452/mo
Nursing home (semi-private)
$8,060/mo
Nursing home (private)
$4,637/mo
Assisted living

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 045345. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-19, 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.

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