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The Blossoms At Oakdale Rehab & Nursing Center

101 Cynthia Street, Judsonia, AR 72081 · For profit - Limited Liability company · 154 certified beds · (501) 729-3823 Medicare & Medicaid certified

Call the home — (501) 729-3823 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 27 lower-level deficiencies on record (see below)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 25% of its spending goes to commonly-owned related companies

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.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3524 E Race Ave · (501) 227-0184 · Call to confirm hours
Pharmacy
803 Highway 367 N · (501) 729-3670 · Call to confirm hours
Grocery
3509 E Race Ave · (501) 520-9420 · Call to confirm hours
Park
588 Missile Base Rd · Typically dawn to dusk
Place of worship

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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 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 increased15.5%9.5%15.4%typical
Long-stay residents who lose too much weight11.0%4.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%0.6%0.9%better
Long-stay residents with a urinary tract infection2.3%1.2%2.0%worse
Long-stay residents with depressive symptoms0.0%1.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.2%3.9%3.3%worse
Long-stay residents whose ability to walk worsened15.2%10.1%16.1%typical
Long-stay residents on antianxiety or hypnotic medication24.8%21.7%18.9%worse
Long-stay residents given the seasonal flu vaccine98.9%96.1%95.3%typical
Long-stay residents with pressure ulcers8.0%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control14.4%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table22.8%10.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.0%1.3%1.4%worse
Short-stay residents given the seasonal flu vaccine79.3%77.7%79.4%typical
Short-stay residents rehospitalized after admission27.0%24.1%22.6%worse
Short-stay residents with an outpatient ER visit5.1%12.5%12.0%better
Long-stay hospitalizations per 1,000 resident days3.292.011.67worse
Long-stay outpatient ER visits per 1,000 resident days1.802.131.80typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ 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.

53.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 110 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.7%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
57.1%U.S. median 56.6%
Met the expected recovery
0.10U.S. median 0.31
Therapy hours / resident / day
0.03hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 57.1% 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 63 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 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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 SNF53.7%CMS range 45.2–63.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 8.3–14.710.7%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 discharge57.1%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 discharge47.6%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 discharge52.4%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 worsened11.0%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 hospitalization8.4%CMS range 5.2–14.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.261.02Oct 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

0.31
RN hours/ resident / day
0.96
LPN hours/ resident / day
1.86
Aide hours/ resident / day
3.12
Total nurse hours/ resident / day
0.35
RN hoursweekends
51.1%
Total nursing turnover
72.7%
RN turnover

How full it usually is: this home is certified for 154 beds and averages 101.9 residents a day — about 66% occupied, or roughly 52 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.12 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 2.73 hrs/resident/day on weekends vs 3.29 on weekdays — 17% thinner on weekends. RN hours go from 0.29 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as 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

10
deficiencies at the latest standard inspection (2025-01-16)
5
at the previous standard inspection (2024-01-26)

Deficiencies are more than at the previous inspection — worsening. 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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Fcited before2025-01-16 · 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 that food was dated properly, food was sealed properly, drip pans under the stove top were cleaned, and that cross contamination did not occur during 2 of 2 observations in the kitchen. The findings are: On 01/13/2025 at 10:22 am, in the dry storage area a large, opened bag of elbow pasta was not sealed, Dietary Manager confirmed this finding and stated that it is approximately eight pounds of pasta. On 01/13/2025 at 10:26 am, a fifteen-pound box of dinner rolls was not sealed, left opened in the walk-in freezer. The Dietary Manager confirmed the findings. On 01/13/2025 at 10:30 am, a gallon pitcher of reconstituted milk was in the double door fridge with no date. The Dietary Manger verified it was not dated. On 01/13/2025 at 10:32 am, in a two-door cooler, a five-pound bag of shredded mozzarella cheese was observed with no receive date or open date. The Dietary Manager confirmed that the dates are missing and roughly a pound left in the bag. On 01/13/2025 at 10:36 am Dietary Manager pulled out drip…

    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 · E2025-01-16 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 a resident's Advance Directive was signed by resident or resident's power of attorney regarding the resident's right to request, refuse, and/or discontinue treatment, and to formulate an advance directive for 1 (Resident #49) of 1 resident reviewed for advanced directives/ The findings are: Resident #49 ' s Minimum Data Set with an Assessment Reference Date of [DATE], identified the resident as having a Brief Interview for Mental Status (BIMS) of 12 , a score of 8-12 indicating the resident has moderate cognitive impairment. Resident #49 ' s Care Plan identified the resident's Brief Interview for Mental Status (BIMS) score was 9 indicting moderate cognitive impairment on [DATE]. Resident #49 medical diagnoses, as identified on the resident's Order Summary Report , included type 2 diabetes mellitus; hypertension; depression; chronic kidney disease; abdominal pain. On [DATE], at 02:16 PM, a review of Resident #49 ' s Physician Order dated [DATE]…

    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 before2025-01-16 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for one out of one resident (Resident #69) and ensuring residents face and nails were cleaned before or after meals for one out of one resident (Resident #76). The significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/22/2024, revealed Resident #69 had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment. A review of Resident #69's Care Plan, revised on 11/12/2024, revealed the resident had an ADL self-care performance deficit related to hemiplegia left side, strokes, and contractures of his left hand. Intervention initiated 12/06/2023 included assistance by one staff member with personal hygiene. On 1/14/2025 at 1:12 PM, Resident #69's nails were long with a black substance underneath. On 1/14/2025…

    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 before2025-01-16 · 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, record review, interview, and facility policy review, the facility failed to ensure 1 of 1 sampled (Resident 47) resident was transferred from the chair to bed appropriately with a lift belt to prevent injury. The facility failed to ensure 1 of 1 sampled (Resident 62) the resident' environment remains as free of accident hazards as is possible. The facility failed to ensure 1 of 1 sampled (Resident 2) received adequate supervision to prevent accidents. Findings include: 1. Review of Resident 47's Care Plan revealed diagnoses of dementia, depressive disorders, and anxiety. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/17/2024 and Staff Assessment for Mental Status (SAMS) suggest long and short-term memory problems. Section GG 0170 shows resident requires moderate assistance transferring from the chair/bed-to-chair. Review of Resident 47's Care Plan revealed Resident 47 has a self-care deficit related to dementia and requires 1 person assistance. On 01/14/2025 at 02:18 PM, the surveyor observed Certified Nursing Assistant (CNA) 3…

    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 before2025-01-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and facility policy review, it was determined that the facility failed to ensure an effective infection control program was implemented to prevent the potential spread of Clostridium Difficile (C. diff). for 1 resident (Resident #66) of 1 resident reviewed for isolation precautions, and the facility failed to ensure a gown was worn for 1 (Resident #39) of 1 resident that was on Enhanced Barrier Precautions. The findings are: Upon review of the admission Record, Resident #66 was initially admitted to the facility on [DATE], then readmitted on [DATE] with an admitting diagnosis of cellulitis of left lower limb. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 12/16/2024 revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15 (13-15 suggest cognitively intact). On 01/13/25 at 11:53 AM, the surveyor observed Resident #66 in bed with multiple wounds to their lower extremities. Per review of Resident #66 ' s physician…

    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 · D2025-01-16 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 resident's discharge/transfer information was sent in a timely manner to the Office of the Ombudsman, affecting 1 (Resident 28) of 1 resident sampled for transfers and discharge, and any resident discharged or transferred since the system change. Findings include: A review of the Medical Diagnosis portion of the electronic health record revealed Resident 28 had diagnoses of respiratory failure, heart attack, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 10/15/2024 suggested a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates the resident was cognitively intact). On 01/16/2025 at 09:45 AM, the Administrator was asked for a list of discharge/transfers that were sent to the Ombudsman since October 2024 showing Resident 28's hospitalization on October 6, 2024, and he stated that he will be honest it got behind, and [MDS] is doing them and had to catch them up. On 01/16/2025 at 10:35 AM, the Administrator confirmed he does…

    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 · D2025-01-16 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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, interview, and facility policy review, the facility failed to ensure a resident or their representative received a written notice of the bed hold policy in a language they can understand for 1 of 1 sampled (Resident 28) resident. Findings include: A review of Medical Diagnosis revealed Resident 28 had diagnoses of respiratory failure, heart attack, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 10/15/2024 revealed Resident 28 received a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact). On 01/16/2025 08:33 AM, the Administrator was asked for bed holds for Resident 28 for April and October of 2024. The Administrator revealed that they did not have a business office manager during that time, and he would be reaching out to the person that was doing bed holds to see if Resident 28 had one. On 01/16/2025 at 09:00 AM, Resident 28 was asked if she received a bed hold policy, or…

    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 · D2025-01-16 · 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 interview and record review, the facility failed to ensure the state designated authority was informed when 1 (Resident #39) of 2 (Resident #39 and #41) sampled residents reviewed for Preadmission Screening and Resident Review (PASARR) received a new diagnosis that required evaluation. The findings included: A review of Resident #39's Medical Diagnoses indicated that Resident #39 was diagnosed with bipolar disorder, unspecified on 9/01/2023. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #39 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. On 1/16/2025 at 10:22 AM, the state designated authority indicated the last Level 1 application for PASARR for Resident #39 was on 12/20/2021. When contacted by phone, the state designated authority indicated that they were not informed that Resident #39 was a resident at this facility, and they were not aware of his bipolar diagnosis. On 1/16/2025…

    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 · D2025-01-16 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 a physician order was followed for a dose reduction for 1 (Resident #43) of 5 residents reviewed for unnecessary medications. The findings are: The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024, revealed Resident #43 had a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. A review of Resident #43's Care Plan, initiated on 6/07/2024, indicated staff were to administer antidepressant medications as ordered by the physician. A review of an Order Summary Report, revealed Aripiprazole, a medication that is used for depression, was ordered on 4/29/2024 at a dose of 15 milligrams. A review of a form titled Pharmacy MRR (Medication Regimen Review), indicated that the pharmacist made a recommendation to reduce the resident ' s dose of Aripiprazole to 10 milligrams daily on 9/03/2024. The physician agreed with the pharmacist's recommendation on 9/04/2024. The Director of Nursing (DON) or designated nurse did not reduce 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 a resident had a functional call light, and that call light was kept in reach to prevent accidents and injuries for 1 (Resident 25) of 1 resident sampled for resident communication availability and functionality. A review of Medical Diagnosis revealed Resident 25 with a diagnoses of dementia, stroke, and heart failure. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2024 suggest a Brief Interview for Mental Status (BIMS) score of 00 (00-7 indicates severe cognitive impairment). Section GG0120 reveals resident uses a walker, and section GG0170 indicates Resident 25 can walk 50 feet with supervision. Findings include: On 01/13/2025 at 11:21 AM, Resident 25 was observed resting in A bed without a call light in reach. There is only one call light, and it is on the unoccupied B bed. The surveyor pulled the bathroom emergency cord and the light did not come on above the outside door. Resident 25 asked what would you do if you needed to call for help, and Resident 25…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · E2025-01-16 · 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 observation, record review, and interview, the facility failed to ensure that the environment was clean and hazard free on the secure unit (200 Hall) affecting 14 residents. A review of the facility policy titled Accidents and Hazards Policy, with a review date of 01/2024, indicated the facility strives to ensure that the resident environment remains as free of accidents and hazards as possible. A review of the facility document titled Housekeeping 200 Hall Cleaning Schedule, undated, indicated that handrails are included in the cleaning check list. On 01/14/2025 at 9:19 AM, the surveyor observed in room [ROOM NUMBER] that the vents were missing on the air conditioning and heating unit for the room, exposing metal edges and electrical components to Resident #60 who resides in the room. On 01/14/2025 at 9:27 AM, the surveyor observed in room [ROOM NUMBER] that the air conditioning and heating unit cover was off on top, exposing metal edges to Resident #73 who resides in the room. On 01/14/2025 at 9:30…

    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 · E2024-01-26 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview and record review, the facility failed to provide pharmaceuticals to meet the needs for 1 (Resident #27) of 1 sampled resident. The findings are: Resident #27 had diagnoses of chronic pain, hypomagnesemia, and nausea. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/2023 documented a Brief Interview for Mental Status (BIMS) of 15 (13-15 indicates cognitively intact) and had received scheduled pain medication with frequent pain rated 5 on a scale of 10 over the past 5 days. On 01/24/24 at 11:17 AM, while conducting a review of the 600 Hall medication cart it was noted that Resident #27's supply of Oxycodone 10 milligrams (an opioid pain medication) had been depleted to zero. Upon further investigation the Emergency Box's supply had been depleted to zero. Resident #27's Physicians Orders dated 01/20/2024 documented Oxycodone 10 milligrams 1 tablet by mouth every 12 hours for Pain; Magnesium Gluconate Oral Tablet 500 milligrams 1 tablet by mouth two times a day related to Hypomagnesemia; and Ondansetron HCl…

    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 · E2024-01-26 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure pureed foods were processed to the correct consistency to meet the needs of 4 residents who had physician's order for a pureed diet according to a list provided by the Dietary Manager on 01/22/24 at 12:05 PM. The findings are: a. On 01/24/24 at 11:00 AM, Dietary Aide #1 began prepping chili mac for the four puree diets in the facility. Dietary Aide #1 used an 8 ounce scoop to put four servings of chili mac in the food processor bowl and turned it on. Dietary Aide #1 added two 5.5 ounce cans of tomato juice to the pureed chili mac and continued to run it. At 11:15 AM, Dietary Aide #1 washed her hands and then checked on the puree and poured thickener in it without measuring. The Surveyor asked how much thickener did you use? Dietary Aide #1 said approximately 2 teaspoons of thickener. Dietary Aide #1 turned on the food processor and blended it without measuring. At 11:18 AM, the the puree chili mac had a runny texture. Dietary Aide #1 continued to prep for lunch, and then came back to check on the puree for a second…

    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 · E2024-01-26 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
    Have a plan that describes the process for conducting QAPI and QAA activities.
    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 the Quality Assurance and Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for, (677) providing nail care for resident dependent on staff. The failed practice had the potential to affect 89 residents as identified on the Census by Hall provided by the Administrator on 01/22/24 at 12:00 pm. The findings are: 1. A Recertification survey was conducted on 01/26/24 at the facility. During this survey, F677 was cited for the facility's failure to ensure residents who required assistance with activities of daily living (ADL) were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for 1 (Resident # 31) of 31 sampled residents who required assistance with personal hygiene and grooming. A review of the facility' s Plan of Correction, with a correction date of 12/04/22 indicated: a. 11/03/2022, upon identification, the DON/designee…

    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 · Ecited before2024-01-26 · 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 observation, record review, and interview, the facility failed to ensure staff followed contact precautions including the appropriate use of Personal Protective Equipment (PPE) and Hand Hygiene during resident care and after exiting Contact Isolation rooms, to prevent the potential spread of infection to other residents for 1 (Resident #27) of 1 sampled resident who was in contact isolation due to positive Clostridium Difficile Colitis (C-Diff). This failed practice had the potential to affect 15 residents who required the use of the mechanical lift, as documented by a list of residents provided by the Nurse Consultant on 01/26/24 at 10:30 am. The findings are: 1. On 01/23/24 at 10:22 am, Certified Nursing Assistant (CNA) #2 donning (put on) PPE before entering Resident #27's room. Resident #27 was on contact isolation due to C-Diff. CNA #2 took a mechanical lift to the room after donning PPE. CNA #1 and Licensed Practical Nurse (LPN) #1 donned PPE and went into Resident #27's room. The Surveyor donned PPE and followed the staff into the room. Resident #27's door was shut,…

    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 · Dcited before2024-01-26 · 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 observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for 1 (Resident #31) of 31 (Residents #4, #8, #9, #17, #19, #20, #23, #25, #27, #30, #31, #32, #35, #40, #41, #45, #46, #49, #57, #58, #59, #73, #75, #83, #84, #85, #87, #243, #246, and #247) sampled residents who required assistance with personal hygiene and grooming. The findings are: a. Resident #31 had diagnoses of down syndrome, intellectual disability, and a cognitive communication deficit. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/23 documented the resident received a score of 8 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). b. On 01/22/24 at 01:00 PM, Resident # 31 was eating lunch with his right hand. Observed the resident sucking food off his first and second fingers 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-18 · 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 observation, interview and record review, the facility failed to ensure oxygen cylinders were secured to prevent possible injury or explosion as evidenced by two oxygen cylinders observed in 1 (Resident #3) of 1 Resident ' s room. The findings included: On 08/17/2023 at 2:43 PM, observed Resident #3 was transferring self from the wheelchair to the side of the bed. A portable oxygen cylinder tank was standing next to the end of the bed unsecured. There was a second oxygen cylinder tank in a plastic bag sitting next to the two-drawer nightstand. The Surveyor asked Resident #3, Do you use this oxygen cylinder tank next to your nightstand? Resident #3 stated, That one is mine from home. My family brought it up here in case I go out with them for a while, I would have a smaller one here. On 08/17/2023 at 2:46 PM, the Surveyor asked the Advanced Practice Registered Nurse (APRN) should the two oxygen cylinder tanks be sitting on the floor unsecure? The APRN said no, they shouldn't it could create an explosion. On 08/17/2023 at 2:49 PM, the Surveyor asked Licensed Practical Nurse…

    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 · Dcited before2023-08-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview and record review, the facility failed to ensure oxygen orders were obtained prior to administering oxygen therapy to 1 (Resident #3) of 3 case mix residents. The findings included: During observation on 08/17/2023 at 2:43 PM, Resident #3 was wearing oxygen via nasal cannula at 2 Liters connected to an oxygen concentrator in the room. During record review, it was found Resident #3 did not have orders for oxygen therapy. On 08/18/2023 at 3:25 PM the Surveyor asked ADON (Assistant Director of Nursing) #1, Should Resident #3 have an order for oxygen? ADON #1 stated, Yes, it was documented on her admission assessment that she uses oxygen. I don't know why an order was not put in. On 08/18/2023 at 3:27 PM ADON #2 confirmed there were no physician's order for oxygen. Review of facility's policy titled Oxygen Administration undated provided by the Administrator on 08/18/2023 at 3:43 PM showed, Check the physician's order for liter flow and method of administration.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-11-04 · 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, record review, and interview, the facility failed to ensure foods stored in the freezer, the refrigerator and the 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; expired food items were promptly removed and/or discarded on or before the expiration or use by date to prevent the growth of bacteria; failed to ensure 1 of 2 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen; leftover food items were used properly to maintain food quality for residents who received meal trays from 1 of 1 kitchen; and dietary staff washed their hands before handling clean equipment. These failed practices had the potential to affect 98 residents who receive meals from the kitchen (total census:98) as documented on a list provided by the Dietary Supervisor on 11/01/22 at 2:00 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-04 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for 4 (Residents #24, #45, #84 and #347) of 31 (Residents #3, #4, #6, #16, #21, #22, #23, #24, #25, #26, #29, #30, #43, #45, #57, #64, #68, #71, #74, #76, #77, #79, #81, #84, #85, #86, #89, #91, #296, #297 and #347) sampled residents and failed to ensure facial hair was removed regularly for 1 (Resident #24) of 17 (Residents #4, #16, #22, #23, #24, #25, #26, #30, #43, #68, #71, #74, #86, #89, #296, #346 and #347) sampled residents who required assistance with personal hygiene and grooming. The findings are: 1. Resident #84 had diagnoses of Metabolic Encephalopathy and Dementia. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/09/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status…

    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 · E2022-11-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure necessary care and services were provided for management of urinary catheters as evidenced by, failure to ensure urinary catheter drainage tubing was kept off the floor to prevent potential cross contamination and Urinary Tract Infections for 1 (Resident #30) and failed to ensure a urinary catheter was secured by a leg strap for 1 (Resident 4) of 5 (Residents #4, #6, #30, #38 and #84) sampled residents who had an indwelling urinary catheter. The findings are: 1. Resident #30 had diagnoses of Obstructive and Reflux Uropathy and Retention of Urine. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/2022 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and had an indwelling catheter. a. The Care Plan with a revision date of 11/18/2021 documented, .has Indwelling Catheter related to urinary retention of 325 ml with in/out cath…

    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 before2022-11-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    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 oxygen tubing was properly labeled and stored to prevent the potential of cross contamination and infection for 2 (Residents #68 and #296) sampled residents; failed to ensure oxygen tubing and humidified water was changed weekly to prevent the potential of respiratory complications for 1 (Resident #296) sampled resident; failed to ensure a physician's order was obtained prior to the administration of oxygen to prevent the potential of complications for 1 (Resident #68) sampled resident and failed to ensure the correct flow rate was administered per physician orders to prevent potential complications for 1 (Resident #45) of 7 (Residents #4, #45, #68, #85, #89, #297 and #347) sampled residents who received oxygen therapy and failed to ensure an updraft mask was properly stored to prevent the potential of cross contamination and infection for 1 (Resident #77) of 1 sampled residents who received nebulizer treatments. The findings are: 1. Resident #68 had diagnoses of Chronic Obstructive Pulmonary Disease…

    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 · E2022-11-04 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 the physician was immediately consulted regarding a change of condition that required a physician's intervention to prevent a potential delay in treatment for 1 (Resident #45) of 2 (Residents #45 and #89) sampled residents who had conjunctivitis in the last 30 days. The findings are: 1. Resident #45 has a diagnosis of Macular Degeneration, Myopia with Intraocular Lens, Strabismus, and Cataracts. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/2022 documented the resident scored 9 (8 -12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had adequate vision and corrective lenses. a. The Care Plan with a revision date of 06/22/20 documented, .has impaired visual function r/t [related to] Macular Degeneration, Myopia with intraocular lens, Strabismus, and cataracts . Monitor/document/report PRN [as needed] any s/sx [sign and/or symptoms] of acute eye problems . b. On 10/31/22 at 1:40 PM, Resident #45 was resting in bed. Both eyes had a…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-04 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 meals were served at temperatures that were acceptable to the residents, to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practice had potential to affect 8 residents on the 100 Hall, 21 residents on the 200 Hall, 10 residents on the 300 Hall, 12 residents on 400 the Hall, 11 residents on the 500 Hall and 11 residents on the 600 Hall who received their meal trays in their rooms as documented on a list provided by the Dietary Supervisor on 11/1/2022. The findings are. 1. Resident #29 had diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side Acute Pulmonary Edema Cognitive Communication Deficit. Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 9/14/22 documented a BIMS of 15 (13-15 indicated intact) on a Brief Interview for Mental Status. On 10/31/22 at 11:33 AM, Resident #29 stated, Sometimes the food is cold. 2. On 10/31/22 at 11:50 AM, an unheated food cart that contained…

    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 · D2022-11-04 · tag F0622 — isolated
    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.
    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 document an acute decline in the resident's condition prior to transferring to the hospital for 1 (Resident #94) of 5 (Residents #79, #84, #87, #94 and #146) sampled residents who had been discharged to the hospital. The findings are: Resident #94 had diagnoses of Malignant Neoplasm of Prostate, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease (COPD). The admission Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident scored 15 (13-15indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. Resident #94 was admitted [DATE], after an acute decline he was discharged to the hospital on [DATE], where he expired. b. The Care Plan with a revision date of [DATE] documented, .has altered respiratory status/difficulty breathing r/t [related to] COPD, Chronic bronchitis, cough, and shortness of breath . Monitor/document changes in orientation, increased restlessness, anxiety, and air…

    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 · D2022-11-04 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 the Minimum Data Set (MDS) were completed accurately as related to a contracture and functional status for 1 (Resident #4) of 6 (Residents #58, #43, #76, #29, #4 and #16) sampled residents who had contractures. The findings are: Resident #4 had a diagnosis of Cerebral Vascular Accident (CVA). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and did not have an upper extremity impairment. a. The MDS section G0400 Functional Limitation in Range of Motion (A) documented, Upper extremity ( .hand) . No impairment . b. The Care Plan with a revision date of 08/27/21 documented, .[Resident #4] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] weakness . CONTRACTURES: The resident has a contracture to left hand . c. On 11/01/22 at 8:26 AM, Resident #4 was resting in bed, her left hand was contracted in a fist position. d. 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-04 · tag F0657 — failed to keep the care plan current — isolated
    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 observation, record review and interview the facility failed to ensure the care plan was revised to identify the discontinuation of oxygen therapy for 1 (Resident #68) of 38 (Residents #2, #3, #4, #6, #8, #16, #21, #23, #24, #25, #26, #29, #30, #38, #43, #45, #56, #57, #64, #68, #69, #71, #74, #76, #77, #79, #81, #84, #85, #89, #91, #94, #95, #146, #296, #297, #346, and #347) whose care plans were reviewed. The findings are: Resident #68 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Shortness of Breath. The Significant Change of Condition Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/22 documented the resident scored 15 (13-15 indicates cognitively intact) and did not require oxygen. a. The Care Plan with an initiated date of 12/21/21 documented, .Oxygen Settings: O2 [Oxygen] @ [at] 2-3L [Liters]/NC [Nasal cannula] PRN [as needed] Dyspnea . [Resident #68] has altered respiratory status/difficulty breathing r/t [related to] COPD, and Shortness of breath . b. The November 2022 Physician Orders did not address oxygen therapy. c. 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 Assessment and Care Planning 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 2 of 52.6-0.6 vs chain
Health inspection 2 of 52.7-0.7 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 2 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 Fort Smith Rehab & Nursing CenterFort Smith, 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 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
SOUTHWIND OPCO HOLDING LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/01/2024
AKS AR OPCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2024
MH AR OPCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2024
HERZKA, MATISYOHUIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2024
SCHREIBER, ABRAHAMIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2024
CARTER, CHARLESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2024
PAINE, JOHNNYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2024

CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$10.6M
Net patient revenuemost recent cost report
+1.4%
Operating marginrevenue minus expenses
$2.6M
Related-party expense25% of expenses
Who pays — share of resident-days
Medicaid 58%Medicare 16%Other / private 26%

This home reported $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 25% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. 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

$295per resident / day
operating cost
$8,980per month
≈ monthly operating cost
$300per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). 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 045418. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-16, 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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