The Blossoms at Breckenridge Rehab & Nursing Cente
800 Brookside Drive, Little Rock, AR 72205 · For profit - Limited Liability company · 143 certified beds · (501) 224-3940 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
- 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 (F0569)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $28,654 in federal fines (most recent 2025-09-12)
- 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 (1/5)
- nursing-staff turnover (65%) runs well above the national median (45%)
- about 20% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 1 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 fell from 2 to 1 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.2% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.0% | 4.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.2% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.3% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.9% | 21.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.5% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.2% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 33.1% | 10.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 5.4% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 95.8% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.8% | 24.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.5% | 12.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.14 | 2.01 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.07 | 2.13 | 1.80 | worse |
* 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.
37.4% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.9% 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 28 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 0.05 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 37.4%CMS range 22.2–55.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.2%CMS range 9.1–17.5 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 42.9% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 25.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 25.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 83.8% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.3–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 143 beds and averages 84.8 residents a day — about 59% occupied, or roughly 58 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.18 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 2.98 hrs/resident/day on weekends vs 3.71 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.20 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 65% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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
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.
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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · J2025-01-08 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents were free from abuse for 2 (Residents #3 and #5) of 3 sampled residents reviewed for abuse. Specifically, the facility failed to ensure Resident #3 and #5 were free from emotional and physical abuse. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to the residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, §483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. The IJ began on 12/30/2024 at 10:40 PM, when Licensed Practical Nurse (LPN) #3 made loud and aggressive statements while standing over Resident #5. At 10:45 PM, LPN # 3 was seen going into Resident #5's room and then coming out, wheeling Resident #5 out of the room in a wheelchair with a blood-soaked towel held to the resident ' s face. LPN #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.
- Potential for harm · Ecited before2026-04-02 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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, and facility policy review, it was determined that the facility failed to ensure a safe, clean, comfortable and homelike environment was maintained for three (Resident #1, Resident # 37 and Resident #16) of three residents reviewed.The findings include: Resident #1 Review of Resident #1's admission Record revealed the facility admitted Resident #1 on 06/30/2021 with diagnoses which included schizoaffective disorder, chronic obstructive pulmonary disease, asthma, shortness of breath, and abnormal results of liver function studies. Review of Resident #1's annual Minimum Safety Data Set (MDS) with Assessment Reference Date (ARD) 02/16/2026, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also revealed Resident #1 was independent of Activities of Daily Living (ADLs) but frequently displayed delusions and needed guidance in safe decision making. Review of Resident #1's Order…
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.
- Potential for harm · Fcited before2025-09-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespreadEnsure 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, the facility failed to ensure a resident who was at risk for elopement was adequately supervised in order to prevent the resident eloping from the secure unit for one (Resident #2) of three residents reviewed for accidents and supervision. The failed practice resulted in past noncompliance at the level of harm, which had the likelihood of causing more than minimal harm to Resident #2, who resided on the secure unit. The Administrator was notified of the past harm situation on 09/12/2025 at 3:50 PM. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/15/2025, revealed Resident #2 had a Brief Interview for Mental Status score of 11which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #2 had active diagnoses which included non-Alzheimer's dementia, psychotic disorder, schizophrenia, and Parkinsonism. A review of Resident #2's Care Plan, with an initiation date of 02/12/2025, had interventions related 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.
- Potential for harm · D2025-01-08 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interview, record review, and facility policy review, it was determined the facility failed to report an alleged violation involving abuse to the proper state agency within the allotted time frame for 1 (Resident #3) of 1 sampled resident reviewed for abuse allegations. The findings are: Review of a facility policy titled Prevention and Prohibition of Abuse indicated The facility administrator or designee shall complete a report to be made to the mandated state agency and may also be made to the local law enforcement agency after corporate approval or immediately if the abuse constitutes an emergency. Administrator or designee will have 5 working days from the initial report of abuse to complete SIMS (Statewide Incident Management System) report. Immediately means as soon as possible, in the absence of a shorter State time frame requirement, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse…
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.
- Potential for harm · D2025-01-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interview, record review, and policy review, the facility failed to develop a comprehensive care plan for one (Resident #5) of one resident reviewed for care plans, specifically that a resident ' s post-traumatic stress disorder diagnosis was addressed in the resident ' s care plan. The findings are: Resident #5 had diagnoses including schizoaffective disorder bipolar type, nightmare disorder, post-traumatic stress disorder, and type 2 diabetes mellitus without complications. A review of the significant change in status Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/04/2024, revealed the resident received a score of 1 (severely impaired) on the Brief Interview for Mental Status (BIMS). The resident required moderate assistance with bed mobility and transfers. The resident required substantial assistance with personal hygiene and dressing. A review of Resident # 5's care plan, initiated on 02/13/2023, revealed the resident had an Activity of Daily Living (ADL) self-care performance…
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.
- Potential for harm · Fcited before2024-11-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, interview and record review, the facility failed to ensure foods stored in the dry storage areas were covered, sealed and dated; 1 of 2 ice machines were maintained in clean and sanitary condition; the kitchen light fixtures were covered; ceiling tiles and door frames were maintained in good repair and were free of chips, stains and rust; baseboards were secured and were maintained in clean sanitary conditions, and dietary staff washed their hands before handling clean equipment or food items for 2 of 2 meals observed. The findings are: 1. On 11/19/24 at 2:34 PM, the following observations were made in the kitchen: a. An opened box of salt was on the food counter. The box was not covered. b. An opened box of mashed potatoes was on the counter. The box was not fully covered. c. An opened bag of grits was in a basket on the counter. The bag had no opened date on it. 2. On 11/19/24 at 2:38 PM, Dietary [NAME] (DC) #2 pushed a cart toward the counter that contained bowls to be used in portioning dessert to be served to the residents for supper. He picked up gloves…
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.
- Potential for harm · F2024-11-21 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
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 facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 81 residents. The findings are: The Facility Assessment 2024, dated as completed 05/15/2024, was reviewed and did not contain the following required information: -The involvement of the medical director, director of nursing and direct care staff (these signatures were missing on the review page dated 08/22/2024). -Staffing plan which addressed staffing needs for each resident unit and each shift. -The facilities resources including all personnel (management, direct care staff and volunteers) which included employees and contracted employees along with their education and competencies. On 11/21/2024 at 1:26 PM, the Administrator was interviewed and stated this was the first facility assessment she had completed. She stated a member of the governing…
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.
- Potential for harm · D2024-11-21 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 observation, interview, record review, and facility policy review, the facility failed to ensure a bottle of acid reducer liquid medication was properly stored in the refrigerator, per the pharmacy instructions on the bottle, for 1 (Resident #33) of 1 sampled resident whose medication was in the 100-hall medication cart. The findings are: On 11/19/2024 at 3:18 PM, this surveyor reviewed the contents inside the 100-hall medication cart with Registered Nurse (RN) #1. A drawer on the right side of the 100-hall medication cart contained a bottle of acid reducer 2 milligrams per milliliter (mg/ml) liquid for Resident #33 with instructions to give 10 ml (20 mg) by percutaneous endoscopic gastrotomy (PEG) (a tube inserted through a surgical opening in the abdominal wall leading into the stomach). The bottle of acid reducer had a blue sticker which indicated to refrigerate the medication and contained approximately 210 ml to 240 ml of liquid. The bottle was not cold and did not have any condensation on the outside. Resident #33's electronic Medication Administration Record (eMAR)…
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.
- Potential for harm · D2024-11-21 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned, written menu to ensure that nutritionally balanced meals were provided for the residents for 1of 1 meal observed. The findings are: 1. On 11/19/2024, the menu for the supper meal revealed residents on pureed diets were to receive two #8 scoops (1 cup) of pureed chili. a. On 11/19/24 at 5:13 PM, Dietary [NAME] (DC) #2 used a #8 scoop (1/2 cup) to serve a single portion of pureed chili to all the residents on pureed diets, instead of 2 #8 scoop s (1 cup). b. On 11/19/24 at 5:40 PM, DC #2 was asked, during an interview, what scoop size he had used when serving pureed chili to the residents who required pureed diets. DC #2 stated he used the gray scoop (#8), which was equivalent to 1/2 cup, to give a single serving of pureed chili to each resident. When asked if he had looked at the menu. DC #2 confirmed he had not.
- Potential for harm · E2024-03-14 · tag F0569 — patternNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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 convey funds within 30 days and send conveyed funds to the individual or probate jurisdiction administering the resident's estate for 7 ( Residents #5, #6, #7, #8, #9, #10, and #11) of 7 case mix residents reviewed for personal funds. 1. Resident #5 was admitted to facility on [DATE] and expired on [DATE]. A review of the resident #5'spersonal funds account managed by the facility revealed on [DATE] at 10:27 AM the resident's personal fund had a balance of $6,124.80. Resident #5 is receiving a social security check each month which is deposited into the resident trust fund even thought Resident #5 expired on [DATE]. 2. Resident #6 was admitted to the facility on [DATE] and expired on [DATE]. A review of the resident #6's personal funds account managed by the facility revealed on [DATE] at 12:25 PM that the residents' personal fund has a balance of $1,425.87. Resident #5 expired 14 months ago. 3. Resident #7 was admitted to the facility on [DATE] 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.
- Potential for harm · Fcited before2023-12-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, interview and record review, the facility failed to ensure food stored in the freezer was covered or sealed to prevent potential contamination or freezer burn; 1 of 2 ice machines was maintained in clean and sanitary condition to prevent potential contamination of resident beverages; the kitchen wall and door frames were maintained in good repair and were free of chips, paint peeling, stains and rust; baseboards were secured and were maintained in clean sanitary conditions; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 86 residents who received meal trays from the kitchen, (total census of (88), as identified on a list provided by the Dietary Supervisor on 12/15/2023 at 12:01 PM. The findings are. 1. On 12/11/23 at 9:30 AM, the counters in the kitchen had crumbs on them. The floors were dirty and had crumbs on them. The food cart had standing water in it and the outside of it was…
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.
Show the remaining 15 citations
- Potential for harm · E2023-12-15 · tag F0554 — patternAllow residents to self-administer drugs if determined clinically appropriate.
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 was assessed and deemed safe for self-administration for 1 (Resident #86) of 1 sampled resident on the 400 Hall whose medication was left at the bedside. This failed practice had the potential to affect 20 residents who resided on the 400 Hall. The findings are: Resident #86 had diagnoses of chronic kidney disease, dementia, hypertension, and depression. a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/2023 documented the resident scored 03 (00-07 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). b. On 12/11/2023 at 10:55 a.m., 11:49 a.m., and 1:15 p.m., observed Resident #86 lying in his bed with 6 pills in a medicine cup on his bedside table. c. On 12/14/2023 at 10:00 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #1 what is the proper way for a nurse to give a resident their medication. LPN (#1) said stay with them while they take their medicine. The Surveyor asked if they refuse to take their…
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.
- Potential for harm · E2023-12-15 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
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 bathroom sink was in working order to ensure access to running water to perform activities of daily living (ADLs) for 1 (Resident #86) of 20 residents who resided on the 400 Hall. The findings are: Resident #86 had diagnoses of chronic kidney disease, and dementia. The Quarterly Minimum Data Set with an Assessment Reference Date of 08/30/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was independent with all ADLs. a. On 10/14/15 at 10:07 a.m., observed in Resident #86's bathroom there were no knobs on his sink to turn on his water. b. On 10/14/23 at 10:07 a.m., the Surveyor asked Resident #86 how long the sink has been like this. Resident #86 replied I really don't know, but it has been a while. I go into another resident room and brush my teeth. c. On 10/14/23 at 10:18 a.m., the Surveyor asked Maintenance Supervisor if he was aware there was no way for Resident #86 to get water from his sink in his bathroom.…
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.
- Potential for harm · Ecited before2023-12-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 and interview, the facility failed to ensure 4 rooms on the 100 Hall were clean and maintained a homelike environment, and staff changed gloves when cleaning resident rooms. The findings are: On 12/11/23 at 11:09 AM, Resident room [ROOM NUMBER], the blind to left side of the double window were missing 4 of the slats. On 12/11/23 at 11:15 AM, the bathroom floor, toilet, and tub in the shared bathroom in Resident Rooms 117/116 had brown stains on them. On 12/11/23 at 11:24 AM, in Resident room [ROOM NUMBER], the bathroom floor and the toilet had brown stains on them. On 12/11/23 at 11:30 AM, in Resident room [ROOM NUMBER], the toilet and bathtub had brown stains on them. On 12/13/23 at 9:59 AM, the Surveyor asked Housekeeper #1, Can you tell me what's on the toilet, and floor in room [ROOM NUMBER]? He stated, It's dirty. On 12/13/23 at 10:14 AM, Housekeeper #1 went into Resident room [ROOM NUMBER] and wiped the yellowish/brownish stains off the toilet. He walked out of the room with the paper…
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.
- Potential for harm · E2023-12-15 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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, interview and record review, the facility failed to ensure 3 (Residents #1 #75, and #92) of 3 sampled residents who were dependent on staff for nail care to promote good hygiene and cleanliness. The findings are: 1. On 12/11/2023 at 10:48 AM, observed Resident #75 in his room with fingernails 1/2 inch past the fingertip on both hands with a dark brown substance under the nails. a. On 12/11/2023 at 02:51 PM, observed Resident #75 in his room with fingernails 1/2 inch past the fingertip on both hands with a brown substance under the nails on both hands. b. On 12/12/2023 at 9:45 AM, observed Resident #75 in his room sitting on the side of the bed. The Surveyor asked to see his hands. He had fingernails 1/2 inch past the fingertip on both hands with a brown substance under the nails. The Surveyor asked if the facility staff clean and cut his nails. Resident #75 stated, Nope. 2. On 12/11/23 at 11:12 AM, observed Resident #92 in his room. with fingernails 1/2 inch past the fingertip with a brown substance under the nails on both hands. a. On 12/12/23 at 11:38 AM,…
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.
- Potential for harm · Ecited before2023-12-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 and interview, the facility failed to ensure an intervention for a fall was implemented for 1 (Resident #19) of 1 sampled resident with a major injury in the last 30 days, and razors were removed from the bathroom for 1 (Resident #78) of 2 (Residents #77 and #78) sampled residents on the 100 Hall. The findings are: 1. An Incident Report dated 12/2/23 at 12:00 pm noted Resident #19 fell out of his bed and broke his left wrist. a. A Late Entry Progress Note dated 12/02/23 at 12:00 pm, noted Long-term/Care Planned Intervention: Bolster Mattress. b. On 12/12/2323 at 3:51 pm, observed Resident #19 lying in bed with no bolster mattress on bed. c. On 12/13/23 at 8:37 am, observed Resident #19 lying in bed with no bolster mattress on bed. d. On 12/14/23 at 9:29 am, observed Resident #19 lying in bed with no bolster mattress on bed. e. On 12/14/23 at 10:19 am, the Surveyor asked Licensed Practical Nurse (LPN) #1 if a resident has an incident happen how do you know what the intervention is. LPN #1 said if it happens on my shift, and I do the incident report…
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.
- Potential for harm · E2023-12-15 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
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 fluids were readily accessible to promote adequate hydration for 3 (Residents #39, #75 and #352) sampled residents and interventions were promptly implemented after continued weight loss was identified to attain or maintain acceptable nutritional status for 1 (Resident #92) of 2 (Residents #92 and #352) with weight loss. The findings are: 1. Resident #39, the physician orders documented Resident #39 had diagnoses of dementia, major depressive disorder, and anxiety disorder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/08/2023 documented a Brief Interview of Mental Status (BIMS) score of 04, (0-7 indicates severe cognitive impairment) and required no supervision or assistance with meals. a. On 12/11/23 at 11:40 AM, 1:14PM, 1:59PM, and 2:56 PM, Resident #39 did not have fluids at the bedside. b. On 12/12/23 at 10:14 PM, there was not a water pitcher, or fluids in Resident #39's room. c. On 12/14/23 at 10:33 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1…
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.
- Potential for harm · E2023-12-15 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 as needed antipsychotic and antianxiety medications were discontinued or reevaluated for use after 14 days for 1 (Resident #92) of 2 sampled residents who were reviewed for unnecessary medication. The findings are: A review of Resident #92 record indicated he had a diagnosis of unspecified psychosis, muscle wasting and atrophy, cognitive community deficit, unspecified dementia, insomnia, anxiety disorder, and alcohol abuse. A significant change Minimum Data Set (MDS) with an Assessment Reference Date of 12/7/2023 documented Resident #92 was severely cognitively impaired per a Staff Assessment for Mental Status. Resident #92's active Physician Orders as of 12/12/2023 documented the resident had the following: a. Lorazepam 0.5 milligrams IM (intramuscular) every 4 hours as needed. b. Lorazepam 0.5 milligrams every 6 hours as needed. Order Date 11/23/23. c. Haloperidol 5 milligrams IM every 4 hours as needed. Order Date 11/23/23. d. Haloperidol 2.5 milligrams every 6 hours as needed. On 12/14/23 at 11:02 am, 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.
- Potential for harm · E2023-12-15 · tag F0919 — failed to provide a working call system — patternMake 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a call light was accessible to 3 (Residents #28, #59, and #89) of 11 (Residents #14, #22, #28, #39, #59, #60, #75, #86, #89, #90, and #92) sampled residents and the call light was in working order for 2 (Rooms 415-B and 303-B) of 2 rooms. The findings are: Resident #28 1. Resident #28's diagnoses showed mild vascular dementia with behavioral disturbance, cerebral infarction, muscle wasting, fracture of T5-T6 vertebra. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/23 showed a Brief Interview for Mental Status (BIMS) of 8 (8-12 indicates moderate cognitive impairment) and required partial and/or moderate assistance with toileting and personal hygiene. 1a. The Care Plan showed Resident #28 is at risk for falls and to be sure the resident's call light is within reach and is to be encouraged to use it for assistance and prompt response to all requests for assistance. 1b. On 12/11/23 at 02:34 PM,…
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.
- Potential for harm · D2023-12-15 · tag F0574 — isolatedThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, the facility failed to ensure residents were informed of who the Ombudsman is, what the Ombudsman does and where the Ombudsman's contact information is located in the facility. The findings are: 1. On 12/13/23 at 10:30 AM, during a Resident Council Meeting the Surveyor asked Residents #50, #64, #70 and #82 if they knew how to contact their Ombudsman. All 4 residents stated, No. what is an Ombudsman. 2. On 12/13/23 at 10:30 AM, the Surveyor asked the 4 Residents if anyone ever explained to them what an Ombudsman does or where to find their information. All 4 residents shook their heads no, and stated, We have never heard of this person. 3. On 12/15/23 at 9:47 AM, the Surveyor asked the Administrator who was responsible for informing the residents who their Ombudsman is. The Administrator stated our Activities Director, Myself, the Director of Nursing, and the Social Worker. The Surveyor asked who educates the residents to let them know what the Ombudsman does, and where the poster with their contact information is located. The Administrator stated the Activity…
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.
- Potential for harm · D2023-12-15 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 residents, resident representatives/family, and visitors had the right to examine the results of the most recent survey conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility without asking. The findings are: 1. On 12/13/23 at 10:50 AM, the Surveyor was unable to locate the most recent survey results in the facility. 2. On 12/13/23 at 10:45 AM, during a resident council meeting, the Surveyor asked Residents #50, #64, #70, and #82), if they had seen the survey results in a binder posted anywhere in the facility. The four residents in attendance stated they had not been told about or had seen any survey results. The Surveyor asked the group if those results would be important to them. The 4 residents said it would be nice to see sometime. 3. On 12/13/23 at 11:00AM, the Surveyor asked the girl sitting at the front desk. Where is your Survey Binder located. The front desk lady replied, I have no idea I have never seen it. I would try in the Administrator's…
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.
- Potential for harm · D2023-12-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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 1 (Resident #89) of 1 sampled resident had an Advance Directive readily available in their clinical record. The findings are: On [DATE] at 09:06 AM, a Do Not Resuscitate (DNR)/Cardiopulmonary Resuscitation (CPR) Instructions signed by the Resident #89 on [DATE] showed, I want CPR. There was no Advance Directive located in Resident #89's records. On [DATE] at 11:30 AM, the Surveyor requested the Advance Directive for Resident #89 from the Administrator. On [DATE] at 03:20 PM, the Surveyor requested the Advance Directive for Resident #89 from the Director of Nursing (DON). On [DATE] 03:39 PM, the Social Services Director (SSD) provided the Surveyor with a copy of Resident #89's Advance Directive signed by the resident on [DATE] that showed, I do not choose to formulate or issue any Advance Directive at this time. On [DATE] at 03:40 PM, the SSD confirmed a copy of the Advance Directive was not always available in Resident #89's electronic chart.…
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.
- Potential for harm · D2023-12-15 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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, interview, and record review, the facility failed to ensure residents' individualized care plans were updated to ensure appropriate care was received for 1 (Resident #75) of 1 sampled resident who had a new service or level of care ordered or provided. The findings are: 1. On 12/14/23 at 10:04 AM, Resident #75 was lying in bed. A fall mat was across the room from the resident's bed. 2. On 12/14/23 at 2:30 PM, Resident #75 was lying in bed. A fall mat was across the room from the resident bed. 3. On 12/14/23 at 2:57 PM, Resident #75's Care Plan did not address Resident #75was to use a fall mat. 4. On 12/14/23 at 3:49 PM, the Surveyor asked the Minimum Data Set (MDS) Coordinator how do you know when to care plan an intervention? The MDS Coordinator said, when it is discussed in the morning meeting, or the IDT (Interdisciplinary Team) meeting or when I review orders. The Surveyor asked who is responsible for care planning an intervention? The MDS Coordinator said, I am. The Surveyor asked if a resident has an intervention in place should it be care planned. 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.
- Potential for harm · D2023-12-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 physician's orders were followed for wound care for 1 (Resident #79) of 4 (Residents #2, #14, #45 and #79) sampled residents with orders for wound care. The findings are: 1. Resident #79 had a diagnosis of Vascular Dementia and Type 2 Diabetes Mellitus. a. A Physician's order with an order date of 11/27/23 instructed the Resident's wounds to be cleansed with (Brand Name) broad spectrum wound care solution. b. A Care Plan with a completion date of 11/06/23 documented the Resident had an abscess to his left inner buttock and an unstageable pressure ulcer to his sacrum. c. On 12/13/23 at 3:29 PM, the Treatment Nurse was observed performing the Resident #79's dressing change. She used (Brand Name) Wound Cleanser instead of (Brand Name) broad spectrum wound care solution on both wounds. d. On 12/14/23 at 3:18 PM, the Treatment Nurse stated the resident's order changed today [12/14/23] to use wound cleanser instead of the (Brand Name)…
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.
- Potential for harm · D2023-12-15 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, interview, and record review, the facility failed to ensure staff had on appropriate Personal Protective Equipment (PPE) for 2 (Residents #19 and #39) of 5 (Residents #14 #40, #19, #39 and #352) sampled residents who were on contact isolation. The findings are: 1. On 12/11/23 at 11:31 AM, Residents #19 and #39 had a sign on the door that documented, Droplet Precautions. Observed Certified Nurse Assistant (CNA) #1 enter Resident #19 and #39's room without donning a gown or gloves and then provide care to both residents and change their linens with no isolation gown or gloves on. On 12/11/23 at 11:37 AM, the Surveyor asked CNA #1, If a resident is on droplet isolation what should you wear in the room when you're providing care? He stated, Gloves and a gown. On 12/11/23 at 11:45 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, If a resident is on droplet isolation what should you wear in the room when you are providing care? She stated, Gown and gloves. On 12/13/23 at 10:55 AM, the Surveyor asked the Director of Nursing (DON), If a resident is on droplet…
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.
- Potential for harm · D2023-12-15 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 pneumococcal immunizations were administered to eligible residents and the immunization records were updated in the electronic medical record (EMR) for 1 (Resident #75) of 5 (Residents #1, #45, #60, #75 and #92) sampled residents. The findings are: 1. On 12/12/23 at 4:05 PM, Resident #75's EMR was reviewed and there was no documentation that he received a Pneumonia immunization or if the Resident's Representative consented or declined the immunization. a. On 12/15/23 at 8:58 AM, a review of the Resident #75's EMR documented no allergies. b. On 12/15/23 at 9:32 AM, the Director of Nursing (DON) was asked for a declination form for the pneumonia vaccine for Resident #75. c. On 12/15/23 at 11:36 AM, the Administrator brought a Consent To Participation In Immunization Programs form dated 6/20/22 documenting, .I recognize that pneumonia and influenza, together, is the sixth leading cause of death in Arkansas . I, therefore, agree to participate voluntarily in the Facility's immunization programs . There was a title 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.
“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.
- 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.
Fines & penalties
$28,654 in federal fines across 2 penalties.
- $9,269 — penalty dated 2025-09-12
- $19,385 — penalty dated 2024-11-21
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
About 79% 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 $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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
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
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.
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 045458. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-02, 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.