The Blossoms At Midtown Rehab & Nursing Center
5720 West Markham Street, Little Rock, AR 72205 · For profit - Limited Liability company · 154 certified beds · (501) 664-6200 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- 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 (F0602), cited Oct 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- 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
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (65%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 4 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 | 5.3% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.3% | 4.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.4% | 1.4% | 6.5% | better than state‡ — see note marked double-dagger 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 | 2.9% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.0% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.2% | 21.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.7% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 13.4% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 4.9% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.3% | 10.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.9% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.9% | 24.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 27.8% | 12.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.44 | 2.01 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.30 | 2.13 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
38.9% 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 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 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 0.08 therapist hours per resident per day in 2026Q1 — more than 4% 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 | 38.9%CMS range 26.0–54.0 | 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 | 10.9%CMS range 7.5–15.4 | 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 | 63.0% | 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 | 51.9% | 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 | 59.3% | 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 | 100.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 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 | 1.9% | 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 | 11.5% | 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 | 8.0%CMS range 4.8–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.23 | 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 154 beds and averages 85.7 residents a day — about 56% occupied, or roughly 68 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 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 3.02 hrs/resident/day on weekends vs 3.71 on weekdays — 19% thinner on weekends. RN hours go from 0.58 to 0.50 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%. 1 administrator has left in the past year.
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 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Ecited before2025-08-28 · 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 and interviews, it was determined that the facility failed to ensure a comfortable homelike environment for Rooms #430, #428, and #433 occupied by residents reviewed for a homelike environment. The findings include: During an observation on 08/25/2025 at 12:34 PM, the bathroom in room [ROOM NUMBER] was noted to have an unidentified brownish/black residue on the walls of the shower stall walls, floors, and shower curtain. This surveyor observed a basin with brownish/black residue noted sitting on the floor of the shower stall. The bathroom smelled of urine. A urinal was observed sitting on the nightstand with toothbrushes beside it. During an observation on 08/25/2025 at 12:46 PM, a shower chair in room [ROOM NUMBER] was noted to have a brownish residue on the bars of the shower chair and the mesh-like backing. This surveyor observed in the same bathroom missing and cracked tiles on the floor. The wall was noted to have scrape marks towards the bottom of the wall near the floor and there…
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 before2025-08-28 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to accurately assess and complete the Minimum Data Set (MDS) for two (Resident #71 and Resident #48) of two residents reviewed. The findings include: Resident #71Review of an admission Record indicated Resident #71 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure, obstructive sleep apnea, and presence of a surgically created opening through the neck into the windpipe to allow air to fill the lungs. Review of Physician Orders for Resident #71 indicated to change tracheostomy collar and to perform tracheostomy care daily. The Physician Orders also included to check oxygen saturation daily and to give oxygen via trach cuff at 5 liters as needed. Review of the quarterly MDS with an Assessment Reference Date (ARD) of 08/05/2025 incorrectly indicated that Resident #71 did not require tracheostomy care, did not use oxygen and did not require suctioning, which are needed when a resident has 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.
- Potential for harm · Ecited before2025-08-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews the facility failed to ensure chemicals were properly stored away from residents to prevent accidents and injuries. Specifically, the storage room door, directly across the hall from the elevator door on 300 hall was left unlocked and unsecured. The room had chemicals, biohazard waste, a housekeeper's cart, and equipment stored inside. The Administrator provided a list of 55 ambulatory residents who could have been potentially affected. The facility failed to ensure razors were properly stored to prevent accidents and injury for one (Resident #57) of one resident reviewed for accidents. The findings include: Facility On 08/26/2025 at 11:06 AM, this surveyor observed a set of keys hanging from the doorknob of the soiled room directly across the hall from the elevator on 300-Hall. This surveyor turned the key and the door opened. This surveyor observed an unlocked housekeeping cart with a mop and water in a bucket on the cart, sitting just inside the door; 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.
- Potential for harm · Ecited before2025-08-28 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 facility policy review, the facility failed to ensure that the ice scoop holder was maintained in a sanitary manner; food items stored in the refrigerator, freezer, and dry storage area were covered or sealed; expired food items were promptly discarded on or before the expiration or use by-date; that dietary staff washed their hands between handling dirty and clean equipment; and hot food items were maintained at required temperature for one of one meal observed. The findings include: During an observation and interview on 08/26/2025 at 12:41 PM, this surveyor observed the ice scoop holder, on the wall by the ice machine, had an accumulation of wet black residue at the bottom of it, and the ice scoop was resting on the residue. The Dietary Manager (DM) confirmed the scoop holder was dirty and had mold-like residue at the bottom of it and should be cleaned daily. During an observation and interview on 08/26/2025 at 12:46 PM, this surveyor observed a box of alfredo sauce on a shelf in the refrigerator, the manufacturer's instructions specified that…
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 before2025-08-28 · tag F0880 — failed to prevent and control infections — patternProvide 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, interview and record review the facility failed to ensure isolation practices were being followed by housekeeping staff to prevent the possible spread of infectious disease on one (Fourth) floor of the nursing facility. The findings include: On 08/25/2025, a contact isolation sign was observed on the door of room [ROOM NUMBER]. On 08/26/2025 at 11:00 AM, Housekeeper (HSK) #9 was observed on west 400 hall pushing the housekeeping cart with gloved hands. HSK #9, without changing gloves or performing hand hygiene, nor donning an isolation gown, was observed going into room [ROOM NUMBER] with a broom and dustpan. HSK #9 came out of the room and placed a small bag of trash in the trash compartment of the housekeeping cart. HSK #9 was observed, through the open room door, to move dirty linen and a trash container from room [ROOM NUMBER]'s bathroom to the room,. HSK #9 then came out of room [ROOM NUMBER] and picked up a bottle of spray and a toilet brush and went back into room [ROOM NUMBER]. 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.
- Potential for harm · E2025-02-11 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure medications were administered as ordered by the physician for 2 (Residents #2 and #4) of 3 residents reviewed for correct medication administration as ordered by the physician. The findings include: A review of a facility policy titled, Policies and Procedures: Subject: Medication Administration, revised on 11/25/2022, indicated that medications were to be administered as ordered, including the required time frame. 1. A review of the admission Record, indicated the facility admitted Resident #2 with diagnoses that included schizophrenia, bipolar disorder, major depressive disorder, and generalized anxiety disorder. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/10/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #2 was marked as taking antipsychotic 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 · E2024-10-28 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure residents were free from misappropriation of property for 4 (Resident #3, #4, #5, #7) of 15 residents reviewed for misappropriation of property. Findings include: A review of a facility policy titled, Abuse, Neglect, and Exploitation revised on 01/01/2024, indicated, Policy Statement: We are committed to the safety and well-being of all our residents. We believe that the resident has the right to be free from .misappropriation of property .The facility considers all the above to be abuse and uses the general term abuse to specify all .Investigation: 3. In the event of misappropriation, a thorough search of the building is conducted to determine possible misallocation of missing items. A Missing Item Form is completed, and missing items are analyzed for patterns, location and care givers . A review of a facility policy titled, Controlled Substances, revised on 01/31/2023, indicated, .Schedule II, III, IV, and V medications remaining…
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 · E2024-10-28 · tag F0609 — failed to report abuse allegations — patternTimely 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 observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure allegations of misappropriation of property were reported to the State Agency for 15 Resident, with 3 residents remaining on medications, (Resident #4, Resident #5, Resident #7) of 15 residents reviewed for abuse. Specifically, the facility failed to ensure alleged misappropriations of Resident #4, #5, #7 medications were reported. Findings include: A review of a facility policy titled, Abuse, Neglect, and Exploitation revised on 01/01/2024, indicated, Policy Statement: We are committed to the safety and well-being of all our residents. We believe that the resident has the right to be free from .misappropriation of property .The facility considers all the above to be abuse and uses the general term abuse to specify all .Reporting .3. The facility will report all alleged violations involving mistreatment, neglect, or abuse to the Office of Long-Term Care, Family, Police, and MD [medical doctor]. Suspicion or allegation of abuse shall…
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 before2024-05-08 · 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, record review and interview, the facility to ensure foods stored in the refrigerator, freezer and storage room were covered, and sealed to maintain freshness and decrease the potential for cross contamination; the ice machine and ice scoop holder were maintained in clean condition to prevent potential contamination of residents' food and beverages; dietary employees washed their hands or changed gloves before handling clean equipment or food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 main kitchen. The failed practices had the potential to affect 20 residents who received meals from the kitchen on the 200 Hall; 30 residents who received meals from the kitchen on the 300 Hall; and 39 residents who received meals from the kitchen on the 400 Hall (total census of 97), as documented on a list provided by the Dietary Supervisor on 05/06/24 at 12:34 PM. The findings are: 1. On 05/05/2024 09:08 AM, the following observations were made in the kitchen area: a. There was water standing on the floor between the hand…
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 · E2024-05-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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, record review and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to prevent respiratory complications for 2 (Residents #71 and #248) sampled residents. This failed practice had the potential to affect 57 residents that had physician orders for oxygen therapy. The findings are: 1. Resident #71 had diagnoses of stroke, end stage renal disease and coronary artery disease. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/2024 documented the resident scored 00 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS). a. A Physicians Order dated 05/01/2024 documented, .Oxygen at (3) L/Min (Liters per minute) per Nasal Cannula as needed for Shortness of Breath maintain O2 [oxygen] sats [Saturations] above ( ) . b. On 05/05/2024 at 12:01 PM, Resident #71 was lying in bed with oxygen in use at 2.5 liters via nasal cannula. c. On 05/06/2024 at 08:41 AM, Resident #71 was lying in bed with eyes closed. Oxygen was in use at 2.5 liters per nasal…
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 16 citations
- Potential for harm · Ecited before2024-05-08 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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 — an excerpt from the official record, 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 meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 74 residents who received regular diets and 13 residents who received mechanical soft diets from 1 of 1 kitchen. The findings are: 1. The menu for the lunch meal documented that the residents who received regular diets were to receive 4 ounces of oven fried chicken and the residents who received mechanical soft diets were to receive 4 ounces of ground oven fried chicken. b. On 05/05/2024 at 12:52 PM, the following observations were made during the noon meal service on the 200 Hall. The Dietary Supervisor served 12 residents one fried chicken leg each. c. On 05/05/2024 at 01:37 PM, the following observations were made during the noon meal service on the 400 Hall. The Dietary Supervisor served one fried chicken leg to 7 residents who were on regular diets on the 400 Hall kitchenette. d. On 05/05/2024 at 02:06 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 · E2024-05-08 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 vegetables were not overcooked and were served in a method that maintained the appearance of food product and hot food items were served at temperatures that were acceptable to the residents to improve palatability and encouraged good nutritional intake during 1 of 2 meals observed. This failed practice had the potential to affect 20 residents who receive meal trays on the 200 Hall, 30 residents who receive meal trays on the 300 Hall, 39 residents who receive meal trays in their room on the 400 Hall. The findings are: 1. Review of Resident #41's Physicians Orders documented a diagnosis of Diabetes Mellitus Without Complications and an order for a general texture regular diet. a. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/05/2024 showed a Brief Interview for Mental Status (BIMS) of 13 (13 to 15 suggests cognitively intact). b. On 05/05/24 at 11:05 AM, the Surveyor asked Resident #41 how the food was. Resident #41 stated, Not good, same thing three or four times 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.
- Potential for harm · Ecited before2024-05-08 · tag F0880 — failed to prevent and control infections — patternProvide 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, interviews and policy review, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) between resident rooms to prevent cross contamination. This failed practice had the potential to affect all 99 residents in the facility. Findings Include: On 05/05/2024 at 9:22 AM, the Surveyor observed CNA #4 come out of room [ROOM NUMBER] with gloves on and go straight into room [ROOM NUMBER]. Both rooms #423 and #427 had a sign showing Enhanced Barrier Precautions (EBP). On 05/05/2024 at 9:40 AM, the Surveyor spoke with CNA #4. The Surveyor asked CNA #4 what proper hand hygiene is when you are entering and exiting a room with EBP. CNA #4 indicated you are supposed to leave your gloves on when you carry trash out of a room. The Surveyor asked if it was proper hand hygiene to go from one room to another room with gloves on. CNA #4 stated, No. The Surveyor asked how long she had worked in the facility. CNA #4 indicated about 2 months, prior to that she worked in the hospital…
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 · Dcited before2024-05-08 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a discharge Minimum Data Set (MDS) assessment to accurately reflect the residents discharge status for 1 (Resident #95) sampled residents. This failed practice had the potential to affect 76 residents that were discharged in the last 90 days. The findings are: 1. Resident #95 had a diagnosis of fracture shaft of right tibia, arthritis, and seizure disorder. The admission MDS with an Assessment Reference Date (ARD) of 02/09/2024 documented that the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 05/08/2024 at 11:20 AM, the Surveyor reviewed Resident #95's Discharge Return Not Anticipated MDS with an ARD of 02/23/2024 that documented, . A2105 Discharge Status .04 .Short Term General Hospital (acute Hospital .) . b. A Physician's Order dated 02/23/2024 documented, .Discharge home with home health services Prescriber . c. On 05/08/2024 12:35 PM, the Surveyor asked the MDS Coordinator…
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 · D2024-05-08 · 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 review and revise the care plan to include oxygen therapy was in use to ensure appropriate coordination of care for 1 (Resident #71) sampled resident that had physician's orders for oxygen therapy. This failed practice had the potential to affect 55 residents that had physician's orders for oxygen therapy. The findings are: 1. Resident #71 had diagnoses of stroke, end stage renal disease and coronary artery disease. The admission Minimum Data Set (MDS) with an Assessment Reference Date of 03/12/2024 documented that the resident scored 00 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS). a. A Physicians Order dated 05/01/2024 documented, .Oxygen at (3) L/Min (liters/minute) per Nasal Cannula as needed for Shortness of Breath maintain O2 sats [Saturations] above ( ) . b. On 05/05/2024 at 12:01 PM, Resident #71 was lying in bed with oxygen in use at 2.5 liters via nasal cannula. c. On 05/06/2024 at 08:41 AM, Resident #71 was lying in bed with eyes closed. Oxygen was in use…
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 · D2024-05-08 · 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
Based on record review and interview, the facility failed to ensure 1 (Resident #199) received wound care as ordered by the physician to prevent wound infection and healing. This failed practice had the potential to affect 8 residents with pressure ulcer orders. The findings are: 1. Resident #199 had diagnoses of right lower amputated stump infection, type II diabetes mellitus, and acute kidney failure. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/2024 indicated a Brief Interview for Mental Status score of 12 (8-12 suggest moderate cognitive impairment). a. A Care Plan documented, .I have a pressure ulcer. Coccyx, Left heel .Date Initiated 01/11/2024 .Administer treatments as ordered and monitor for effectiveness . b. A Physicians Order dated 03/01/2024 documented, Apply [Povidone-iodine] to left heel and around left foot two times a day for wound care. c. On 05/08/2024 at 02:00 PM, the Surveyor observed the March Treatment Administration Record (TAR) and noted that there was no documentation that Resident #199 received the second application…
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 · Dcited before2024-05-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure potentially hazardous items were stored in a secured manner for 1 (Resident #38) of 1 sampled resident. The findings are: A review of Policy titled Accidents and Hazards Policy effective date 08/2021 stated, .The facility strives to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents . A review of Resident #38's Care Plan shows the resident was admitted on [DATE] with diagnosis that included Unspecified Atrial Fibrillation (irregular and often very rapid heart rhythm), Type 2 Diabetes Mellitus without complications, Essential (Primary) Hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/16/2024 showed a Brief Interview for Mental Status (BIMS) of 12 (8 to 12 suggests moderate cognitive impairment). A review of Resident #38's Care Plan dated 05/01/2024 revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-11-22 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 policy review, the facility failed to ensure resident rooms were maintained in good repair for 4 (Rooms 202, 301, 304 and 406) resident rooms, and resident rooms and hallways Heating, Ventilation, and Air Conditioning (HVAC) units were maintained in a clean and sanitary manner. The findings are: 1.On 11/21/2023 at 3:10 PM, damage to the wall behind the bed in room [ROOM NUMBER] was observed. There were two areas where the paint had been scraped away leaving a gouge in the drywall. 2. On 11/21/2023 at 3:44 PM, damage to the wall behind the bed in room [ROOM NUMBER] was observed. Several long vertical gouges measuring 12 to 18 inches in length, had removed the paint and parts of the drywall. 3. On 11/21/2023 at 3:53 PM, damage to the wall behind Bed A and Bed B in room [ROOM NUMBER] was observed. The paint and portions of the drywall had been removed in four areas. 4. On 11/21/2023 at 4:16 PM, there were three areas where white plaster had been applied to perform repairs 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.
- Potential for harm · Fcited before2023-05-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the dietary staff washed their hands and changed their gloves before handling food items to prevent the potential for cross contamination for the residents who received meals from 1 of 1 kitchen; Hot food items were not maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 81 residents who received meals from the Kitchen (Total Census: 81), according to the list provided by the Dietary Supervisor on 05/07/23 at 2:55 PM. The findings are: a. On 05/07/23 at 10:20 AM, Dietary Employee (DE) #1 opened the walk-in refrigerator. She removed the pitchers that contained the lemonade and placed them on the food cart by the dirty side of the dish washer. Without washing her hands, she picked up a pan from the shelf under the food preparation counter to be used in…
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 · E2023-05-11 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 ensure that a resident's drug regimen was free from unnecessary drugs for 1 (Resident #82) sample mix resident who was prescribed and received Antipsychotic Medication and Anti-Epileptic medication without adequate indications for its use. The findings are: 1. Resident #82 had diagnoses of Infection of Intervertebral Disc (Pyogenic), Anxiety Disorder and Depression. The admission 5-day Medicare Minimum Data Set (MDS) dated [DATE] documented the resident scored 12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS). a. The State Designated Professional Associates document dated 04/04/23 documented Resident #82 was oriented, alert, and cooperative. State Designated Professional Associates documented that Resident #82 had no history or Diagnosis of Mental Illness. b. The Physician Order with a revision date of 04/04/23 documented, Trazodone HCl [Hydrochloride] Oral Tablet 100 MG [milligrams] (Trazodone HCl) Give 1 tablet by…
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 · E2023-05-11 · tag F0761 — failed to label and store drugs safely — patternEnsure 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, and record review, the facility failed to ensure medication was secured by leaving it on a bedside table in a resident's room, for 1 (Resident #22) sampled resident. The failed practice had the potential to affect all 35 residents who reside on the 300 hall. The findings are: 1. Resident #22 had diagnoses of Acute and Chronic Respiratory Failure with Hypoxia, Metabolic Encephalopathy, Delirium due to known physiological condition. The admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 01/17/23 documented the resident scored 12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS). a. The Physician Orders, with a revision date of 05/09/23 documented, can safely self-medicate oral inhalers for Resident #22. b. The Care Plan failed to document Resident #22 was assessed for self-administration of medication. c. On 05/07/23 at 11:07 AM, Resident #22 had medication on her bedside table. The medication was Wixela 100/50, an inhaler, and one bottle of Eye Drops Dorzol/Timol. d. On 05/07/23 at 12:51 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 · E2023-05-11 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure 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 that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 5 residents who received pureed diets as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 09/08/22. The findings are: a. On 05/07/23 at 10:51 AM, Dietary Employee (DE) #2 used an 8 ounce (oz) serving spoon to place 4 servings of cream corn into a blender, added ¾ cup of thickener, pureed, and poured it into a pan. At 10:55 AM, she used an 8 oz serving spoon to put 4 more servings of cream corn into a blender and pureed it. At 10:59 AM, she poured the pureed cream corn into a different pan. The consistency of the cream corn was lumpy. b. On 05/07/23 at 11:47 AM, DE #2 used ½ portion of the 6-ounce spoon and placed 7 servings of diced chicken, broth, and thickener into a blender, pureed and poured it into 2 pans. At 11:49 AM, she added 5 more…
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 · E2023-05-11 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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 residents' meals were consistently being served at regularly scheduled times, and failed to provide the residents with a dependable eating schedule for 1 of 1 meal service observed. The failed practice had the potential to affect all 81 residents who received meals from the kitchen (total census: 81), according to the list provided by the. The findings are: 1. Resident #3 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Type II Diabetes, and Acute Respiratory Failure. The Admission/Medicare-5-day Minimum Data (MDS) with an Assessment Reference Date (ARD) of 02/20/23 documented the resident scored a 12 (8-12 indicates Moderately Cognitively Impaired) on a Brief Interview for Mental Status (BIMS). Required set up only for eating. a. The Physician Order with a start date of 11/04/21 documented, General diet, Regular texture, thin liquids consistency. b. The Facility Mealtimes on 05/07/23 documented, 7:30 AM for breakfast, 12:30 PM for lunch, and 5:30 PM for dinner. c. On 05/07/23 at…
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 · Dcited before2023-05-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 and interview, the facility failed to clean the tube feeding pumps, poles, fall mat and floors for rooms #322, #326, #307, #312, which failed to provide a safe and homelike environment. The findings are: a. On 05/07/23 at 10:14 AM, in room [ROOM NUMBER], there was a pile of clothes and an adult brief with a brown substance lying on the floor. The bathroom floor had a black substance with footprints in it. b. On 05/07/23 at 10:25 AM, in room [ROOM NUMBER], there was a black substance on the bathroom floor. c. On 05/07/23 at 11:52 AM, in room [ROOM NUMBER], the tube feeding pump had a dried cream-colored substance on the stand and on the pole. d. On 05/07/23 at 12:11 PM, in room [ROOM NUMBER], the tube feeding pump and the pole had a dried cream-colored substance on them, and there were spatters on the fall pad on the floor. The resident's [family member] stated, Looks like it hasn't been cleaned. e. On 05/07/23 at 2:09 PM, in room [ROOM NUMBER], the tube feeding pump and the pole had a dried…
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 · D2023-05-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 devices were put in place in the hands to prevent further contracture and/or decline in Range of Motion (ROM), for 1 (Resident #33) of 4 (#24, #25, #33, and #72) sampled residents with contractures. The findings are: 1. Resident #33 had diagnoses of contractures of the right and the left hand. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/05/23 documented a Brief Interview of Mental Status of 00 (indicated severely cognitively impaired), was totally dependent in Activities of Daily Living skills with 1-2-person physical assist. a. The Physician's Order with a start date of 03/20/23 documented, Ensure rolled towels are in both hands each shift. b. On 05/08/23 at 11:17 AM, Resident #33 has a contracture on her right and left hand. She did not have a splint or rolled towels in either hand. c. On 05/10/23 at 7:50 AM, Resident #33 was sitting up in her bed and had rolled towels in both of her hands. d. On 05/10/23 at 12:57 PM, the Surveyor asked the Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-11 · 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 — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure that meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets and 10 residents who received mechanical soft diets from 1 of 1 kitchen, according to a list provided by the Dietary Supervisor on 05/09/23 The findings are: a. The menu for lunch documented that the residents who received pureed diets were to receive a #16 scoop (¼ cup) of pureed yellow cake and pureed bread. The menu also specified for each resident on the mechanical soft diets to receive ground pork cutlet and for each resident on the pureed diets to receive pureed pork cutlet, pureed yellow cake, and pureed bread. b. On 05/07/23 at 2:26 PM, the residents on the 300 Hall who required pureed diets were served pureed chicken, pureed cream corn and mashed potatoes. There was no pureed dessert and pureed bread served to the residents on pureed diets. c. On 05/07/23 at 2:28…
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
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.6 | -1.6 vs chain |
| Health inspection | 1 of 5 | 2.7 | -1.7 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 22 homes this chain runs (chain average 2.6★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PINE TREE HOLDING LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/05/2021 |
| MH AR OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/05/2021 |
| HERZKA, MATISYOHU | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/05/2021 |
| GRIFFIN, RICKY | Individual | W-2 MANAGING EMPLOYEE | — | since 04/05/2021 |
| SCHEINBAUM, SHLOMO | Individual | CORPORATE OFFICER | — | since 04/05/2021 |
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 74% 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 $607K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AR
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 045450. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, 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 →
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