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The Blossoms at Newport Rehab & Nursing Center

326 Lindley Lane, Newport, AR 72112 · For profit - Limited Liability company · 120 certified beds · (870) 523-6539 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuse1 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$21,823 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $21,823 in federal fines (most recent 2026-05-07)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (72%) 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.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
ARcare0.2 mi
2000 McLain St · (870) 523-2944 · Call to confirm hours
Pharmacy
Walgreens0.1 mi
2401 Malcolm Ave · (870) 217-0170 · Call to confirm hours
Grocery
Kroger0.3 mi
2200 Malcolm Ave · (870) 523-6741 · Call to confirm hours
Park
Wilkerson Dr · Typically dawn to dusk
Place of worship
205 Ray St · (870) 830-7316

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.7%9.5%15.4%better
Long-stay residents who lose too much weight3.8%4.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection1.9%1.2%2.0%typical
Long-stay residents with depressive symptoms0.0%1.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.5%3.9%3.3%worse
Long-stay residents whose ability to walk worsened10.5%10.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.4%21.7%18.9%worse
Long-stay residents given the seasonal flu vaccine93.6%96.1%95.3%typical
Long-stay residents with pressure ulcers5.3%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control14.1%13.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table26.5%10.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.8%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine76.8%77.7%79.4%typical
Short-stay residents rehospitalized after admission28.9%24.1%22.6%worse
Short-stay residents with an outpatient ER visit14.5%12.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.642.011.67worse
Long-stay outpatient ER visits per 1,000 resident days4.632.131.80worse

* 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.

37.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 104 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

37.8%U.S. median 51.5%
Got home and stayed home
12.8%U.S. median 10.7%
Went back to hospital
57.1%U.S. median 56.6%
Met the expected recovery
0.06U.S. median 0.31
Therapy hours / resident / day
0.03hours / resident / day
Physical therapy
0.02hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 57.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 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 0.06 therapist hours per resident per day in 2026Q1 — more than 3% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF37.8%CMS range 29.4–44.751.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.8%CMS range 9.4–17.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge57.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge60.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened6.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.7%CMS range 3.9–12.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.171.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.34
RN hours/ resident / day
1.11
LPN hours/ resident / day
2.26
Aide hours/ resident / day
3.70
Total nurse hours/ resident / day
0.24
RN hoursweekends
71.6%
Total nursing turnover
85.7%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 71.3 residents a day — about 59% occupied, or roughly 49 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 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 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 3.06 hrs/resident/day on weekends vs 3.96 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.38 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% 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

2
deficiencies at the latest standard inspection (2026-05-07)
10
at the previous standard inspection (2024-11-07)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · G2026-05-07 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 protect one (Resident #85) of two residents from physical abuse during a resident-to-resident altercation that occurred between Resident #85 and Resident #86 after the secured unit was left unsupervised by LPN #2 and CNA #5, staff who were assigned to the secured unit. The findings include: Resident #85 Review of an admission Record revealed the facility admitted Resident #85 on 03/28/2025 with diagnoses that included dementia, falls, panic disorders, heart conditions, anxiety, a pacemaker, a defibrillator, muscle weakness, lack of coordination, unsteadiness on feet, mild cognitive impairment, and insomnia. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/2025, revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #85 had…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2023-09-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a mechanical lift transfer of 1 (Resident #1), which resulted in a fall with the resident sent to the emergency room for evaluation of complaint of pain to touch of right hip. This failed practice had the potential to affect 12 residents who require a mechanical lift for transfers. The findings are: Review of Resident #1's comprehensive plan of care dated [DATE], showed the resident was a potential risk for falls, had contractures to bilateral hips and legs, was non ambulatory, and required a mechanical lift x 2 staff for all transfers with a bariatric lift #13 pad. Review of Resident #1 ' s nurses note dated [DATE] at 7:29 AM, showed the nurse was called into Resident #1's room by a Certified Nursing Assistant (CNA) who reported the resident fell and landed on the floor during a mechanical lift transfer. During post fall assessment, the resident complained 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review and facility policy review, it was determined that the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) and wore appropriate Personal Protective Equipment (PPE) to prevent the potential for cross contamination when providing direct, high contact care to a resident that had a feeding tube for one (Resident #34) of one resident reviewed for infection control. The findings include: Review of an admission Record revealed the facility admitted Resident #34 on 06/24/2025, with diagnoses that included cerebral palsy (a group of conditions that affect movement, balance and posture); lennox-gastaut syndrome (severe form of seizures), and dysphagia (difficulty or discomfort when swallowing). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 03/26/2026, revealed Resident #34 had a Brief Interview for Mental Status score of 0, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #34 had a feeding tube while a resident. Review of Resident #34's Care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-11-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff thoroughly washed their hands and changed gloves when contaminated and before handling food and clean equipment when contaminated; food items stored in the refrigerator, freezer and dry storage area were covered or sealed. expired food items and spices were promptly removed/discarded on or before the expiration or use by date; 1 of 1 ice machine and 1 of 1 scoop holder were maintained in a sanitary condition for 2 of 2 meals observed. The findings are: 1. On 11/4/24 at 9:57 AM, Dietary Aide (DA) #1 pulled her hair net down. Without washing her hands, DA #1 picked up clean plates and stacked them on the cart with her fingers inside of them. 2. On 11/4/24 at 9:59 AM, the ice machine in the kitchen had wet mixture of colors on the panel where ice touched before dropping into the ice collector. The Surveyor asked Dietary Manager if she could wipe the area in the ice machine that had wet mixture of colors on it. She did, and residue easily transferred to the tissue, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-07 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, facility document review, and facility policy review, it was determine the facility failed to ensure written information regarding the right to formulate an advanced directive was provided to residents or their responsible parties, to enable them to make informed decisions regarding which measures would be provided or withheld at end of life for 02 (Resident #62, #2) of 2 sample mix residents reviewed for Advance Directive. The findings are: Review of Resident #62's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of August 12, 2024, noted a score of 6 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and noted a diagnosis of paralysis (quadriplegia), traumatic brain injury, and post-traumatic stress disorder (PTSD). Review of Resident #62's electronic medical record contained a Physician Ordered Life Sustaining Treatment (POLST) form with advance directive selected that indicates it is available to review and signed on 5/9/24. No advance directive was located. Review of Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-07 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 2 (Resident #54, #72) of 2 sample mix residents reviewed for care plan. The Findings are: 1. During an interview with Resident #54 on 11/04/24 at 11:54 AM, the resident said I fell here in my room trying to use the urinal. My chair went out from under me, hit my head on the wall and ended up on my left side. My ribs are still sore. I got sent for x-rays. I've fallen twice and didn't have my brakes locked. Review of Resident #54's Care Plan with an initiated date of 2/5/2024 did not note an intervention for the residents fall on 9/27/2024. Review of Resident #54's Progress Notes dated 9/27/2024 at 1:35 PM, noted Resident #54 fell out wheelchair onto the floor and complained of head and left rib pain. Emergency Medical Services (EMS) were called. Review of Resident #54's Progress Notes dated 9/27/2024 at 1:46 PM, noted Resident #54 had a transfer/…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-07 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, facility document review, and facility policy review, it was determined the facility failed to ensure female residents had hair removed from their face for 1 (Resident #46) of 1 sample mix resident to promote good hygiene; ensure residents clothing was changed when stained or dirty for 2 (Resident #24, #52) of 2 sample mix residents to promote good hygiene; to ensure residents fingernails were kept clean and trimmed for 3 (Resident #2, #179, #52) of 3 sample mix residents to promote good hygiene. The findings are: 3. On 11/4/24 at 11:30 AM, the Surveyor observed Resident #2's fingernails untrimmed with a brown/ black substance underneath the nails. Review of Resident #2's admission Record with an admission date of 3/21/2016 revealed the resident has a need for assistance with personal care, Rheumatoid Polyneuropathy (simultaneous malfunction of many nerves throughout the body) with Rheumatoid Arthritis, and lack of coordination. Review of Resident #2's Care Plan with an initiated date of 7/6/2023 noted check the resident's fingernail…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-07 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations, and interviews, the facility failed to ensure that clean linen carts were properly covered and Enhanced Barrier Precautions (EBP), were implemented for 1 (Resident #279) of 1 sampled resident to prevent potential infection and/or the spread of infections. The findings are: During observation on 11/4/2024 at 10:18 AM, the clean linen carts had the front flap completely open on halls 100, 200, 300. 400, and 500. During observation on 11/5/2024 at 4:32 AM, the clean linen carts had the front flap completely open on halls 100, 200, 300, 400 and 500. 11/7/2024 at 3:24 PM, the Director of Nursing (DON) confirmed the clean linen carts should be covered because it is clean linen. Review of a facility policy provided by the (DON) titled Policy and Procedures with subject being Enhanced Barrier Precautions had a revised date of 03/12/2024, indicated that residents with indwelling medical devices such as a central line, catheter or feeding tube should be placed on EBP to prevent the spread of infections. The policy indicated staff should wear correct…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure residents were dressed appropriately for the day for 1 (Resident #179) of 1 sample mix residents. The findings are: On 11/4/2024 at 11:01 AM, Surveyor observed Resident #179 lying in bed in a hospital gown. Review of Resident #179's admission Record with an admission date of 10/18/2024 revealed the resident has a need for assistance with personal care. Review of Resident #179's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/2024 noted a score of 10 (8-12 indicates moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS) with a diagnosis of symptoms and signs involving the Musculoskeletal system, and revealed the resident requires partial assistance with dressing upper body and dependent for dressing the lower body. Review of Resident #179's Care plan with an initiated date of 10/25/2024 noted the resident requires partial assist to dress upper and lower body. On 11/5/2024 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 observation, interview, record review, and facility document review, it was determined the facility failed to ensure physician orders were in place for wound care treatment for 1(Resident #24) of 1 sample mix residents reviewed for pressure ulcer that was acquired within the facility. Findings include: A review of an admission Record noted Resident #24 was admitted to facility on 4/12/2024 with a diagnosis of Alzheimer's Disease (Disease that destroys memory and mental functions). Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/14/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 03, which indicates the Resident had severe cognitive impairment. Section M subsection M0300 part F revealed that there was one (1) unstageable pressure ulcer. Review of Resident 24's Care Plan, with an initiated date of 7/19/2024, revealed Resident #24 has an unstageable pressure ulcer to the coccyx (small triangular bone at lower back); unstable pressure injury coccyx with interventions that include:…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 ensure that nutritionally balanced meals were provided for the residents for 1 of 1 meal observed. The findings are. 1. On 11/04//2024, the menu for noon meal documented residents on pureed diets were to receive ¾ cup of pureed spaghetti. a. On 11/04/24 at 11:34 AM, DC #2 used a 4-ounce ladle spoon (1/2 cup) to place 4 servings of spaghetti with meat sauce into a blender and pureed, instead of ¾ cup. At 11:35 AM, DC #2 poured the pureed spaghetti into a pan, covered it with foil and placed it in the oven. 2. On 11/04/24 at 12:20 PM, DC #2 used a #10 scoop (1/3 cup) to serve a single portion of pureed spaghetti with meat sauce to the residents who required pureed diets, instead of ¾ cup. 3. On 11/04/24 at 12:50 PM, DC #2 when asked during an interview what spoon size she had used when portioning spaghetti with meat sauce into a blender to be pureed. DC #2 stated she used 4-ounce ladle spoon when putting it into a blender to puree 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, interview, and review of the facility policy, the facility failed to ensure 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 1 of 1 meal observed. The findings are: 1. On 11/04/24 at 11:34 AM, during the noon meal preparation. The DC #2 used a 4-ounce ladle spoon to place 4 servings of spaghetti with meat sauce into a blender and pureed. At 11:35 AM, DC #2 poured the pureed spaghetti into a pan, covered it with foil and placed in the oven. The consistency was chunky and was not smooth. There were chunks of noodle visible in the mixture. 2. On 11/04/24 at 12:20 PM, the following observations were made during the noon meal service in the kitchen. a. The residents on the pureed diets were served pureed spaghetti. The consistency was lumpy and was not smooth. There were pieces of noodles in the mixture. b. Pureed bread consistency was runny. c. At 12:47 PM, DA #1 confirmed the consistency of the pureed bread was runny because she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2024-11-07 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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, record review, and facility document review, it was determined that the facility failed to ensure proper assistive devices are utilized during meals for 1 (Resident #52) of 1 sample mix residents observed during meals who feed themselves. Findings include: During an observation on 11/4/2024 at 12:49 PM, Resident #52 was observed having difficulty with feeding self with regular fork. Using fingers of the resident's other hand to assist with food placement on utensil. A review of the admission Record noted Resident #52 was admitted to the facility on [DATE] with a diagnosis of Peripheral Vascular Disease (condition that affects blood flow to limbs. Resident also has diagnosis of Dementia (condition that affects brain function such as memory, judgement, and daily function), reduced mobility, muscle weakness, lack of coordination, Dysphagia (difficulty swallowing food), and abnormal posture. Review of Resident 52's Care Plan, initiated 4/9/2024, revealed the resident demonstrates…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure physicians orders were followed for follow up doctor's appointments and physician's orders for wound care for 1 (Resident #6) of 1 resident reviewed for discharge from hospital following surgery. Findings include: On 07/03/2024 at 5:21 PM, the DON (Director of Nursing) stated the facility did not have a policy for physician's orders. A review of the admission Record, indicated the facility admitted Resident #6 with diagnoses that included displaced bimalleolar fracture of left lower leg, other fracture of left lower leg, and repeated falls. A review of Resident #6's Care Plan revealed the resident was at risk for falls, and the resident returned with left lower leg splinted from orthopedic surgical repair of the left ankle. Interventions included encourage resident to use call light in bathroom for assistance related to a fall on 05/06/2024 this was initiated on 05/07/2024. A review of Patient…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-12-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to remove damaged canned goods from storage areas, and to maintain the kitchen can opener in a clean and sanitary manner. These failed practices had the potential to affect 77 residents who received meals from the kitchen. The findings are: On 12/05/2023 at 04:45 PM, the industrial can opener that was attached to the metal preparation table in the kitchen was encrusted with solid, dried substances. On 12/07/2023 at 10:31 AM, a tour of the kitchen pantry revealed: 1. One 6 pound 9 ounce can of sliced pears with a dent on the top of the can to include the seal. 2. Two 7 pound 5 ounce jellied cranberry sauce with dent on top of the can to include the seal. 3. One can of pork and beans indented on the side of the can. 4. Four 6 pound 10 ounce cans with dents on top of the cans to include the seal. On 12/07/2023 at 12:10 PM, the Dietary Manager confirmed there should not be any dents on the canned food and there should not be any debris on the can opener from previously opened cans to prevent contaminating the food…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-12-08 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure isolation precaution signs with instructions for personal protective equipment (PPE) (gown, mask etc.) needed when entering the room was placed on the door for 2 (Residents #29 and #340) and staff provided proper isolation procedures when dispensing ice for 1 (Resident #340) of 2 (Residents #29 and #340) sampled residents who were on isolation precautions. The findings are: 1. On 12/5/23 at 4:24 pm, observed on Resident #340's door a 'see nurse before entering' sign, and the door was open with 2 large red barrels by the door. There was no signage indicating the resident was on isolation or what personal protective equipment (gown, mask etc.) was needed when entering the room. a. On 12/6/23 at 8:20 am, observed no isolation signage on Resident #340's door. The door was open with 2 red barrels in front of door and a 'see nurse before entering' sign was on the door. b. On 12/6/23 at 2:06 pm, observed no isolation signage on Resident #340's door. The door was open with 2 red barrels in front of door and 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-12-08 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and record review, the facility failed to ensure an effective pest control program was in place to keep the kitchen area free of rodents. The findings are: On 12/05/2023 at 4:50 PM, the Surveyor witnessed a mouse run out of the rodent trap located under the dishwasher sink on the right-hand side by the wall. The mouse ran to the end of the leg of the dishwasher sink then turned around and entered back into the rodent trap. The mouse remained in the trap just beyond the opening. The facility pest control logs showed evidence of rodents being active within the facility beginning on 08/03/2023 as follows: 1. On 08/03/2023, a (Pest Control Company Name) Detailed Service Report noted a mouse glue board and bait was placed throughout the building. 2. On 08/15/2023, a (Pest Control Company Name) Detailed Service Report noted the company returned to the facility with one rodent captured outside the building. All rodent traps were cleaned and rebaited. 3. On 09/20/2023, the facility contacted (Pest Control Company Name) confirming there were mice in the kitchen area.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-08 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure 3 (Residents #22, #29, and #35) sampled residents had an Advance Directive readily available in their clinical record. The findings are: 1. Resident #22's diagnosis showed dementia without anxiety, behavioral, psychotic, or mood disturbance. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] showed the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) a. A Physician's Order dated [DATE] showed DNR (do not resuscitate). b. The Care Plan with an initiated date of [DATE] showed Resident #22 had requested that no cardiopulmonary resuscitation (CPR) measures are to be performed. Please follow my DNR instructions. Please follow my instructions as detailed inside my Advance Directives &/or Living Will if I have one. c. On [DATE] at 02:10 PM, the Surveyor requested the Advance Directive for Resident # 22. d. On [DATE] at 02:44 PM, the Admissions 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-08 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow care planned interventions for nail care for 1 (Resident #51) of 6 (Residents #12, #37, #43, #50, #51 and 78) sampled residents who had a diagnosis of Diabetes and required assistance with nail care. The findings are: Resident #51 had diagnoses of traumatic brain injury, type 2 diabetes without complications, and need for assistance with personal care. On 12/05/2023 at 04:20 PM, Resident #51 was lying in bed. Contractures were noted in both hands. The fingernails on both hands extended 3/8 inch beyond the tips of the fingers and had jagged edges. The fingernails were pressing into the resident's palms. On 12/06/2023 at 08:06 AM, Resident #51 was lying in bed with contractures noted in both hands. The fingernails on both hands extended 3/8 inch beyond the tips of the fingers and had jagged edges. The fingernails were pressing into the resident's palms. On 12/07/2023 at 11:47 AM, Resident #51 was lying in bed with contractures noted in both hands. The fingernails on both hands extended 3/8 inch beyond…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure the environment was free of potential accident hazards as evidenced by failure to ensure a curling iron was not plugged in for 1 (Resident #20) sampled resident who was independently ambulatory on the 200 Hall; and mouthwash and razors were not left in the bathroom for 1 (Resident #37) sampled resident who was independently ambulatory on the secured unit as documented on a list provided by the Administrator on 12/7/23 at 2:17 PM; and oxygen signage was placed on the door for 5 (Residents #28, #42, #44, #50 and #339) sampled residents who received oxygen as documented by a list provided by the Administrator on 12/7/23 at 4:45 PM. The findings are: 1. On 12/5/23 at 3:08 PM, observed a curling iron by Resident #20's bedside plugged in and turned on. a. On 12/5/23 at 5:46 PM, observed a curling iron by Resident #20's bedside plugged in and turned on. b. On 12/6/23 at 3:51 PM, observed a curling iron by Resident #20's bedside plugged in and turned on. c. On 12/7/23 at 10:55 AM, during an interview the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-08 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow care planned interventions to elevate the head of bed when administering medications and enteral nutrition for to one (Resident #51) of three (Residents #29, 51, 79) sampled residents with percutaneous endoscopic gastrostomy (PEG) tubes. The findings are: On 12/05/2023 at 04:20 PM, Resident #51 was lying in bed with a PEG tube in place. The PEG tube was connected to an infusion pump set to administer 55 cubic centimeters (cc) per hour. The head of Resident #51's bed was positioned at 15 degrees from horizontal. On 12/06/2023 at 08:06 AM, Resident #51 was lying in bed with a PEG tube in place. The PEG tube was connected to an infusion pump set to administer 55 cc per hour. The head of Resident #51's bed was positioned at 19 degrees from horizontal. On 12/06/2023 11:47 AM, Resident #51 was observed lying in bed with the head of the bed at 9 degrees from horizontal. [NAME] foam and bubbles were flowing from Resident #51's mouth. On 12/06/2023 at 11:49 AM, the Director of Nursing (DON) was asked 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician for 1 (Resident #44); a physician's order was obtained to administer oxygen for 1 (Resident #42) to minimize the potential for hypoxia or other respiratory complications; and oxygen tubing was dated and contained for 1 (Resident #44) of 5 (Residents #28, #42, #44, #50 and #339) sampled residents who received oxygen. The findings are: 1. Resident #44 had a diagnosis of chronic obstructive pulmonary disease (COPD) and heart failure. The Medicare Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/23 showed a Brief Interview for Mental Status (BIMS) of 11 (8-12 indicates moderately cognitively intact) and did not receive oxygen therapy. a. The Physician's Order Summary showed Resident #44 was to receive oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath or increased anxiety causing shortness of breath. b. The Care Plan with an initiated date of 05/10/23 showed Resident #44 is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-08 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to follow a physician's order for 1 (Resident #12) of 5 (Residents #4, #37, #51, #65 and #79) sampled residents who required a routine Hemoglobin A1C (a blood test that shows what your average blood sugar (glucose) level was over the past two to three months) laboratory draw. The findings are: Resident #12 diagnosis showed Type 2 Diabetes Mellitus. 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 9 (8 to 12 suggests moderate cognitive impairment) and had received insulin injections 7 days of the 7 day lookback period. Review of the Physician Order with a start date of 8/25/2022 showed an order for Lispro Insulin (a fast-acting insulin) based on a sliding scale before meals and at bedtime. The physician is to be notified for a blood sugar below 60 or above 500. Review of a Physicians Order with an order date of 7/12/2022 showed an order for a Hemoglobin A1C (HBa1c) lab draw to be completed every 12 months starting 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-08 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. This failed practice had the potential to affect 4 residents who received pureed diets as documented on a list provided by the Director of Nursing Supervisor on 12/7/2023 at 3:35 PM. The findings are: On 12/07/2023 at 10:45 AM, Dietary Employee (DE) #1 pureed beef goulash in the kitchen's blender before transferring it into a pan. The consistency of the pureed beef goulash was lumpy and not smooth. There were pieces of meat visible in the mixture. On 12/07/2023 at 12:10 PM, the Dietary Manager confirmed there should not be any lumps in the pureed food. On 12/08/2023 at 09:40 PM, DE #1 confirmed there should not be any lumps in the pureed food and that the consistency should be smooth like a pudding. A policy provided by the Nurse Consultant on 12/07/2023 at 03:45 PM titled, Texture and Consistency-Modified Diets…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-08 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to ensure an indwelling catheter drainage bag was concealed in a privacy bag when visible to promote dignity and privacy for 1 (Resident #29) of 4 (Residents #29, #41, #50 and #340) sampled residents who had an indwelling catheter. The findings are: Resident #29's diagnosis showed neuromuscular dysfunction of the bladder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/21/23 documented the resident was severely impaired and had an indwelling catheter. The Care Plan with an initiated date of 08/30/23 documented Resident #29 required an indwelling catheter and was to be provided a catheter privacy bag. The Physicians Order Summary noted Resident #29 was to have an indwelling catheter. On 12/05/23 at 02:46 PM, the Surveyor observed a catheter bag hanging on the bottom of a geri chair (a specialized seating solution for seniors and individuals with limited mobility), not contained within a dignity bag. On 12/05/23 at 6:14 PM, the Surveyor observed Resident #29 lying in bed with the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure the urinary catheter tubing was secured to prevent potential trauma for 1 (Resident #340) of 4 (Residents #29, #41, #50 and #340) sampled residents who had an indwelling urinary catheter. The findings are: 1. On 12/06/23 at 08:20 am, observed Resident #340 did not have any security device to hold the catheter tubing in place to prevent the tubing from pulling. 2. On 12/7/23 at 11:17 am, during an interview the Surveyor asked Licensed Practical Nurse (LPN) #1 how should a catheter be secured. LPN #1 said by a leg strap or stat lock. The Surveyor asked who was responsible for making sure an indwelling catheter security device was on the resident. LPN #1 confirmed the nurse is. 3. On 12/7/23 at 11:23 am, during an interview the Surveyor asked the Director of Nursing (DON) how a catheter should be secured. The DON confirmed by using a catheter strap or stat lock. The Surveyor asked who was responsible for making sure a resident with an indwelling catheter had this in place. The DON confirmed the nursing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-08 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to ensure the call light was accessible to 1 (Resident #22) of 18 (Residents #4, #12, #20, #22, #28, #29, #32, #35, #37, #42, #43, #44, #50, #52, #65, #79, #339 and #340) sampled residents who used a call light. The findings are: Resident #22's diagnoses showed dementia, muscle weakness, abnormalities of gait and mobility. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/10/2023 showed a Brief Interview for Mental Status (BIMS) of 0 (0 to 7 suggests severe cognitive impairment). Resident is an extensive assistance from staff with all activities of daily living. The Care Plan with an initiated date of 01/07/2017 showed the resident was at potential risk for falls related to unsteady gait, weakness, dementia, and poor safety awareness. The staff are to ensure the call light is always within reach and answered promptly. On 12/06/23 at 08:21 AM, observed Resident #22 sitting up in a wheelchair beside the bed with the call light lying across the bed out of reach of the resident. 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.

    Environmental Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$21,823 in federal fines across 2 penalties.

  • $14,380 — penalty dated 2026-05-07
  • $7,443 — penalty dated 2023-09-28

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.

Part of a chain

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

RatingThis homeChain avg
Overall 2 of 52.6-0.6 vs chain
Health inspection 2 of 52.7-0.7 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 2 of 53.0-1.0 vs chain
The other 22 homes this chain runs (chain average 2.6★, per CMS)
1 of 5The Blossoms At Conway Rehab & Nursing CenterConway, AR 1 of 5The Blossoms At Eureka Springs Rehab & Nursing CenEureka Springs, AR 1 of 5The Blossoms At Fort Smith Rehab & Nursing CenterFort Smith, AR 1 of 5The Blossoms At Midtown Rehab & Nursing CenterLittle Rock, AR 1 of 5The Blossoms At Van Buren Rehab And Nursing CenterVan Buren, AR 1 of 5The Blossoms at Berryville Rehab & Nursing CenterBerryville, AR 1 of 5The Blossoms at Cumberland Rehab & Nursing CenterLittle Rock, AR 1 of 5The Blossoms at Woodland Hills Rehab & Nursing CenLittle Rock, AR 2 of 5The Blossoms At Oakdale Rehab & Nursing CenterJudsonia, AR 2 of 5The Blossoms At West Dixon Rehab & Nursing CenterLittle Rock, AR 2 of 5The Blossoms At White River Rehab & Nursing CenterNewport, AR 2 of 5The Blossoms at White Hall Rehab & Nursing CenterWhite Hall, AR 3 of 5The Blossoms At North Little Rock Rehab & NursingNorth Little Rock, AR 3 of 5The Blossoms At Star City Rehab & Nursing CenterStar City, AR 3 of 5The Blossoms at Nashville Rehab and Nursing CenterNashville, AR 3 of 5The Blossoms at the Village Rehab & Nursing CenterHot Springs, AR 4 of 5The Blossoms At Mountain View Rehab & Nursing CenMountain View, AR 5 of 5The Blossoms At Hot Springs Rehab And Nursing CentHot Springs, AR 5 of 5The Blossoms At Prescott Rehab & Nursing CenterPrescott, AR 5 of 5The Blossoms At Rogers Rehab & Nursing CenterRogers, AR 5 of 5The Blossoms At Stamps Rehab & Nursing CenterStamps, AR 5 of 5The Blossoms at Dierks Rehab and Nursing CenterDierks, AR

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

Who owns this facility

Owner / managerTypeRoleShareSince
PINE TREE HOLDING LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/05/2021
MH AR OPCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2023
HERZKA, MATISYOHUIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2023
DOWNEY, MACKIndividualW-2 MANAGING EMPLOYEEsince 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.

$9.6M
Net patient revenuemost recent cost report
+13.2%
Operating marginrevenue minus expenses
$481K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 10%Other / private 17%

About 72% 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 $481K 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

$272per resident / day
operating cost
$8,276per month
≈ monthly operating cost
$314per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in AR

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arkansas Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045334. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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