The Blossoms At Star City Rehab & Nursing Center
702 N Drew St, Star City, AR 71667 · For profit - Limited Liability company · 95 certified beds · (870) 628-4144 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- 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 a citation for mishandling residents’ money or property (F0570)
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- about 23% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 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 improved from 1 to 3 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 | 7.0% | 9.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.8% | 4.3% | 5.4% | worse |
| 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 | 1.7% | 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 | 3.9% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.8% | 10.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.5% | 21.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.3% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 8.9% | 13.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.8% | 10.9% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 53.1% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.8% | 24.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.8% | 12.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.32 | 2.01 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.29 | 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.
39.5% 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 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 45.2% 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 31 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 0.07 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 5% 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
| 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 | 39.5%CMS range 28.6–55.6 | 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 | 13.3%CMS range 9.5–17.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 45.2% | 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 | 29.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 41.9% | 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 | 98.2% | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 3.8–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 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 95 beds and averages 79.5 residents a day — about 84% occupied, or roughly 16 beds typically open. It usually has some room. 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 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.35 on weekdays — 9% thinner on weekends. RN hours go from 0.22 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as 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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · E2025-01-30 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure privacy and dignity was provided for 1 ( Resident #28) of 2 sampled residents reviewed for privacy and dignity. The findings are: A review of a facility policy titled, Resident Rights, dated 01/01/2024, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents ' right to: a. a dignified existence. b. be treated with respect, kindness, and dignity . A review of the admission Record indicated the facility admitted Resident #28 with diagnoses that included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, Asperger's syndrome, and bipolar disorder, current episode mixed, severe, with psychotic features. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A review of Resident #28's care plan…
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 · E2025-01-30 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 observations, interviews, and record reviews, the facility failed to accurately complete the care plan to address bipolar disorder and post-traumatic stress disorder (PTSD) (Resident #13) and contractures (Resident #44) for two (Resident #13 and Resident #44) of 23 sampled resident who were reviewed for care plan accuracy. The findings are: 1. Resident #13's Order Summary Report was reviewed and indicated diagnoses of a mental health condition caused by a traumatic event affecting one's ability to function daily (post-traumatic stress disorder) and a mental disorder characterized by periods of depression and periods of abnormal moods (bipolar disorder). [Antipsychotic medication name] 25 milligrams (mg) give 1 table by mouth at bedtime for post-traumatic stress disorder (PTSD) and [antipsychotic medication name] 2.5 mg give 1 tablet by mouth two times a day for bipolar disorder was ordered. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/2024 was reviewed and revealed Resident #13 had a Brief Interview for Mental Status (BIMS) of 7, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure smoking paraphernalia was not stored in the resident rooms and failed to ensure residents with vape devices were assessed for safe usage for 2 (Residents #24 and #176) of 2 sampled residents reviewed for smoking. The findings are: On 01/27/2025 at 2:34 PM, Resident #24 was sitting up on the side of the bed awake and there was a small device on the overbed table. The resident was interviewed and when asked about the device, the resident picked up the device, placed it in the resident's mouth, inhaled and blew white smoke from the resident's mouth. The resident stated once the vape device was empty, it was refilled. The resident opened the top drawer on the nightstand and removed a glass bottle. The label on the bottle indicated the contents were a flavored liquid for vaping and contained nicotine. Resident #24's care plan, dated 01/16/2025, was reviewed and indicated the resident was a smoker and tobacco user and vaped and to instruct the resident about the facility policy 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 · E2025-01-30 · 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, record review, and facility policy review, the facility failed to ensure a glucometer was disinfected per disinfectant wipe directions for one of one glucometer disinfecting observed; failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by leaving a clean linen cart uncovered and placing used hangers with clean clothes on linen cart; failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by failure to keep dirty briefs and linen off of the floor in Resident #28 ' s room and failure to contain items during transport through the hallway. The findings are: 1. On 01/29/25 11:28 AM, Licensed Practical Nurse (LPN) #1 was observed walking up the North Hall with a glucometer in her hand, she unlocked her medication cart, removed a disinfectant wipe from the bottom drawer of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-28 · 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
Based on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure wound measurements were completed and wound care was documented for 1 (Resident #6) of 3 residents reviewed for skin issues. Findings include: A review of a facility policy titled, Wound and Pressure Ulcer Management Policy, revised on 01/01/2024, indicated, .Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. The goal is one of promoting healing and minimizing infection unless a resident's preferences and medical condition necessitate palliative care as primary focus .1. A system for pressure injury assessment and documentation with each dressing change or at least weekly is established 2. Comprehensive wound assessment includes the following parameters (at a minimum): . b. length, width, depth measurements recorded in centimeters. C. direction and length of tunneling and undermining. D. appearance of the wound base. E. Type and percentage of tissue in wound. F. Drainage amount 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 · Dcited before2024-06-14 · 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, interview, and record review, it was determined the facility failed to ensure interventions were consistently implemented to prevent further harm or injury to a resident who had a previous fall with a major injury for 1 (Resident #3) of 3 (Residents #1, #2 and #3) residents who were reviewed for falls. The findings are: A review of the Order Summary indicated the facility admitted Resident #3 with diagnoses of dementia and muscle wasting and atrophy. The 5-day Medicare Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/2024 indicated Resident #3 had a Brief Interview of Mental Status (BIMS) score of 3 (0-7 indicates severe cognitive impairment). Review of Resident #3's Care Plan, revised 04/22/2024, revealed the resident was at risk for falls and had an actual fall on 03/10/2024 and was to have non-skid strips to the bedside and a fall mat bedside the bed. A Nsg (nursing) I&A (incident and accident) note, dated 03/10/2024, indicated Resident #3 was sitting on the floor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-05 · 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 and interview, the facility failed to ensure foods stored in the refrigerator, freezer and storage areas were sealed and dated, storage shelves were free of paint peelings, door frames, pillars, and floor tiles in the kitchen were intact to allow for thorough cleaning/disinfecting, kitchen and storage room floors were free of rust and wax build-up; the ice scoop holder was maintained in clean and sanitary condition; dietary staff washed their hands before handling clean equipment or food to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; cold foods were maintained at or below 41 degrees Fahrenheit. The failed practices had the potential to affect 86 residents who received meals from the kitchen. The findings are: 1. On 01/02/24 at 9:31 AM, the following observations were made in the kitchen area. a. An opened bag of classic coffee bag was on counter by the coffee maker. The bag was not sealed. Exposing it to air and potential cross contamination. b. The floor throughout the kitchen was stained. The door frames leading…
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 · E2024-01-05 · tag F0570 — patternAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure a Surety Bond was purchased, or there was an alternate means of assuring the security of all personal funds deposited in the Trust Fund Account managed by the facility, to prevent the financial loss for 75 residents who have individual Trust Fund Accounts. The findings are: a. On 01/03/24 at 3:18 PM, a review of [Named Facility] Trust - Current Account Balance of $32,218.21 as of 01/03/24. b. On 01/03/24 at 3:20 PM, a Surety Bond provided by [Surety Company Name] documented an amount of $30,000 this bond shall be effective beginning on the 1st day of June, 2023 and shall be deemed a part of the original bond, does not create a new obligation, and is executed upon the express condition and provision that the Surety's liability under the above-referenced bond, along with all Continuation Certificates issued in connection therewith, shall not be cumulative and that the Surety's aggregate liability under the bond on account of all defaults committed during the period(s) the bond has been and shall be in force, shall not…
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 before2024-01-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews and record reviews, the facility failed to ensure that hazardous chemicals were secured in a closed locked room from wondering residents. This failed practice had the potential to affect 2 sampled Residents #49, and #51 with the potential to affect 10 Residents who wonder. The facility also failed to ensure that Resident #238 ' s environment was free from accident and hazards by making sure lift pad/sling was free of fraying to prevent accidents. This failed practice had the potential to a affect 1 Resident (238) requiring mechanical lift transfer with the potential to affect 7 sampled Residents requiring lift assistants. The findings are: 1. a. On 1/2/24 at 1:25 PM, Surveyor observed Housekeeping Staff #1 exit room with bed pan and oxygen signs on door, but the door did not fully close. There was a key hanging on a string just outside the door. b. On 1/2/24 at 1:27 PM, Surveyor observed Maintenance Staff grab the key to enter room. Surveyor stopped Maintenance Staff prior to putting key into doorknob and asked him to push the door. c. On 1/2/24 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 · E2024-01-05 · 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 that meals were prepared and served according to the planned written menu and recipe 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 23 residents from 1 of 1 kitchen. The findings are: 1. The menu for the 01/02/2024 noon meal documented a #6 dip (6 ounces) for pureed sandwich. a. On 01/02/24 at 12:30 PM, the Dietary Supervisor #2 used a 4-ounce spoon to serve a single portion of pureed cold ham/turkey sandwich for the residents on pureed diets a difference of 2 ounces. b. On 01/02/24 at 2:24 PM, the surveyor asked Dietary Supervisor #2 what spoon serve she had used to serve pureed sandwich and how many servings she gave to each resident. She stated, I used a -4-ounce spoon and gave a serving each. 2. The facility recipe for fortified sweetened oatmeal provided by the Dietary Supervisor on 01/03/24 at 8:39 AM documented, for 10 servings used 4 cups of water, one cup of non-fat dry milk, ½…
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 13 citations
- Potential for harm · E2024-01-05 · 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 meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 2 meals observed. The failed practices had the potential to affect 21 residents who received their meal trays their rooms on 500 Hall, 10 residents who received meals in their rooms on [NAME] Hall 7 residents who received meals in their rooms on North Hall. The findings are: 1. Resident #68 with a diagnosis of paraplegia (paralysis of all or part of your trunk, legs, and pelvic), hypokalemia, and vitamin D deficiency. The quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 12/19/2023 indicates a Brief Interview Mental Status [BIMS] score of 15 (13 to 15 suggest cognition is intact). Resident #68 requires set up assistance for meals and oral hygiene, and is dependent for dressing, transfers, toileting, and personal hygiene. a. A Physicians Order dated 09/14/2023 documented . Regular diet, regular texture and regular consistency . b. 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 · E2024-01-05 · 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 7 residents who received pureed diets and 2 residents who received pureed meat only. The findings are: 1. On 01/02/24 at 12:12 PM, Dietary Employee (DE) #1 used a regular spoon to put 6 servings of cream corn into a blender, added whole milk and pureed. At 12:14 PM, DE #1 poured the pureed cream of corn, into a pan and placed it on the steam table to be served to the residents on pureed diets for lunch. The consistency of the pureed cream corn was runny and not formed. 2. On 01/02/24 at 7:15 AM, the following food items were served to the residents on pureed diets. a. Pureed ham served to the residents pureed diets was gritty and not smooth. b. Pureed oatmeal served to the residents on pureed diets was runny and was not formed. At 8:21 AM, the surveyor asked the Dietary…
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 · D2024-01-05 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 ensure that Resident #66 received privacy during incontinence care. The Findings are: 1. Resident #66 had a diagnosis of Alzheimer's Disease and according to Annual Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 11/8/23 the resident scored 01 (0-7 indicates severe impairment) on the Brief Interview Mental Status (BIMS) and was always incontinent of bowel and bladder. a. On 01/02/24 at 1:35 PM, Surveyor observed Certified Nursing Assistant #1 and #2 providing incontinence care with the privacy curtain partially pulled. b. On 01/02/24 at 1:45 PM, Surveyor asked CNA #1 If someone entered the room right now with the curtain partially pulled what would they see? CNA #1 stated Her being changed. c. On 01/02/24 at 2:15 PM, Surveyor asked Director of Nursing (DON) if a Resident is receiving incontinence care with the curtain pulled only between the Resident but not all the way around to the door what would someone entering the room see immediately upon entering the room? The DON stated they are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-05 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 Minimum Data Set [MDS] assessment accurately reflected a level II Preadmission Screening and Resident Review [PASARR] evaluation with recommendations to facilitate the ability to plan, coordinate and provide necessary care for 1(Resident #52) of 16 residents who have a level II PASRR. The findings are: 1. Resident #52 with a diagnosis of intracranial injury with loss of consciousness of duration, Epilepsy, and seizures and Schizoaffective disorder. The significant change minimum data set [MDS] with an assessment reference date [ARD] of 09/04/2023 indicated a brief interview for mental status [BIMS] score of 09 (8-12 suggest moderately impaired). a. A care plan with a (Revision, 10/11/2023) documented .state designated authority has approved admittance to facility see approval packet . monitor and document behaviors. b. On 01/02/2024 at 08:01 PM, the Surveyor observed a Level II PASARR evaluation for Resident #52 with serious mental illness, dated 03/18/2022. c. 01/04/24 10:00 AM, MDS nurse #1 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 · D2024-01-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure person centered nail care was provided to promote good hygiene and reduce the risk for infection in 1 (Resident #4) of 8 sampled residents on 500 hall requiring fingernail care assistance. The findings are: a. Resident #4 has an activity of daily living [ADL] self-care performance deficit . The resident requires assistance from staff with showering 3 x/week and as necessary . The resident requires assistance by staff with personal hygiene and oral care . b. On 01/02/24 at 10:08 AM, the Surveyor observed Resident #4's fingernails are long and has very faded red nail polish. The Surveyor asked Resident #4 what she thinks about her nails. Resident #4 said she would like to have her nails cut, and said her polish is almost gone. The Surveyor asked who normally takes care of Resident #4's fingernails and Resident #4 said, The nurse. c. On 01/02/24 at 3:21 PM, the Surveyor observed Resident #4 coloring at the bedside, with long fingernails and small patches of red nail polish. d. On 01/03/24 at 9:38 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 observations, interviews and record review, the facility failed to ensure that Resident #66 received proper incontinence care. This failed practice had the potential to cause skin breakdown, poor hygiene, and/or infection. The Findings are: 1. Resident #66 had a diagnosis of Alzheimer's Disease and according to Annual Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 11/8/23 the resident scored 01 (0-7 indicates severe impairment) on the Brief Interview Mental Status (BIMS) and was always incontinent of bowel and bladder. a. On 01/02/24 at 1:30 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 and #2 transferring Resident #66 from chair to bed via lift. Surveyor observed incontinence brief lying in the bed and CNA #1 and #2 placed Resident #66 and lift pad on top of the clean brief. CNA #1 and #2 rolled Resident #66 from side to side, removed lift pad with incontinence brief, and pulled brief that was under Resident in place. Surveyor observed blue line on incontinence brief that indicate that Resident #66 was incontinent of bladder prior to CNA…
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 · D2024-01-05 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 ensure tube feedings were turned off by nursing when residents were laid flat for personal care or dressing changes to prevent the risk for aspiration for 1 (Resident #3) of 2 residents receiving tube feedings. The findings are: 1. Resident #3 with a diagnosis of Dysphagia, Pressure Ulcer of Sacral Region, Stage 4, and Type 2 Diabetes Mellitus. The quarterly Minimum Data Set [MDS] with an assessment reference date [ARD] of 12/28/23, indicates a Brief Interview of Mental Status [BIMS] of 3 (0-7 suggest severe cognitive impairment). Resident #3 is dependent for toileting, bathing, and dressing, and requires maximal assistance for eating and personal hygiene. a. A Physicians order dated 10/23/2023 documented, .two times a day related to DYSPHAGIA, UNSPECIFIED Diabetasource 1.2 at 85 cc [cubic centimeter] per hour continuous - H20 [water] at 145 every 4 hours continuous. b. On 01/03/24 at 11:45 AM, the Surveyor accompanied Licensed Practical Nurse [LPN] #1 to room Resident #3 ' s room to observe a dressing change.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-20 · 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
Based on observations, interview and record review, the facility failed to complete nail care for 3 (Residents #4, #5 and #6) of 6 (Residents #1, #2, #3, #4, #5 and #6) sampled residents who required assistance of staff with activities of daily living (ADL). The findings are: 1. Resident #4 had a diagnosis of Glaucoma. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/2023 documented a Brief Interview for Mental Status (BIMS) of 13 (13-15 indicates cognitively intact) and required assistance with ADLs. a. On 11/20/2023 at 9:45 AM, Resident #4 was in bed. The fingernails on both hands were ¼ inch past the tips of her fingers, with chipped polish and had a dark brown substance under the nails. The Surveyor asked the resident if they liked their nails long. Resident #4 replied no not really but they (staff) are going to give me a shower in just a little bit. b. The Care Plan with an initiated date of 10/06/2023 documented, .The resident has an ADL self-care performance deficit . The resident requires assistance by staff with personal hygiene . Avoid…
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 · D2023-10-26 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 complete a baseline care plan within 48 hours of admission for one (Resident #5) of 6 (Residents #1, #2, #3, #4, #5 and #6) sampled residents. The findings are: 1. Resident #5 was admitted to the facility on [DATE]. Review of the Physicians Orders for 10/19/23 to 10/26/23 noted Resident #5 had diagnoses to include: hypertension, cardiac pacemaker, arthritis, macular degeneration, disorientation, depression, cognitive communication deficit, anxiety disorder, legal blindness, unsteadiness on feet, asthma, fracture of left radius, unspecified fall, atrial fibrillation, and acute kidney failure. On 10/26/2023 at 10:11 AM, review of Resident #5's admission assessment dated [DATE] at 2:32 PM, noted Resident #5 was totally dependent or required assistant with activities of daily living and was at risk to wander. The Baseline Care Plan with an effective date of 10/19/23 at 2:31 PM had Resident #5 diagnosis, but no other information documented. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-27 · 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
Based on observation, record review, and interview, the facility failed to ensure that there were no brown stained ceiling tiles, a hole in one ceiling tile in resident room West-6, and failed to ensure that the paint was not scuffed off on the wall behind the head of the bed, and side wall, and failed to ensure that a ceiling tile was securely attached for 1 (Resident #32) of 17 finalized sampled residents (#2, #4, #5, #19, #23, #24, #25, #26, #31, #32, #33, #36, #38, #42, #44, #45, #46). This failed practice had the potential to affect 48 residents residing in the facility. The findings are: a. On 10/24/22 at 12:09 PM, during a tour of (room number). There were 2 circular brown spots on the ceiling tile in the room, and a hole in the corner of the ceiling tile on the B side of the room. This room was occupied by 2 Residents. b. On 10/24/22 at 01:17 PM, in (named room number) there is a moderate amount of scuffed paint on the wall on the opposite side of the room, scuffed paint areas at the head of the bed, on the wall around the side of the resident's bed, and the side of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-27 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to review and revise the care plan to reflect the focus, goals, and interventions for 1 (Resident #38) of 1 sampled residents that had been admitted to hospice services, for 1 (Resident #36) of the 8 (#1, #2, #5, #24, #31, #36, #41, #46) sampled residents that had a diagnosis of Schizoaffective Disorder, and for 1 (Resident #44) of 10 (#1, #2 , #5, #24, #31, #32, #36, #41, #44, #46) sampled residents who had an Antipsychotic Prescribed. 1. Resident #38 had diagnoses of Type 2 Diabetes Mellitus without Complications, Hypothyroidism, Unspecified Atrial Fibrillation, Metabolic Encephalopathy, Dysphagia. The Significate Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/1/22 documented a Brief Interview for Mental Status (BIMS) of 3 (0-7 indicates severely impaired). a. On 10/1/22 Resident #38 was admitted to hospice services and a Significant Change completed. The Person-Centered Care Plan, reviewed on 10/26/22, was not revised or updated to reflect the residents change of condition. 2.…
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 · E2022-10-27 · tag F0744 — failed to care for residents with dementia — patternProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 Develop and implement Person-Centered Care Plans that included and support the dementia care needs of a resident with a Dementia diagnosis for 1 (Resident #44) of 2 (Resident #38 and Resident #44) sampled residents. This failed practice had the potential to affect 6 resident's that had diagnoses of Dementia and resided in the facility per a list provided by the Administrator on 10/26/22 at 3:30pm. The findings are: Resident #44 had diagnoses Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/5/22 documented the resident scored 7 (0-7 indicates Severe Impairment on a Brief Interview for Mental Status (BIMS), required extensive assist of two person with toileting, and bed mobility and totally dependent with 2 persons for transfers. a. On 10/25/22 at 1:27pm, a review of the resident's Electronic Health Record (EHR) documented diagnoses of .Unspecified…
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 · D2022-10-27 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a written discharge summary was completed that included a recapitulation of the resident's stay that consisted of a concise summary of the stay, course of treatment for 1 (Resident #50) of 1 sampled residents who was discharged in the past 90 days. 1. Resident #50 had diagnoses of Unspecified Dementia with Behavioral Disturbance, Muscle weakness (generalized), Essential Primary Hypertension, Paroxysmal Atrial Fibrillation. The Significate Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/22 documented a Brief Interview for Mental Status (BIMS) of 2 (0-7 Indicates Severely Impaired.) a. On 10/26/22 at 10:32 a.m., the Discharge Return Anticipated MDS with an ARD of 09/07/22 documented Resident #50 was discharged to another nursing home or swing bed. b. On 10/26/22 at 10:32 a.m., a Nursing Note dated 09/12/22 documented, went to another NH (Nursing Home) after hospital . c. On 10/26/22 at 11:02 a.m., the Nursing (Nsg)-Discharge Location and Status dated 09/07/2022 documented, Hospital for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 | 3 of 5 | 2.6 | +0.4 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 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 |
|---|---|---|---|---|
| SOUTHWIND OPCO HOLDING LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 08/01/2024 |
| AKS AR OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2024 |
| MH AR OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2024 |
| HERZKA, MATISYOHU | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2024 |
| SCHREIBER, ABRAHAM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2024 |
| MOSS, JANE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2024 |
| HARRIS, JOHN | Individual | ADP OF THE SNF | — | since 08/01/2024 |
CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AR
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arkansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 045269. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-30, 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.