Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Blossoms At Cumberland Rehab & Nursing Center during CMS and state inspections, most recent first.
A resident with mental health diagnoses, intellectual disabilities, and a TBI became agitated over smoking and exchanged racial slurs with a CNA. Staff accounts described the CNA confronting the resident, the resident placing the CNA in a headlock, and the CNA striking the resident in the head with a cup multiple times during the struggle. The resident sustained a head laceration requiring staples, and the facility substantiated abuse by the CNA.
Failure to provide written bed hold notification for two residents transferred to the hospital. One resident had vascular dementia, schizoaffective disorder, and anxiety disorder, and the other had adjustment disorder, MS, type II DM, and schizoaffective disorder; both had BIMS scores of 15. Records showed ER transfers and return-anticipated/discharge documentation, but no written bed hold notices were found. Staff confirmed no bed holds were completed, despite the facility policy requiring written information to residents or their representatives before transfer.
A resident with bipolar disorder, intellectual disabilities, traumatic brain injury, and other mental health diagnoses was inappropriately discharged without a provider discharge order. After a physical altercation with a CNA and a same-day hospital return, records showed no further aggressive behaviors, no grievances, and notes describing the resident as pleasant and happy living in the facility. Although family had discussed a possible transfer closer to them, the resident was later sent to a behavioral health hospital and the family believed the resident had been discharged there instead of transferred as discussed.
Failure to carry out ordered blood glucose monitoring: A resident with type 2 DM, hypoglycemia, and severe cognitive impairment had an MD order for AM blood glucose checks with notification if results were above 250, but the order did not appear on the June MAR. An LPN stated orders were entered into the electronic record and should flow to the MAR, while the DON confirmed the order was in the order summary but not on the MAR and stated staff were expected to enter orders correctly and ensure they were carried out.
A resident with COPD, depression, AFib, PE, allergic rhinitis, and oxygen use reported that housekeeping spray outside the room was worsening breathing, and a towel was placed under the door to block fumes. Surveyors observed a heavy chemical smell in the hallway, and staff described using a stronger pink cleaner in resident areas despite knowing the resident had breathing issues. The resident’s care plan did not address the impact of cleaning products on breathing or anxiety.
Two residents with moderate cognitive impairment and independent mobility were repeatedly seeking each other’s attention and were found by a CNA on the floor with their pants down, appearing to be engaged in consensual sexual activity. Staff separated them and returned them to secure units, and an LPN reported there was no plan for a consensual sexual relationship or private time, despite awareness of prior similar behavior. Both residents described themselves as being in a loving relationship, but the facility completed no assessments related to sexual activity, made no related care plan revisions, and obtained no orders for contraception, STD testing, or specialty consults. Conversations held by leadership with the residents about privacy and protection were not documented, and there was no facility policy addressing resident sexual relations, despite a general resident rights policy referencing self-determination and support in exercising rights.
The facility failed to develop and implement comprehensive care plans addressing sexual health and a consensual sexual relationship for two cognitively impaired, independently mobile residents with psychiatric and neurological diagnoses. Both residents were known to seek each other’s attention and had a prior relationship, yet their care plans only directed staff to separate and redirect them, without any individualized interventions for sexual health, privacy, or safe sex. A CNA later found the two residents on the floor with their pants down, appearing to engage in consensual sexual activity, and they were separated by staff. Subsequent staff interviews confirmed there was no documented assessment, no care plan revisions for sexual health or the relationship, no safe sex education, no established access to contraception, and no facility policy on resident sexual relations.
Two residents with severe cognitive and behavioral impairments were involved in a violent altercation when one entered the other's room and was attacked with a wet floor sign, resulting in serious injuries including brain bleed, fractures, and eye trauma. Only one CNA was present on the unit, and the attack was not immediately prevented. Both residents had a history of behavioral issues, and the facility failed to provide adequate supervision and control access to potentially dangerous objects, leading to the incident.
The facility was found to have multiple deficiencies in food safety and sanitation, including the improper storage and use of dented cans, expired food items, and unsanitary conditions in the kitchen. The ice machine had residue, and dietary staff failed to follow hand hygiene protocols. Structural issues such as cracks, rust, and grease buildup were also observed, indicating a lack of maintenance.
Two residents in the facility did not receive wound care as per physician's orders, leading to deficiencies in pressure ulcer management. One resident with a stage 3 pressure ulcer and another with a stage 2 ulcer and a gastrostomy site had multiple instances of missing documentation in their Treatment Administration Records (TARs). The DON confirmed these omissions, emphasizing the importance of documenting dressing changes to monitor wound conditions. The facility's policy on wound management was not adhered to, as evidenced by the lack of documentation and care provided.
The facility did not follow the planned menu for resident meals, resulting in residents on regular, mechanical soft, and pureed diets not receiving the correct portions or types of food. Dietary staff failed to review the menu and served incorrect amounts, omitting dinner rolls and serving smaller portions than specified.
A facility failed to document a resident's advance directive in the clinical record, necessary for ensuring the resident's wishes regarding life-sustaining treatments are known. The resident, with intact cognition and multiple diagnoses, had a POLST form and Resuscitation Designation Order that did not accurately reflect their health care decision-making authority. The Power of Attorney on file did not authorize health-care decisions, and the Administrator acknowledged the need for an advance directive.
A facility failed to obtain a completed Level II PASARR evaluation for a resident with schizoaffective disorder and other mental health diagnoses. Despite approval for nursing home placement and instructions to contact the state agency for the evaluation, the administrator could not locate it. The facility also lacked a policy for handling PASARRs.
A resident, who is cognitively intact, reported not receiving showers as frequently as scheduled, with the expectation being three times per week. The facility's process involves alternating days for even and odd-numbered rooms, but documentation showed 9 instances where no bath or shower was recorded. An LPN stated that nurses do not have access to verify bathing records, and the DON confirmed the missing documentation, highlighting a deficiency in maintaining proper hygiene care.
A resident, who was cognitively intact and had multiple diagnoses, was left unsupervised with medications by both an LPN and a Medication Technician. The facility's policy required staff to observe residents taking medications to prevent harm, but this was not followed, leading to a deficiency in ensuring safety during medication administration.
A facility failed to ensure proper hand hygiene during catheter and wound care for two residents. A nurse did not perform hand hygiene between glove changes while caring for a resident with an indwelling urinary catheter and another with a gastrostomy tube and pressure ulcer. The facility lacked a formal hand hygiene policy, as confirmed by the Administrator.
A resident with multiple medical conditions did not receive physician-ordered topical ointment for dry skin on three occasions. The Treatment Nurse was unaware of the missed applications, and the Administrator reported delays in being notified about such omissions, especially when agency nurses were involved.
A resident with multiple medical conditions did not receive prescribed narcotic pain medication as ordered because the medication was not available and was awaiting delivery from the pharmacy. Staff confirmed that medication delivery delays could last one to two days, and the facility's policy required nurses to order medications and assume responsibility for delays. The administrator was often informed of these issues after they occurred, especially when agency nurses were involved.
The facility failed to complete skin treatments as ordered for three residents, leading to deficiencies in wound care management. One resident with venous ulcers missed 15 treatments, another with dry skin missed 40 days of emollient application, and a third with a deep tissue injury had 25 missed dressing changes. Observations revealed soiled and undated dressings, and residents expressed concerns about inconsistent care. The facility's minimal orientation for agency staff contributed to these issues.
The facility failed to ensure nursing staff completed treatments per physician's orders for three residents. One resident with venous ulcers had wound care treatments undocumented 15 times over three months. Another resident with pyelonephritis had emollient application undocumented for 40 days, expressing concerns about dry skin. A third resident with deep tissue damage had heel wound care undocumented 25 times. Minimal orientation for agency staff was noted, with the DON acknowledging its insufficiency.
The facility failed to maintain a clean environment, with observations of unsanitary conditions in multiple resident rooms, including dark brown buildup, sticky floors, and strong odors. The Housekeeping Supervisor admitted to the surveyor that the areas were dirty and promised to address the issue, but also revealed that the facility lacked a formal cleaning policy.
Staff-to-Resident Abuse During Escalating Conflict Over Smoking
Penalty
Summary
The facility failed to prevent staff-to-resident abuse involving a resident with diagnoses including adjustment disorder with mixed disturbances of emotions and conduct, mood affective disorder, bipolar disorder, intellectual disabilities, and traumatic brain injury. The resident’s care plan identified the resident as needing supervision to smoke and described maladaptive behaviors related to chronic mental illness, with interventions focused on redirection, respectful behavior, behavior management techniques, and reducing stimulation and agitation. The resident’s quarterly MDS indicated cognitive intactness and no behavioral symptoms toward others or rejection of care. On the day of the incident, the resident was upset about smoking and became verbally aggressive toward a CNA, using racial slurs. Staff accounts described escalating conflict between the resident and CNA, including the CNA entering the resident’s room, confronting the resident about the resident’s dislike of her, and both parties exchanging insults. The resident then became physically aggressive and placed the CNA in a headlock. During the struggle, the CNA struck the resident in the head with a cup multiple times, and another CNA intervened and was struck in the mouth while trying to separate them. The resident sustained a head laceration and later required staples in the emergency room. The resident reported being struck in the head by the CNA, while staff and the administrator described the event as a physical altercation that began with verbal name-calling and escalated to violence. The facility’s investigation substantiated abuse by the CNA toward the resident. The report also noted that the resident was not allowed to smoke until after the incident was addressed, and staff interviews reflected that the resident’s agitation centered on the smoking issue and that assistance was not immediately available when requested.
Failure to Provide Written Bed Hold Notification
Penalty
Summary
The facility failed to provide written bed hold notification to the resident or the resident’s representative when two residents were transferred to the hospital. Resident #3 was admitted with diagnoses including vascular dementia, schizoaffective disorder bipolar type, and anxiety disorder, and had a BIMS score of 15 on the admission MDS, indicating cognitive intactness. Records showed an order to transfer Resident #3 to the ER for further evaluation and treatment, with discharge and return anticipated MDS coding and progress notes documenting the hospital transfer and return, but no written bed hold notice was found in the electronic medical record. The resident’s admission packet included a readmission and bed hold policy signed by the resident’s POA, but the required written notice for the transfer was not documented. Resident #71 was admitted with diagnoses including adjustment disorder, multiple sclerosis, type II diabetes, and schizoaffective disorder, and had a BIMS score of 15 on a quarterly MDS, indicating cognitive intactness. Progress notes documented physician recommendations to send the resident to the ER for chest pain and for a behavior-related change of condition, but no bed hold was completed for either transfer. During interviews, the Nurse Consultant stated no bed hold had been completed for Resident #3 or Resident #71, and the Social Director stated she was responsible for sending written bed holds but found none in either resident’s record. The facility policy titled Bed Holds and Returns stated that prior to transfer, written information would be given to residents and resident representatives explaining the rights and limitations regarding bed holds.
Inappropriate Discharge Without Provider Order
Penalty
Summary
The facility inappropriately discharged one resident without a provider discharge order and without documentation supporting that the resident needed to leave the facility. The resident had diagnoses including adjustment disorder with mixed disturbances of emotions and conduct, mood affective disorder, bipolar disorder, intellectual disabilities, traumatic brain injury, and nicotine dependence. The resident’s assessment showed a Brief Interview of Mental Status score of 14, indicating cognitive intactness, and the care plan stated the resident chose to smoke, required supervision to smoke, had no plans to discharge, and considered the facility their home. After an altercation between the resident and a CNA that resulted in the CNA’s suspension and the resident being sent to the hospital for treatment, the resident returned the same day. Records from the days after the incident showed no documented aggressive behaviors toward residents or staff, no grievances related to the resident, and notes describing the resident as in a good mood, pleasant, compliant with medications, and stating they loved living in the facility. The order summary showed no discharge order from a provider. The facility later issued a notice of immediate discharge stating the resident was being discharged due to inability to meet safety needs and danger to individuals in the facility. Interviews showed the resident’s family had discussed a possible transfer closer to them and the resident agreed to that transfer, but the family later learned the resident had been moved to a behavioral health hospital and believed the resident had been discharged there instead of transferred as discussed. The Ombudsman reported being misled about the timeline of the incident and stated the facility had not had two staff members on the secured unit at the time of the altercation. The Administrator stated the resident had been heard boasting about the incident and that the resident did not need to be in the facility if capable of the altercation, while Social stated the resident loved living there and did not want to move until the family wanted the transfer.
Failure to Carry Out Ordered Blood Glucose Monitoring
Penalty
Summary
The facility failed to perform blood glucose testing as ordered by the physician for one resident with type 2 diabetes and hypoglycemia. The resident was admitted on 04/21/2025, and the admission MDS showed a BIMS score of 7, indicating severe cognitive impairment. An order dated 06/08/2025 directed staff to check blood glucose every morning and notify the MD if the result was greater than 250. Review of the June 2025 MAR showed that the blood glucose order was not entered on the MAR. During interview, an LPN stated that she would repeat physician orders, enter them into the electronic record, and notify the oncoming nurse, and that the order should automatically appear on the MAR once entered. The DON confirmed that the order was present in the Order Summary but not on the June 2025 MAR, and stated she expected staff to enter orders correctly and ensure they were carried out. The DON also stated there were no in-services completed with staff for following physician orders or entering physician orders.
Chemical Odor Outside Resident Room
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for one resident with COPD, major depressive disorder, atrial fibrillation, pulmonary embolism, allergic rhinitis, and housing instability. The resident was cognitively intact, used a walker, experienced shortness of breath with exertion and when lying flat, and was on oxygen therapy. The care plan addressed impaired gas exchange and anxiety related to shortness of breath, but it did not address the effects cleaning products had on the resident’s breathing status or anxiety. During observation, the resident was seen in the room on 2 L of oxygen by nasal cannula, and a towel was placed on the floor inside the door. The resident stated housekeeping’s cleaning spray outside the room was worsening COPD symptoms and that the towel had been placed under the door to block fumes. Surveyors observed a heavy chemical smell in the hallway outside the room. Housekeeping staff described use of multiple cleaners, including a pink spray used on towels and hallways, and the housekeeping supervisor stated the pink cleaner was stronger in odor and was used in resident rooms when residents were away. The supervisor also stated awareness of the resident’s breathing issues and that the room was cleaned lightly because the pink cleaner had more odor. Review of product information showed the blue cleaner had no expected inhalation injuries under normal use, while the pink bathroom cleaner instructed removal to fresh air if inhaled and treatment if symptoms occurred. The facility policy stated residents have the right to a safe, clean, homelike environment.
Failure to Support and Assess Consensual Sexual Relationship Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to support residents’ rights to engage in a consensual sexual relationship between two cognitively impaired residents. Both residents had documented moderate cognitive impairment on their MDS assessments (BIMS scores of 11 and 12) and were independent with mobility. Their care plans identified "inappropriate seeking of other individual's attention" with interventions limited to separating and redirecting them. There was no documented assessment of their capacity for sexual decision-making or sexual activity either before or after an incident in which they were found with their pants down on the floor together. On the date of the incident, a CNA discovered the two residents in a room with their pants down, appearing to be having sex, and reported that it looked like they were consenting and that she had been told they had a history together. The CNA notified an LPN, and the residents were separated and returned to their secure units. The LPN confirmed there was no plan in place to allow a consensual sexual relationship or to provide private time for the residents, despite being aware that similar behavior had occurred previously. Interviews with the residents indicated that they viewed themselves as being in a relationship, that they loved each other, and that they did not intend harm. Record review showed no orders for birth control, sexually transmitted disease testing, or referrals to specialized clinics or physicians for either resident. There was no documentation in progress notes of education or conversations with staff regarding the incident, and no assessments related to sexual activity were completed before or after the event. The MDS nurse and Administrator acknowledged speaking with the residents about the incident and the possibility of providing privacy and protection, but the MDS nurse stated that none of these discussions or interventions were documented and nothing was added to the care plans. The Administrator also stated the facility did not have a policy on resident sexual relations, despite a resident rights policy referencing residents’ rights to self-determination and to be supported in exercising their rights.
Failure to Care Plan for Residents’ Sexual Health and Consensual Relationship
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, measurable care plans addressing sexual health and consensual sexual relationships for two cognitively impaired residents. Resident #3, admitted with traumatic brain injury, bipolar disorder, mood disorder, and an unspecified mental disorder, had a BIMS score of 11 indicating moderate cognitive impairment and was independent with mobility. Resident #4, admitted with schizophrenia, schizoaffective disorder bipolar type, dementia, and psychosis, had a BIMS score of 12, also indicating moderate cognitive impairment, and was independent with mobility. Both residents’ care plans, updated on 03/11/2026, identified “inappropriate seeking of other individuals’ attention,” but the only interventions listed were to separate and redirect, with no individualized care plan addressing their sexual health, their ongoing relationship, or parameters for consensual sexual activity. On 03/11/2026, a CNA discovered Resident #3 and Resident #4 on the floor with their pants down, appearing to be engaged in consensual sexual activity. The CNA notified an LPN, and staff separated the residents and returned them to their secure units. Staff interviews revealed that there was no existing plan for a consensual sexual relationship, no plan for private time, and no documented assessment or care plan interventions related to sexual health, safe sex education, or contraception for these residents, despite knowledge of a prior relationship and the residents’ expressed desire and intent to engage in sexual activity. The MDS nurse and the Administrator acknowledged that no care plan revisions were made to address sexual health or the relationship, no documentation of related discussions or interventions was completed, and the facility had no policy on resident sexual relations and no established interventions for birth control.
Failure to Prevent Resident-to-Resident Abuse Resulting in Severe Injury
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents with significant cognitive and behavioral impairments. One resident, with a history of stroke, cancer, moderate cognitive impairment, and maladaptive behaviors such as inappropriate sexual behavior and wandering, was admitted to a secured unit and identified as being at risk for abnormal bleeding and skin integrity issues due to medication and medical history. The other resident, diagnosed with Alzheimer's disease, severe cognitive impairment, a history of aggression, and behavioral disturbances, was also admitted to the secured unit and had documented physical and verbal behaviors directed toward others. On the night of the incident, the resident with Alzheimer's disease physically attacked the other resident after the latter entered their room. The attack involved the use of a wet floor sign as a weapon, resulting in severe injuries including brain bleed, facial trauma, nasal bone fracture, leg fractures, and eye dislocation. Staff interviews revealed that only one CNA was present on the unit at the time, and the attack was not immediately prevented. The wet floor sign, which was typically hidden, was accessible and used in the assault. The CNA and LPN on duty responded after the incident had already occurred, and the injured resident was transported to the hospital approximately 40 minutes later. Documentation and interviews indicated that both residents had a history of behavioral issues and prior altercations, and that interventions such as one-to-one supervision and separation had been used previously. However, the facility's failure to adequately monitor and supervise these residents, as well as to control access to potentially dangerous objects, directly contributed to the occurrence of the abuse. The incident resulted in significant physical harm and psychological distress, as evidenced by the injured resident's subsequent fear of returning to the facility.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards, as evidenced by several observations during the survey. Dented cans were found stored on a designated shelf in the pantry, with the Dietary Manager admitting that these cans were not removed or returned to the supplier, and were sometimes used when stock was low. Additionally, leftover meat products were improperly stored and reused for mechanical soft diets without ensuring food quality. Expired food items, such as a bag of potato chips, were not promptly removed from stock, and food items in the freezer were not properly covered or sealed. The ice machine was found to be in an unsanitary condition, with pinkish and black residue observed in the area where ice touches before dropping into the collector. The Dietary Manager confirmed the residue and stated that the ice machine was used to fill beverages for residents and was cleaned monthly. Furthermore, dietary staff failed to adhere to proper hand hygiene practices. Instances were observed where staff handled clean equipment with contaminated hands after touching dirty objects, such as removing a gallon of milk or a block of cheese from the refrigerator, without washing their hands. The kitchen environment was also found to be in poor condition, with several structural issues contributing to an unsanitary environment. Cracks in walls, broken door frames, rust stains, and grease buildup were observed in various areas, including the dishwashing machine room and around cooking equipment. These conditions indicate a lack of regular maintenance and cleaning, which are essential for ensuring a sanitary environment for food preparation and service.
Deficiency in Wound Care Documentation and Management
Penalty
Summary
The facility failed to provide wound care as per physician's orders for two residents, leading to deficiencies in pressure ulcer management. Resident #2, diagnosed with cancer, anoxic brain injury, and a stage 3 pressure ulcer, did not receive documented wound care on multiple occasions as per the Treatment Administration Records (TARs) for November and December 2024, and January 2025. The Treatment Nurse and Director of Nursing (DON) confirmed the lack of documentation, indicating that wound care was not performed as ordered, which is crucial for proper healing and infection prevention. Resident #48, with diagnoses including non-Alzheimer's dementia and hemiplegia, also experienced lapses in wound care documentation. The TARs for December 2024 and January 2025 showed missing staff initials for pressure ulcer and gastrostomy site care on several dates. The DON verified these omissions and emphasized the importance of documenting dressing changes to monitor the condition of the wounds and ensure appropriate care. The facility's policy on wound and pressure ulcer management, revised in November 2022, commits to providing comprehensive wound care consistent with residents' treatment goals. However, the lack of documentation and adherence to physician orders for wound care in these cases highlights a failure to meet these standards, as confirmed by the facility's staff during the survey.
Failure to Adhere to Planned Menu for Resident Meals
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, which was intended to meet the nutritional needs of the residents. During the lunch meal service, it was observed that residents on regular diets did not receive the dinner roll that was specified in the menu. Similarly, residents on mechanical soft diets were served only 2 ounces of ground turkey instead of the 3 ounces plus one ounce of gravy as outlined in the menu, and they also did not receive the dinner roll. Residents on pureed diets were served 2 ounces of pureed mixed vegetables and sweet potatoes each, instead of the specified amounts, and did not receive the pureed dinner roll as planned. Interviews with dietary staff revealed a lack of adherence to the menu. Dietary Cook #1 admitted to using a 2-ounce spoon for serving both pureed and mechanical soft meats, providing only a single serving to each resident. Dietary Cook #2 acknowledged that there was no reason for not serving the dinner rolls and admitted to not reviewing the menu before deciding on the portion sizes for the residents on mechanically soft and pureed diets. This lack of menu review and adherence resulted in the residents not receiving the appropriate portions and types of food as planned.
Failure to Document Resident's Advance Directive
Penalty
Summary
The facility failed to document a resident's advance directive in a prominent part of the clinical record, which is necessary to ensure the resident's wishes regarding life-sustaining treatments are known in the event of incapacitation. The deficiency was identified during a review of the clinical records for a resident who was admitted with multiple diagnoses, including respiratory failure and cerebral palsy. The resident's mental status was assessed as intact, with a BIMS score of 15. The Administrator provided a POLST form and a Resuscitation Designation Order for the resident, both dated prior to the survey. However, the POLST form indicated that the advance directive was not available or reviewed, and the Resuscitation Designation Order incorrectly noted that a Power of Attorney was on file for health care decisions. Upon further review, the provided Power of Attorney explicitly stated it did not authorize health-care decisions. The Administrator acknowledged that the resident would need an advance directive to indicate their preferences, as the existing documentation did not cover health care decisions.
Failure to Obtain PASARR Evaluation for Resident with Mental Disorders
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program by not obtaining a completed Level II PASARR evaluation for a resident diagnosed with schizoaffective disorder, auditory hallucinations, delusional disorders, unspecified mood disorder, and anxiety disorder. The resident was admitted to the facility with a care plan initiated to address maladaptive behavioral symptoms related to chronic mental illness, including hallucinations and delusions. Despite a letter from the designated state agency approving the resident for nursing home placement and instructing the facility to contact the agency for the completed PASARR evaluation, the facility's administrator was unable to locate the evaluation. Additionally, the facility did not have a policy in place for handling PASARRs.
Failure to Adhere to Bathing Schedule for Resident
Penalty
Summary
The facility failed to ensure that a resident received a bath or shower according to the established schedule, which is essential for maintaining good hygiene. Resident #44, who is cognitively intact with a BIMS score of 15, reported that residents were not receiving showers frequently enough, with the expectation being three times per week, but only occurring once or twice. The resident requires minimal assistance but still needs staff attendance for bathing. The facility's process, as explained by an LPN, involves even-numbered rooms receiving baths on Monday, Wednesday, and Friday, and odd-numbered rooms on Tuesday, Thursday, and Saturday. However, there were gaps in the documentation, with 9 instances where no staff initials indicated that a bath or shower was completed. The LPN interviewed stated that nurses do not have access to the documentation to verify if a bath was given, and they rely on residents to inform them if they were not bathed. The Director of Nursing confirmed the missing documentation and acknowledged the importance of knowing whether a bath was completed or if there were issues preventing it. The lack of documentation and adherence to the bathing schedule led to the deficiency in providing adequate care for the resident's activities of daily living.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure safety during medication administration for Resident #44, who was cognitively intact with a BIMS score of 15 and had diagnoses including diabetes, seizure disorder, obesity, and an ulcer on the lower extremity. During an observation of the medication pass process, it was noted that both an LPN and a Medication Technician left medications with the resident without supervising their ingestion. The LPN provided two controlled substances, while the Medication Technician provided thirteen medications, both leaving the room before confirming the resident had taken the medications. Interviews with the LPN and Medication Technician revealed an acknowledgment that leaving medications unsupervised could lead to potential harm, such as the resident pocketing the medications. The facility's policy, as provided by the Administrator, explicitly stated that staff should observe residents taking their medications to prevent such risks. The Director of Nursing confirmed that the policy was in place to ensure residents did not remove pills from their mouths, highlighting a failure to adhere to established procedures designed to prevent accidents and ensure resident safety.
Inadequate Hand Hygiene During Catheter and Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during catheter and wound care for two residents. For Resident #36, who had diagnoses including coronary artery disease, neurogenic bladder, and acute kidney failure, the Treatment Nurse was observed irrigating an indwelling urinary catheter without performing hand hygiene between glove changes. The nurse acknowledged the oversight and recognized the importance of hand hygiene in preventing infection. Additionally, the facility lacked a formal hand hygiene policy, as confirmed by the Administrator. For Resident #48, who had diagnoses of non-Alzheimer's dementia, hemiplegia, and encephalopathy, the Treatment Nurse was observed changing dressings for a gastrostomy tube and a pressure ulcer without performing hand hygiene between glove changes. The nurse admitted to not consistently sanitizing hands before donning new gloves, which is crucial for reducing infection spread. The absence of a hand hygiene policy was again confirmed by the Administrator, highlighting a systemic issue in the facility's infection control practices.
Failure to Administer Physician-Ordered Skin Treatment
Penalty
Summary
Staff failed to monitor and apply physician-ordered external ointment to a resident's bilateral lower extremities for dry skin as prescribed. The resident, who had diagnoses including spinal stenosis, coronary artery disease, neurogenic bladder, and acute kidney failure, was cognitively intact according to the most recent assessment. Review of the Treatment Administration Record revealed that the ointment was not applied on three separate days as ordered. The Treatment Nurse was unaware of the missed treatments, and the Administrator acknowledged that she was often informed of such omissions after they occurred, particularly when agency nurses were involved, making timely intervention difficult.
Failure to Provide Ordered Pain Medication Due to Pharmacy Delays
Penalty
Summary
A deficiency occurred when a resident with diagnoses including spinal stenosis, coronary artery disease, and acute kidney failure did not have their ordered narcotic pain medication available for administration as prescribed. Progress notes indicated that the medication was not available on multiple occasions, with entries stating the medication was 'awaiting delivery from pharmacy' or 'pharmacy pending.' The resident was assessed as cognitively intact and was prescribed opioid medication for pain control, but the facility failed to ensure the medication was on hand for timely administration. Interviews with staff confirmed that delays in medication delivery from the pharmacy could take one to two days, and staff would call the pharmacy to request delivery. The facility's policy allowed nurses to order medications from the pharmacy and stated the facility would assume responsibility if there was a delay. The administrator acknowledged being made aware of such incidents, particularly when agency nurses were involved, and confirmed that medication was ordered as soon as possible after the issue was identified.
Failure to Complete Skin Treatments as Ordered
Penalty
Summary
The facility failed to ensure that skin treatments were completed as per physician's orders for three residents, leading to deficiencies in wound care management. Resident #2, diagnosed with venous insufficiency and chronic venous hypertension with ulcers, had a treatment plan that included washing wounds and applying collagen gel every other day. However, the Treatment Administration Record (TAR) for June, July, and August 2024 showed that treatments were not documented as completed 15 times. Resident #2 confirmed that treatments were often skipped due to nurses being busy. Resident #3, with a diagnosis of acute pyelonephritis and hydronephrosis, had an order for daily application of emollient to the lower extremities, but the TAR indicated 40 days of missed documentation. Resident #3 expressed concerns about their skin becoming dry and itchy due to inconsistent treatment. Resident #4, who had a pressure-induced deep tissue injury on the right heel, was supposed to receive daily dressing changes and offloading with a pressure-reducing boot. However, the TAR for June, July, and August 2024 documented 25 instances where the treatment was not completed. An observation revealed that Resident #4's dressing was soiled and undated. The facility's orientation for agency staff was minimal, consisting of a one-page instruction sheet, and the Director of Nursing acknowledged that the orientation was insufficient. The facility's Wound and Pressure Ulcer Management Policy required treatments to be performed according to physician orders, which was not adhered to in these cases.
Failure to Complete Physician-Ordered Treatments
Penalty
Summary
The facility failed to ensure that nursing staff completed treatments as per physician's orders for three of the four sampled residents. Resident #2, diagnosed with venous insufficiency and chronic venous hypertension with ulcers, had a physician's order for wound care that was not documented as completed 15 times over three months. Resident #3, with acute pyelonephritis and hydronephrosis, had a physician's order for applying an emollient to the lower extremities, which was not documented as completed for 40 days over the same period. Resident #3 expressed concerns about the inconsistency of treatments, noting issues with dry, flaky, and itchy skin. Resident #4, who had pressure-induced deep tissue damage and other conditions, had a physician's order for daily wound care on the right heel, which was not documented as completed 25 times over three months. The resident confirmed that treatments were frequently skipped. The facility's orientation for agency staff was minimal, consisting of a one-page instruction sheet, and the Director of Nursing acknowledged that it was not much of an orientation. The Administrator was responsible for staff scheduling, and efforts were made to maintain continuity of care by keeping the same staff with the same residents.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by observations made during rounds on multiple halls. A dark brown buildup with a thick black substance was noted along the baseboards and debris was found behind the doors in several resident rooms. Additionally, sticky floors were observed in some rooms, and unsanitary conditions were noted in others, including a large amount of dark brown substance in a toilet bowl, a wad of toilet tissue soaked in a yellow substance in a sink, and a used bandage on the floor. A strong odor and brown smeared areas were also found in a bathroom and on a privacy curtain. During an interview, the Housekeeping Supervisor stated that the facility performs deep cleaning on certain rooms every day according to a prepared schedule. However, the rooms that were found to be dirty were on the schedule to have already been deep cleaned, indicating a failure in the cleaning process. The Housekeeping Supervisor admitted to the surveyor that the areas were dirty and promised to address the issue. Furthermore, when asked for a cleaning policy, the Housekeeping Supervisor revealed that the facility did not have one, highlighting a lack of formal procedures to ensure cleanliness.
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What surveyors actually found near you
We read the 71 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Little Rock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arkansas State Veterans Home At North Little Rock | 3.3 mi | ★★★★★ | 0 | 0 |
| The Blossoms At North Little Rock Rehab & Nursing | 3.3 mi | ★★★★★ | 1 | 0 |
| The Blossoms At Midtown Rehab & Nursing Center | 4 mi | ★★★★★ | 0 | 0 |
| Briarwood Nursing And Rehabilitation Center, Inc | 4.4 mi | ★★★★★ | 0 | 0 |
| Lakewood Health And Rehab, Llc | 4.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.