Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Blossoms At Midtown Rehab & Nursing Center during CMS and state inspections, most recent first.
Unclean and Damaged Resident Rooms: A resident room bathroom had brownish/black residue on the shower walls, floor, and curtain, a urine smell, and a urinal left on the nightstand beside toothbrushes. Other rooms had a shower chair with residue, cracked and missing floor tiles, unbagged basins under the sink, a fall mat with unidentified spots, a pillow without a pillow case, peeling wall and flooring damage, and a worn chair. Staff, including the ADON, DON, and housekeeping, described the conditions as mold-like, disgusting, and not homelike.
Inaccurate MDS coding affected two residents. One resident with a tracheostomy and orders for daily trach care, oxygen monitoring, and oxygen as needed was coded as not needing trach care, oxygen, or suctioning. Another resident with schizophrenia and a level II PASRR was coded in A1500 as having no serious mental illness or intellectual disability, despite records and the MDS nurse confirming the PASRR II status.
An unlocked soiled room across from the elevator contained multiple unsecured chemicals, biohazard waste, standing water in a hopper, and an unlocked housekeeping cart with unlabeled or improperly stored products. Staff stated the door should never be left unsecured and that residents could access hazardous items. In a separate issue, a resident with schizophrenia, dementia, and moderate cognitive impairment had a razor left in the bathroom and later had a chin skin tear; RN staff stated residents are not allowed to keep razors in their rooms and the Administrator confirmed razors were not to be left in resident rooms.
Unsafe food storage, poor hand hygiene, and inadequate hot food temperatures: The facility failed to keep the ice scoop holder sanitary, properly cover or seal food in the kitchen, freezer, refrigerator, and dry storage areas, and discard expired or spoiled items. Staff also handled clean equipment after wiping dirty surfaces without washing hands, and hot foods on steam tables were held below the required 135 degrees Fahrenheit during meal service.
Housekeeping failed to follow contact isolation precautions when an HSK entered a room with a contact isolation sign, handled trash, dirty linen, cleaning supplies, and the housekeeping cart without changing gloves, performing hand hygiene, or donning an isolation gown. The HSK said he knew what the sign meant but was trying to get it done quickly, and the Administrator confirmed housekeeping was expected to follow the same isolation protocol as nursing staff and good infection control practices.
Two residents did not receive their prescribed medications as ordered due to unavailability and delays in pharmacy delivery, as well as issues with lab work and intravenous access. One resident missed multiple doses of antipsychotic and antimanic medications, resulting in hospitalization, while another missed several doses of intravenous antibiotics due to medication unavailability and PICC line problems. Nursing staff and a regional nurse consultant confirmed the missed administrations and the reasons behind them.
A facility failed to properly account for and surrender discontinued controlled substances, resulting in hundreds of missing narcotic medications for multiple residents with complex medical needs. Despite policies requiring the surrender and documentation of these drugs, discrepancies in medication counts and a failed attempt to report the loss to state authorities led to unaccounted-for controlled substances, constituting misappropriation of resident property.
The facility did not report missing controlled substances affecting multiple residents to the State Agency as required by policy. Despite documentation showing that hundreds of discontinued narcotic medications were unaccounted for, the incident was not reported to the Office of Long-Term Care, and discrepancies were found in medication logs for residents with ongoing pain management needs. Interviews confirmed that residents continued to receive their prescribed medications, but the failure to report the loss of controlled substances constituted a deficiency.
The facility failed to ensure proper food storage, cleanliness, and hygiene practices in the kitchen, affecting 97 residents. Observations included uncovered food items, dirty ice machines and scoop holders, and dietary employees not washing hands or sanitizing equipment properly. The facility's hand washing policy was not followed.
The facility failed to administer oxygen at the physician-ordered flow rates for two residents, leading to discrepancies in oxygen settings. One resident with multiple diagnoses was observed with oxygen set below the prescribed 3 liters per minute, while another resident with severe cognitive impairment had oxygen set at 5 and 10 liters instead of the ordered 8 liters per minute. LPNs and the DON confirmed the incorrect settings and acknowledged the responsibility of the management team to ensure proper oxygen levels.
The facility failed to follow planned menus and portion sizes, serving smaller portions of chicken and oatmeal than required and omitting cheese from scrambled eggs. Dietary staff admitted to not checking the written menu and acknowledged a delay in cheese delivery.
The facility failed to ensure that food was palatable and served at a safe temperature. A resident with Diabetes Mellitus reported cold and repetitive meals, another with multiple fractures noted cold sausage, and a third resident found the vegetables mushy. Food temperatures were found to be below acceptable levels, and staff acknowledged the need for reheating.
The facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) between resident rooms and during high-contact care activities. A CNA was observed moving between EBP-marked rooms without changing gloves or performing hand hygiene. Additionally, an LPN and ADON administered medication to a resident with a PEG tube without wearing the required isolation gowns, contrary to the resident's care plan and facility policy.
The facility failed to accurately complete a discharge MDS assessment for a resident, documenting the discharge status incorrectly as to a short-term general hospital instead of home with home health services. The MDS Coordinator confirmed the discrepancy, and the Administrator admitted the lack of a specific policy on MDS assessments.
The facility failed to update the care plan for a resident with physician's orders for oxygen therapy. Despite multiple observations of the resident using oxygen, the care plan did not reflect this treatment. The MDS Coordinator acknowledged the oversight, emphasizing the importance of accurate care plans for proper resident care.
A resident with multiple diagnoses, including a pressure ulcer, did not receive the second application of Povidone-iodine as ordered on four specific dates in March. This failure had the potential to affect eight residents with similar orders.
The facility failed to secure hazardous items, as an aerosol can of air freshener was found in a resident's room. The resident, who has Dementia with Behavioral Disturbance, indicated that staff provided the item. Both the Social Service Director and the DON confirmed that aerosol cans are not allowed in resident rooms, highlighting a lapse in policy adherence and supervision.
Unclean and Damaged Resident Rooms
Penalty
Summary
The facility failed to ensure a comfortable homelike environment in Rooms #430, #428, and #433. During observations, the bathroom in one room had unidentified brownish/black residue on the shower stall walls, floor, and shower curtain, along with a basin on the shower stall floor with brownish/black residue and a urine smell in the bathroom. A urinal was also observed on the nightstand beside toothbrushes. In another room, a shower chair had brownish residue on the bars and mesh-like backing, the bathroom floor had missing and cracked tiles, the wall had scrape marks near the floor, and basins were stored under the sink without being bagged. In a third room, a fall mat beside the bed had spots of brownish/black unidentified substance, the pillow on the bed did not have a pillow case, the pillow case was flat and had cracks in the plastic-like material, and large scrapes were noted on the wall behind the bed. The chair beside the bed had a worn seat with peeling material, and the flooring at the bottom of the wall was peeling with scrapes and brownish/black scuff marks. Staff interviews confirmed the conditions, with housekeeping describing routine deep cleaning and mold spray use, maintenance stating the area looked like mold and was not homelike, the resident reporting the bathroom had been in that condition for about two months and smelled awful, and the ADON and Administrator both describing the bathroom as disgusting, unsanitary, and unacceptable.
Inaccurate MDS Coding for Tracheostomy Needs and PASRR Status
Penalty
Summary
The facility failed to accurately assess and complete the MDS for two residents. One resident was admitted with acute and chronic respiratory failure, obstructive sleep apnea, and a surgically created opening in the neck into the windpipe for air to reach the lungs. Physician orders directed daily tracheostomy collar changes, daily tracheostomy care, daily oxygen saturation checks, and oxygen via trach cuff at 5 liters as needed. However, the quarterly MDS with an ARD of 08/05/2025 incorrectly indicated the resident did not require tracheostomy care, did not use oxygen, and did not require suctioning, despite these needs being associated with a tracheostomy. The second resident had diagnoses including schizophrenia, diabetes II, and hepatitis C. The annual MDS with an ARD of 06/22/25 showed a BIMS score of 12 and indicated section A1500 as 0, meaning no serious mental illness, intellectual disability, or PASRR IIA. Records reviewed included a care plan noting a level II PASRR, state authority letters indicating PASRR screening and specialized services, and electronic records confirming the resident had a level II PASRR. The MDS nurse stated section A1500 should have been coded 1 to reflect the resident's mental disorder or intellectual disability, and also stated there was no MDS policy.
Unsecured chemicals and razor left accessible
Penalty
Summary
The facility failed to keep a soiled storage room on 300 Hall locked and secured. On 08/26/2025, a surveyor found keys hanging from the doorknob of the room directly across from the elevator, turned the key, and opened the door. Inside were an unlocked housekeeping cart with a mop and bucket of water, a toilet/hopper bowl with standing water, chemicals on shelves and counters, a red biohazard can, a cardboard biohazard box on the floor, and a floor buffing machine. The surveyor remained in the room for about 40 minutes and observed multiple chemical products stored in open or unsecured conditions, including spray buff without a cap, bleach wipes, alcohol gel sanitizer, concentrated glass cleaners, carpet cleaner, acid bathroom cleaner, odor eliminator, degreaser, disinfectant cleaner, and an unlabeled purple liquid in a spray bottle. During interviews, the UM/ADON/RN stated the door should never be left unlocked because chemicals in the room were poisonous and hazardous, and a resident could get in and drink them. The UM/ADON/RN also stated a resident could get stuck in the room, the biohazard box and red container held items that could expose a resident to body fluids or biohazard trash, and the equipment in the room was not supposed to be there. The housekeeper stated the keys had been left in the door by mistake and acknowledged that someone could get the chemicals and stuff, get sick, or die if they drank them. The surveyor also observed that the keypad on the room was not working and had no batteries or cover. The report also identified a separate deficiency involving Resident #57. Resident #57 had diagnoses including schizophrenia, dementia, and depression, and the MDS showed moderate cognitive impairment. The resident was observed with a black razor resting on the bathroom sink in an open bathroom while the resident was not present. Later, the resident had a small skin tear on the chin and asked for shaving cream. RN #8 stated CNAs assist residents with shaving, residents are not allowed to keep razors in their rooms because they could harm themselves, and the resident had previously nicked the chin. The Administrator later confirmed there was no shaving or razor policy and that razors were not to be left in resident rooms.
Unsafe food storage, poor hand hygiene, and inadequate hot food temperatures
Penalty
Summary
The facility failed to maintain the ice scoop holder in a sanitary condition and failed to store food items properly in the kitchen, freezer, refrigerator, and dry storage areas. During observation, the ice scoop holder by the ice machine had an accumulation of wet black residue at the bottom, and the ice scoop was resting on the residue. The Dietary Manager confirmed the holder was dirty and had mold-like residue and stated it should be cleaned daily. Multiple food storage problems were observed throughout the facility. A box of alfredo sauce that was supposed to be kept frozen was found in the refrigerator. In the freezer, opened boxes of pizza, cobbler dough, yeast rolls, and cheese omelets were not covered or sealed, and a box of chocolate ice cream appeared thawed and then refrozen. In the storage room, an opened bag of breadcrumbs was exposed to air, moisture, heat, and potential pests. In the third-floor kitchenette refrigerator, open bags of turkey sandwiches, undated ham and cheese sandwiches, undated egg, cheese and ham sandwich, two bowls of unidentified soup, spoiled melon with grayish-green mold, salad with discolored boiled eggs, grapes with brown spots and fuzz, sour cream dated 08/11/2025, and a plate of leftovers with a foul odor were observed. Additional expired items included a box of steak enchilada in the freezer dated 05/06/2025 and a container of sour cream dated 07/28/2025. The facility also failed to ensure proper hand hygiene and food temperatures during meal service. A dietary staff member wiped spilled food from the counter with a rag and then handled a clean blender blade without washing her hands. At supper service, hot food on steam tables on the third and fourth floors was measured below the required holding temperature, including ground meat at 115 degrees Fahrenheit, mashed potatoes at 130 and 120 degrees Fahrenheit, hamburger patties at 103 degrees Fahrenheit, chicken noodle soup at 130 degrees Fahrenheit, and cut green beans at 120 degrees Fahrenheit. The staff members stated the food should have been reheated before serving. Facility policy required ice to be handled with a sanitized scoop, hands to be washed when changing tasks, hot food to be held at least 135 degrees Fahrenheit, and food to be covered, labeled, dated, and rotated.
Housekeeping Failed to Follow Contact Isolation Practices
Penalty
Summary
The facility failed to ensure isolation practices were followed by housekeeping staff in a room with a contact isolation sign posted on the door. On 08/26/2025 at 11:00 AM, Housekeeper #9 was observed pushing the housekeeping cart with gloved hands and entering the room with a broom and dustpan without changing gloves, performing hand hygiene, or donning an isolation gown. He was then observed placing a small bag of trash into the trash compartment of the housekeeping cart and, through the open room door, moving dirty linen and a trash container from the bathroom to the room at the resident’s request. Housekeeper #9 was also observed picking up a bottle of spray and a toilet brush, returning them to the cart, getting the mop, and going back into the room to mop the bathroom. After mopping, he returned the mop to the cart and continued pushing the cart down the hall without changing gloves or performing hand hygiene. He confirmed he had been trained on cleaning rooms under isolation precautions and knew what the contact isolation sign meant, but stated he was trying to get it done quickly. The Administrator confirmed housekeeping personnel were expected to follow the same isolation protocol as nursing staff and to follow good infection control practices. Review of training showed Housekeeper #9 had been in-serviced on infection control, hand hygiene, and PPE, and the facility policy stated infection prevention involved all disciplines and staff would be monitored for compliance.
Failure to Administer Medications as Ordered Due to Unavailability and Logistical Delays
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for two residents. For one resident with schizophrenia, bipolar disorder, major depressive disorder, and generalized anxiety disorder, there were multiple missed doses of a second-generation atypical antipsychotic and an antimanic agent. Documentation showed that the antipsychotic medication was not administered on several consecutive days due to the medication being unavailable, as the pharmacy would not release it without a current absolute neutrophil count. The facility did not obtain the required lab results in a timely manner, resulting in a delay in medication delivery. Progress notes indicated repeated communication with the pharmacy and delays in obtaining both the medication and necessary lab work. The resident subsequently became increasingly psychotic and disorganized, leading to hospitalization. Another resident, admitted with diagnoses including discitis, lumbago with sciatica, cord compression, and acute respiratory failure, was prescribed intravenous antibiotic therapy via a PICC line. The resident did not receive several scheduled doses of the antibiotic due to the medication being unavailable and issues with the PICC line. Progress notes and interviews confirmed that the antibiotic was not administered on multiple occasions because the medication could not be located or was not delivered in time. Additionally, there was a period when the PICC line malfunctioned and required replacement by a third-party vendor, further delaying administration of the antibiotic. Interviews with nursing staff and the regional nurse consultant confirmed that the missed doses were due to medication unavailability and logistical issues with pharmacy delivery and PICC line access. The affected residents were not informed about the reasons for missed medications at the time, and documentation in the medical record supported the findings of missed administration as ordered by the physician.
Failure to Account for and Surrender Discontinued Controlled Substances
Penalty
Summary
The facility failed to protect residents from misappropriation of property, specifically regarding the management and accountability of controlled substances. Facility policy required that discontinued narcotics be surrendered to the Director of Nursing or Assistant Director of Nursing, logged appropriately, and sent to the Arkansas Department of Health (ADH) Pharmacy Services. However, a review of facility records and state reporting forms revealed that 693 discontinued narcotic medications for 15 residents were not surrendered as required and were unaccounted for. The facility's attempt to report the loss to the ADH Pharmacy Division was unsuccessful due to a failed fax transmission, resulting in a delay in notification. Among the residents affected, several had significant medical conditions requiring controlled substances for pain or anxiety management. One resident with Huntington's disease and malnutrition had 26 oxycodone tablets missing. Another resident with diabetes, bilateral above-knee amputation, and hypertension had one hydrocodone/acetaminophen tablet unaccounted for, with narcotic book records showing a discrepancy in the tablet count. A third resident with chronic respiratory failure, leukemia, and osteoarthritis had 42 hydrocodone/acetaminophen tablets missing. Additionally, a resident with respiratory failure, end-stage renal disease, and dementia had 14 clonazepam and 4 tramadol tablets missing, with records indicating these medications were discontinued and should have been surrendered. Interviews with residents confirmed that they were receiving their prescribed pain or anxiety medications and did not report issues with access to their medications. However, the facility's failure to properly account for and surrender discontinued controlled substances, as well as the delay in reporting the loss to the appropriate state authorities, constituted a failure to protect residents from the misappropriation of their property, specifically their prescribed medications.
Failure to Report Missing Controlled Substances to State Agency
Penalty
Summary
The facility failed to ensure that allegations of misappropriation of property, specifically missing controlled substances, were reported to the State Agency as required. Facility policy mandates that all alleged violations involving mistreatment, neglect, or abuse, including misappropriation of property, be reported immediately or within 24 hours depending on the severity. However, a review of records revealed that 693 discontinued narcotic medications affecting 15 residents were unaccounted for and not surrendered to the state pharmacy services as required. The Chief Nursing Officer (CNO) believed the missing medications had been reported to the Arkansas Department of Health (ADH), but the fax transmission failed, and the issue was not reported to the Office of Long-Term Care because there were no perceived negative outcomes for the residents. Among the affected residents, three had current orders for the missing medications. One resident with diagnoses including acute and chronic respiratory failure, leukemia, COPD, and osteoarthritis had an active order for Norco for pain management, with 42 tablets missing. Another resident with diabetes, bilateral above-knee amputation, and hypertension had an order for Norco, with one tablet unaccounted for. A third resident with respiratory failure, end-stage renal disease, tracheostomy, and dementia had anti-anxiety and pain medications involved in the loss. Despite the missing medications, interviews with two of the residents confirmed they were receiving their opioid pain medications and had no concerns about access or administration. The facility's documentation and narcotic logs showed discrepancies in the accounting of controlled substances, with balances not matching and medications not properly surrendered or reported as lost. The failure to report the missing medications to the appropriate authorities, as required by both facility policy and state regulations, constituted a deficiency in the facility's handling of suspected misappropriation of property.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage, cleanliness, and hygiene practices in the kitchen, which had the potential to affect 97 residents. Observations included standing water on the floor, uncovered and unsealed food items, and dirty ice machines and scoop holders. Specifically, an opened box of plain salt was left uncovered, and the ice machine had wet black residue. Additionally, several food items in the refrigerator and walk-in freezer were not sealed or covered, including shredded parmesan cheese, chocolate chip cookies, bread sticks, dough, and hamburger patties. Dented cans and an opened bag of cornmeal were also found in the storage room, along with a water leak from the ceiling light fixture. The ice scoop holder had pink and brown residue, and the dishwashing machine area had standing water with a strong odor. Dietary employees were observed not washing their hands or changing gloves after handling dirty objects, and food preparation equipment was not properly sanitized before use. The ice scoop holder on the third floor dining area was also found to be dirty, with dark, crusty matter around the screws and dark specks at the bottom. The facility's hand washing policy was not followed, as dietary employees did not wash their hands after engaging in activities that contaminated their hands.
Failure to Administer Oxygen at Physician-Ordered Flow Rates
Penalty
Summary
The facility failed to ensure oxygen was administered at the flow rate ordered by the physician for two residents, which had the potential to affect 57 residents with physician orders for oxygen therapy. Resident #71, who had diagnoses of stroke, end-stage renal disease, and coronary artery disease, was observed multiple times with oxygen administered at lower flow rates than the physician-ordered 3 liters per minute. Despite the physician's order, the resident's oxygen was set at 2.5 liters, 2 liters, and even 1.5-2 liters during different observations. Licensed Practical Nurses (LPNs) confirmed the discrepancies in oxygen settings and acknowledged that nurses were responsible for checking the oxygen settings during rounds. Resident #248, diagnosed with cerebral infarction, anoxic brain injury, and type II diabetes mellitus, was also found to have discrepancies in oxygen administration. The resident's physician order specified 8 liters per minute via tracheostomy, but observations revealed the oxygen concentrator set at 5 liters and later at 10 liters. LPNs and the Director of Nursing (DON) confirmed the incorrect settings and acknowledged that the management team was responsible for ensuring the oxygen was set at the appropriate level. The facility's policy on oxygen administration and an in-service education report emphasized the importance of adhering to prescribed oxygen levels, but these were not followed in practice.
Failure to Follow Planned Menus and Portion Sizes
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents. During the lunch meal service, residents on regular diets were served only one fried chicken leg, which weighed two ounces, instead of the planned four ounces of oven-fried chicken. Additionally, residents on mechanical soft diets were served fewer portions of ground oven-fried chicken than required. This discrepancy was confirmed by the Dietary Supervisor and a dietary employee who acknowledged the error in portion sizes and the insufficient number of servings prepared for residents on mechanical soft diets. During the breakfast meal service, residents were served smaller portions of oatmeal than specified in the menu, receiving only four ounces instead of the required six ounces. Furthermore, scrambled eggs were served without cheese, contrary to the menu's specifications. Dietary employees admitted to not checking the written menu for portion sizes and acknowledged the absence of cheese due to a delay in delivery. These failures in meal preparation and service affected residents on both regular and mechanical soft diets across multiple halls in the facility.
Failure to Ensure Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. During an observation, it was noted that vegetables were overcooked and mushy, and hot food items were served at temperatures that were not acceptable to the residents. Specifically, Resident #41, who has a diagnosis of Diabetes Mellitus Without Complications, reported that the food was often cold and repetitive. Resident #89, with multiple fractures of the pelvis, also reported that the food, particularly the sausage at breakfast, was never hot. Resident #551 mentioned that the vegetables were mushy. Further investigation revealed that the vegetable blend served to residents was indeed overcooked and mushy, as confirmed by Dietary Employee (DE) #2. Additionally, the temperature of food items on the steam table in the 200 Hall kitchenette was found to be below acceptable levels, with scrambled eggs and sausage at 120 degrees Fahrenheit, and gravy and hashbrowns at 100 degrees Fahrenheit. DE #3 acknowledged that the food items should have been reheated before serving them to the residents.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) between resident rooms to prevent cross-contamination. On 05/05/2024, a surveyor observed a CNA exiting one EBP-marked room with gloves on and entering another EBP-marked room without changing gloves or performing hand hygiene. The CNA confirmed that this was not proper hand hygiene and indicated she had been working at the facility for about two months. The Director of Nursing (DON) confirmed that CNAs should not wear gloves out of a room and should sanitize their hands before leaving an EBP-marked room. The facility's policy on EBP, dated 03/21/2024, requires staff training on proper use of PPE and hand hygiene products at the point of care, which was not followed in this instance. Additionally, the facility failed to follow EBP for a resident with a PEG tube. On 05/07/2024, during a medication pass, an LPN and the Assistant Director of Nursing (ADON) administered medication to the resident without wearing the required PPE, specifically isolation gowns. The resident's care plan indicated the need for EBP, including gloves and gowns, during high-contact care activities. Both the LPN and ADON confirmed that an isolation gown should have been worn to prevent contamination. The facility's policy, aligned with CDC guidelines, mandates gown and gloves during high-contact resident care activities, which was not adhered to in this case.
Inaccurate Discharge MDS Assessment
Penalty
Summary
The facility failed to complete an accurate discharge Minimum Data Set (MDS) assessment for Resident #95, who had a diagnosis of fracture shaft of right tibia, arthritis, and seizure disorder. The Admission MDS documented that the resident was cognitively intact. However, the Discharge Return Not Anticipated MDS inaccurately documented the resident's discharge status as being to a short-term general hospital, while the physician's order and electronic records indicated that the resident was discharged home with home health services. The MDS Coordinator confirmed the discrepancy and acknowledged the importance of accurate MDS information for state reporting and ensuring a safe discharge. The Administrator admitted that the facility did not have a specific policy on MDS assessments and relied on the Resident Assessment Instrument (RAI) manual. This lack of a formal policy may have contributed to the inaccurate documentation. The failure to accurately complete the discharge MDS assessment had the potential to affect 76 residents discharged in the last 90 days, as accurate discharge information is crucial for state reporting and ensuring resident safety.
Failure to Update Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to review and revise the care plan to include oxygen therapy for a resident with physician's orders for oxygen therapy. Resident #71, who had diagnoses of stroke, end-stage renal disease, and coronary artery disease, was observed using oxygen therapy at various flow rates on multiple occasions. Despite this, the resident's care plan, initiated on 03/13/2024, did not address the use of oxygen therapy. This oversight was confirmed by the MDS Coordinator, who acknowledged that the care plan should include oxygen therapy if the resident is using it continuously. The MDS Coordinator also noted the importance of having this information in the care plan to ensure that all nurses, including new ones, are aware of the resident's care needs. The deficiency was identified through observation, interview, and record review. The surveyor observed Resident #71 using oxygen therapy on several dates and confirmed that the care plan did not reflect this treatment. The MDS Coordinator admitted that the care plan should have been updated to include oxygen therapy and that the nurses should have communicated the resident's continuous use of oxygen. The facility's Administrator stated that there was no specific policy on care plans, and they followed the Resident Assessment Instrument (RAI) manual. This failure to update the care plan had the potential to affect 55 residents with physician's orders for oxygen therapy.
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to ensure that a resident received wound care as ordered by the physician, which had the potential to affect eight residents with pressure ulcer orders. The resident had diagnoses including a right lower amputated stump infection, type II diabetes mellitus, and acute kidney failure. The care plan indicated the resident had a pressure ulcer on the coccyx and left heel, with orders to administer treatments as prescribed. However, the March Treatment Administration Record showed that the second application of Povidone-iodine to the left heel and around the left foot was not documented on four specific dates in March 2024.
Failure to Secure Hazardous Items
Penalty
Summary
The facility failed to ensure potentially hazardous items were stored securely, as evidenced by the presence of an aerosol can of citrus scent air freshener in a resident's room. Resident #38, who has a diagnosis of Dementia with Behavioral Disturbance and moderate cognitive impairment, was observed with the aerosol can on their nightstand. The resident indicated that staff on the night shift had provided the air freshener. The facility's policy states that the environment should be free of accident hazards, and the Social Service Director confirmed that residents are not allowed to have aerosol cans in their rooms. During interviews, the Social Service Director and the Director of Nursing both acknowledged that aerosol cans are not permitted in resident rooms. The Director of Nursing noted that while it is not safe for the aerosol can to be on the nightstand, attempts to remove it could result in the resident becoming upset. This situation indicates a failure to adhere to the facility's policy on accident hazards and supervision, potentially compromising resident safety.
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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.
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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) |
|---|---|---|---|---|
| Briarwood Nursing And Rehabilitation Center,inc | 0.5 mi | ★★★★★ | 0 | 0 |
| The Green House Cottages Of Poplar Grove | 1.5 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Woodland Hills Rehab & Nursing Cen | 1.6 mi | ★★★★★ | 2 | 1 |
| Presbyterian Village, Inc | 2 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Breckenridge Rehab & Nursing Cente | 2.1 mi | ★★★★★ | 4 | 0 |
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