Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 West Dixon Rehab & Nursing Center during CMS and state inspections, most recent first.
Pharmacist recommendations were not addressed for two residents. One resident with diabetes, depression, and cognitive impairment had pharmacy recommendations to reduce an antidepressant and change insulin therapy, but the orders were not updated and no A1C order was in place. Another resident with epilepsy and severe cognitive impairment had a high anti-seizure medication level, and a pharmacy recommendation for follow-up lab monitoring was not completed.
A resident with severe cognitive impairment and extensive assistance needs had bathroom sink water that remained cold or measured far below a comfortable temperature during repeated checks, and the Maintenance Director acknowledged the water was too cool. In addition, three hall showers had black discoloration in the grout, walls, corners, and lower wall areas, and staff stated the showers needed regrouting. The facility also had a prior grievance about no working water in the resident’s room, and leadership did not provide policy guidance on resident room water temperatures or Environmental Services.
Failure to Notify Physician of Elevated Blood Glucose: A resident with DM2, depression, and insulin use had moderate cognitive impairment and was ordered insulin before meals and at bedtime, but the chart lacked blood glucose notification parameters and A1C orders. The MAR documented repeated high blood sugars, and staff did not promptly notify the MD of the significant change in condition. LPNs and the DON stated the MD should have been notified when no parameters were in place.
A resident with multiple medical and psychosocial needs was not changed out of soiled clothing in a timely manner after requesting assistance, resulting in psychosocial distress. After the resident filed a grievance, the care plan was updated to include statements about making false allegations, despite no prior behavioral documentation, and the resident expressed fear of retaliation. Staff interviews confirmed delays in care and inadequate response to the resident's concerns.
A resident with multiple medical and cognitive conditions was denied unrestricted visitation when a health care liaison, attempting to complete an assessment after a transfer referral, was interrupted by the DON and escorted out by the BOM, despite prior communication and no documented refusal or safety concern. Facility policy and staff interviews confirmed that such visits should have been permitted, but the liaison was not allowed to complete the visit.
The facility did not adhere to the planned menu and recipe for resident meals, affecting the nutritional needs of residents. A dietary staff member prepared oatmeal incorrectly and failed to serve pureed grits and coffee cake to residents on pureed diets, admitting to not following the menu and being in a rush.
The facility failed to prepare meals according to recipes, impacting their nutritive value and taste. During meal preparation, dietary staff used hot water instead of broth or milk for pureed sausage and scrambled eggs, deviating from the facility's recipes. This resulted in meals that lacked flavor, as acknowledged by the dietary staff.
The facility failed to ensure adequate call light systems for residents, with one resident lacking a reachable call light and another experiencing a malfunctioning system. A resident with Alzheimer's and another with schizophrenia shared a room with only one call light, which was inaccessible. Additionally, a resident with respiratory failure had a call light that did not function properly, as it did not light up when activated. The DON confirmed the importance of functional call lights, but maintenance checks were not frequent enough to prevent these issues.
The facility's kitchen had multiple sanitation issues, including unclean and damaged surfaces, improper food storage, and inadequate hand hygiene practices by dietary staff. Uncovered food items and failure to refrigerate opened products were observed, along with staff not washing hands after handling dirty objects. The ice machine also showed signs of inadequate cleaning.
The facility failed to ensure proper hand hygiene during resident care, maintain infection control for a urinary catheter, and consistently implement a water management program. CNAs did not sanitize hands between residents, and catheter tubing was improperly placed on the floor. The water management program lacked documentation of flushing activities and temperature checks.
A facility failed to maintain the dignity of a resident with an indwelling urinary catheter by not covering the catheter bag, as observed when the resident was seated in a hallway with visible contents in the bag. The resident's care plan required a privacy bag, which was not used, and a CNA confirmed the expectation that the bag's contents should not be visible. The facility's policy mandates covering catheter bags to promote dignity.
A facility failed to accurately code a resident's dialysis treatment in the MDS, despite the resident having end-stage renal disease and receiving dialysis three times a week. The omission was confirmed by the MDS Nurse, who acknowledged the importance of accurate coding for proper care planning. This oversight had the potential to misrepresent the resident's health status and impact care planning and reimbursement.
A resident with severe cognitive impairment and impaired vision was found with an uncapped razor left unattended in their room, contrary to facility policy. The facility's policy required razors to be discarded in a designated sharps container outside resident rooms. Observations and interviews confirmed the presence of the razor and the associated risks, highlighting a failure to ensure resident safety.
A resident with chronic respiratory conditions was observed receiving oxygen at a higher rate than the physician-ordered 2 liters per minute. The resident was found on multiple occasions with the oxygen concentrator set between 2.5 to 3 liters. The LPN confirmed the discrepancy with the physician's order, and the DON acknowledged the importance of checking oxygen settings every shift. The facility's policy required oxygen to be administered at the ordered rate, which was not followed in this case.
A resident with type two diabetes and difficulty chewing did not receive a mechanical soft diet as ordered by a physician. The resident's care plan lacked documentation of the need for this diet, and during an observed meal, the resident was served food not prepared in a mechanical soft form. The dietary manager confirmed the oversight, which was contrary to the facility's policy on therapeutic diets.
A facility failed to administer a pneumococcal vaccine to a resident with dementia and an irregular heartbeat, despite having received consent. Orders were in place for the administration of Prevnar 20, but the vaccine was not given. The Infection Preventionist could not explain the oversight, and the facility's policy to offer pneumococcal vaccines was not followed.
Pharmacist Recommendations Not Addressed for Medication and Lab Monitoring
Penalty
Summary
The facility failed to ensure that pharmacist recommendations from monthly drug regimen reviews were addressed for two residents reviewed for unnecessary medications. One resident had diagnoses including type 2 diabetes mellitus, major depressive disorder, and long-term insulin use, and had moderate cognitive impairment. The resident’s care plan identified diabetes with insulin therapy and use of an antidepressant, and the medication record showed an antidepressant order for 60 mg daily and a short-acting insulin order before meals and at bedtime. A pharmacy review recommended a gradual dose reduction of the antidepressant from 60 mg to 30 mg daily, and the physician agreed to decrease the medication once the current supply was completed, but the order summary did not show the decrease. A later pharmacy review recommended discontinuing the bedtime short-acting insulin and starting 5 units of long-acting insulin because of elevated blood sugar levels, and the physician agreed, but the order summary did not show those changes. The pharmacy review also did not acknowledge that there was no laboratory order for an A1C, even though the DON stated staff were to contact the physician if a resident taking insulin did not have an A1C order. The second resident had diagnoses including schizophrenia, epilepsy, major depressive disorder, mild intellectual disabilities, convulsions, and dissociative and conversion disorder, and had severe cognitive impairment. The resident’s care plan called for lab work to be obtained and monitored as ordered for seizure disorder. The resident had anti-seizure medication levels checked, with a high result noted, and the APRN ordered the level repeated in one month. A pharmacy review later noted the high level and recommended follow-up levels, but there was no physician review completed and the lab redraw was not done. The DON acknowledged that the pharmacist recommendation for a repeat level was not followed and stated the physician did not review the recommendation.
Cold Resident Room Water and Unsanitary Shower Conditions
Penalty
Summary
The facility failed to ensure that the water temperature in one resident room was maintained at a comfortable temperature for use. Resident #78, who was admitted with diagnoses including late-onset Alzheimer's disease, dementia, and full incontinence of feces, had a BIMS score of 00 indicating severe cognitive impairment. The resident's MDS showed the resident required partial/moderate assistance with showering and bathing, and the care plan later indicated extensive assistance with toileting, personal hygiene, and bathing. During multiple observations, the hot water in the bathroom sink for this resident remained cold to touch or measured only 70.2 degrees F, 72.7 degrees F after running for three minutes, and 65.8 degrees F after running for 11 minutes. The Maintenance Director stated the water should be 90-100 degrees F for resident rooms and acknowledged that 65.8 degrees F was not sufficient because it was too cool. The report also documented that three of six hall showers were not maintained in a clean and sanitary condition. Observations of the 300-Hall shower, the 100-Hall shower, and the 600-Hall shower showed black discoloration in the grout, walls, corners, and lower wall areas. The 600-Hall shower was located across the hall from the resident's room. A CNA stated housekeeping was responsible for cleaning the showers and noted the discoloration in the 300-Hall shower had been present for a while. The Housekeeping Supervisor stated showers were disinfected twice daily, but also stated the grout needed to be regrouted and described the grout as dark gray and black looking. Record review and interviews showed the facility had prior awareness of the water issue. The December 2025 grievance log included a grievance for Resident #78 indicating no working water, with Social/Maintenance listed as responsible. The resident's family member stated there was no hot water in the bathroom and that the resident had sometimes been cleaned using a towel and water from the faucet. The Maintenance Director stated he was unsure about the water temperature standard and said he was still learning. The Nurse Consultant and Administrator did not provide a policy or guidance on resident room water temperatures or Environmental Services, and staff stated they had no further documentation to provide regarding the water temperature concern or the shower conditions.
Failure to Notify Physician of Elevated Blood Glucose
Penalty
Summary
The facility failed to ensure the physician was promptly notified of a significant change in condition for one resident who was receiving insulin therapy. Resident #4 had diagnoses including type 2 diabetes mellitus, major depressive disorder, and long-term use of insulin, and the quarterly MDS indicated moderate cognitive impairment. The care plan identified diabetes with insulin therapy and risk for low and high blood sugars, and the order summary showed an order for 11 units of insulin before meals and at bedtime, but there were no parameters for when to notify the physician and no A1C labs ordered. Resident #4’s MAR showed elevated blood glucose readings, including values of 444 mg/dL and 400 mg/dL in January 2026, and additional elevated blood sugars documented in December 2026. The pharmacist recommended discontinuing the bedtime 11-unit insulin dose and starting 5 units because the resident’s blood sugars were elevated, but there was no indication for physician notification or an A1C order. During interviews, LPNs stated that if no parameters were listed, the physician should be notified, and the DON stated that if a resident was taking insulin and had no A1C order, the nurse needed to notify the physician to determine how often an A1C should be ordered and to obtain parameters for blood sugar notification. The physician was called and a voicemail was left during the survey, but no return call was received.
Failure to Protect Resident Rights and Dignity During ADL Care and Grievance Process
Penalty
Summary
A resident with chronic kidney disease, type 2 diabetes, left-sided muscle weakness/paralysis, cognitive communication deficit, major depressive disorder, and a history of homelessness was admitted to the facility. The resident had moderate cognitive impairment and was frequently incontinent of bowel, requiring assistance with activities of daily living (ADLs). The care plan for the resident included interventions for medication and pharmacy review related to major depression, but did not address ADL care or psychosocial needs in detail. The resident filed a grievance stating that a CNA did not change them when requested, resulting in the resident remaining in soiled clothing during mealtime. Multiple interviews and documentation confirmed that the resident was not changed in a timely manner, and the CNA assigned to the resident was removed from the hall following the complaint. The resident and external care providers reported that the resident appeared disheveled, had lost weight, and expressed fear of retaliation after making the grievance. The resident also reported being treated roughly and being left in soiled clothing for extended periods, which caused psychosocial distress. Following the grievance, the facility updated the resident's care plan to include statements about the resident making false allegations and exhibiting maladaptive behavioral symptoms, despite no documented behavioral issues prior to this event. The care plan revision was made on the same day the facility received a complaint from an external provider. Interviews with staff indicated that the resident's concerns were not fully addressed, and the care plan was amended in a way that could be perceived as punitive after the resident exercised their right to file a grievance.
Failure to Ensure Unrestricted Visitation Rights
Penalty
Summary
The facility failed to ensure unrestricted visitation rights for a resident who had a history of chronic kidney disease, type 2 diabetes, muscle weakness/paralysis, cognitive communication deficit, major depressive disorder, and a history of homelessness. The resident had varying cognitive assessments, with a BIMS score indicating moderate cognitive impairment at one point and a higher score at another. The resident's care plan addressed major depression but did not include interventions related to visitation or social support. A health care liaison from another facility attempted to visit the resident to complete an assessment following a transfer referral. Upon arrival, the liaison was directed to the resident's room by nursing staff but was soon interrupted by the DON, who asked her to come to the administration office. The liaison was then questioned by the Administrator about her presence and was ultimately escorted out by the Business Office Manager, despite having previously communicated with the BOM about the visit. Staff interviews revealed confusion about the process, with some staff stating that visitors were allowed at any time unless there was a safety issue or the resident refused, neither of which applied in this case. Facility policy and resident rights documents confirmed that residents are entitled to immediate access by individuals providing health or legal services, subject only to the resident's consent. The Social Worker confirmed that the transfer referral had not been withdrawn and that the liaison had not been told not to visit. Despite these policies and the resident's rights, the liaison was not allowed to complete the assessment, resulting in a failure to honor the resident's right to receive visitors of their choosing.
Failure to Follow Menu and Recipe for Resident Meals
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu and facility recipe, which compromised the nutritional needs of the residents. During a breakfast meal service, a dietary staff member prepared oatmeal using a bag of brown sugar and two sticks of butter, deviating from the facility's recipe that specified precise measurements of water, whole milk, rolled oats, non-fat dry milk, margarine, and sugar. Additionally, the facility's breakfast menu indicated that residents on pureed diets should receive pureed grits and pureed coffee cake. However, the dietary staff member served regular grits instead of pureed grits and did not serve pureed coffee cake to these residents. When questioned, the dietary staff member admitted to not following the menu and stated that pureed grits had never been served, and the omission of pureed coffee cake was due to being in a rush.
Failure to Maintain Nutritive Value and Taste in Meal Preparation
Penalty
Summary
The facility failed to ensure that meals were prepared in a manner that maintained their nutritive value and taste, which are essential for improving palatability and encouraging good nutritional intake among residents. During an observed meal preparation, the dietary staff did not follow the facility's recipes for pureed sausage and scrambled eggs. Instead of using hot broth as specified in the recipe for pureed sausage, the dietary staff used hot water from a coffee maker and added thickener, which deviated from the prescribed method. Similarly, for pureed scrambled eggs, the staff used hot water instead of hot milk and added thickener, which was not in accordance with the recipe. When asked about the taste of the scrambled eggs and sausage pureed with water, the dietary staff member acknowledged that they would taste like nothing.
Inadequate Call Light Systems in Resident Rooms
Penalty
Summary
The facility failed to provide adequate call light systems for residents, as observed during a survey. Resident #40, diagnosed with Alzheimer's, left eye blindness, and failure to thrive, was found without a call light within reach. The call light was observed on the floor behind a recliner, making it inaccessible. Additionally, Resident #66, who shares the room with Resident #40 and has diagnoses of schizophrenia, dementia, and anxiety, also lacked access to a call light. A Certified Nursing Assistant confirmed that there was only one call light in the shared room, which was insufficient for both residents to call for assistance. Resident #76, diagnosed with respiratory failure, schizoaffective disorder, and anxiety, experienced a malfunctioning call light system. The resident was heard calling for help, and although the call light alarmed, it did not light up above the doorway, indicating a failure in the system. The Director of Nursing acknowledged that call lights should be available and functional, and that maintenance checks are conducted periodically, though the frequency was not specified. The Maintenance Repair Log indicated a previous check had been conducted, but issues persisted, as evidenced by the non-functional call light in Resident #76's room.
Sanitation and Food Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as evidenced by multiple observations of unclean and damaged surfaces. The kitchen air vent was not cleaned, and various areas, including the dishwashing machine room and storage room, had chipped walls and door frames covered with rust, dirt, and debris. Additionally, the preparation counter and other surfaces had stains and residue, compromising the cleanliness required for food preparation. Food storage practices were inadequate, with several instances of uncovered or unsealed food items in the freezer, such as biscuits, sausage patties, breaded cod fish, chicken nuggets, and a vegetable blend. An opened bottle of lemon juice was not refrigerated as per the manufacturer's instructions, posing a risk of food spoilage. Furthermore, leftover pureed food items were observed being prepared for reheating, contrary to the Dietary Manager's statement that fresh food is made daily. Hand hygiene practices were not consistently followed by dietary staff, as observed in multiple instances where staff failed to wash their hands after handling dirty objects and before handling clean equipment or food items. This included touching faucet handles, tray cards, and plates without washing hands, which could lead to contamination. The ice machine on the 300 Hall also had a wet black residue, indicating inadequate cleaning, despite being used for residents' water pitchers.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to practice proper hand hygiene during meal service and perineal care, leading to potential cross-contamination among residents. A Certified Nursing Assistant (CNA) was observed assisting two residents during meal service without sanitizing hands between interactions, which was confirmed by the CNA as a risk for cross-contamination. Additionally, during perineal care for a resident, another CNA used the same hand to pull out clean wipes and perform the cleaning, which was acknowledged as a concern for cross-contamination by both the CNA and the Director of Nursing (DON). The facility also failed to maintain proper infection control measures for a resident with an indwelling urinary catheter. The catheter tubing was observed lying directly on the floor, and the drainage valve was not in its protective sleeve, increasing the risk of contamination. The CNA responsible for the resident's care confirmed that the tubing should not be on the floor. The facility's infection control policy did not address the placement of catheter tubing, and the urinary catheter care policy did not provide guidance on this issue. Furthermore, the facility did not consistently implement its water management program to monitor for Legionella and other water-borne pathogens. The program lacked documentation of specific water outlets flushed, dates of flushing, and water temperature checks. The Assistant Maintenance Director was not familiar with the water management program, and the Administrator confirmed that the program's documentation was incomplete, with missing temperature logs and unclear records of flushing activities.
Failure to Maintain Resident Dignity with Catheter Bag Coverage
Penalty
Summary
The facility failed to ensure the dignity of a resident with an indwelling urinary catheter by not covering the catheter bag, as observed in the case of Resident #42. The resident, who has Alzheimer's disease and an obstruction in urine flow, was noted to have a catheter bag with visible contents while sitting in a hallway. The resident's care plan specified the use of a privacy bag for the catheter, which was not adhered to. A Certified Nursing Assistant confirmed awareness of the care plan requirements and acknowledged that the contents of the catheter bag should not be visible. The facility's Resident Dignity policy, effective since April 2021, mandates that staff promote dignity by ensuring urinary catheter bags are covered.
Inaccurate MDS Coding for Dialysis Treatment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the dialysis treatment received by a resident with end-stage renal disease, right lower lobe cancer, and type II diabetes mellitus. The resident, who was severely cognitively impaired, had an active diagnosis of dependence on renal dialysis. Despite this, the admission MDS did not indicate that the resident was on hemodialysis upon admission or while residing in the facility. This oversight was identified during a review of the resident's medical records, which showed that the resident received dialysis three times a week and had a care plan addressing the risk of fluid volume excess due to dialysis treatment. The MDS Nurse confirmed that dialysis was omitted from the MDS and acknowledged the importance of accurately coding such treatments to ensure proper care planning. The nurse relied on the discharge summary from the resident's hospital stay and the Resident Assessment Instrument (RAI) Manual for coding guidance. The omission of dialysis from the MDS had the potential to misrepresent the resident's health status, affecting care planning, reimbursement levels, and the identification of necessary interventions. The importance of documenting special treatments within a resident's 14-day look-back period was emphasized to ensure the appropriateness of ongoing care.
Uncapped Razor Left Unattended in Resident's Room
Penalty
Summary
The facility failed to ensure the safety of a resident by leaving an uncapped razor unattended in the resident's room, which posed a risk of accidents or injuries. The resident, who had a severe cognitive impairment with a BIMs score of 4, was diagnosed with schizoaffective disorder, dementia, and stroke. The resident was dependent on personal hygiene and had impaired vision, as indicated in the Minimum Data Set (MDS) and care plan. The facility's policy required that razors be discarded in a designated sharps container outside resident rooms after use, but this was not followed. During the survey, the uncapped razor was observed on multiple occasions in the resident's room, alongside a toothbrush and toothpaste. Interviews with the LPN and the Director of Nursing confirmed that residents should not have uncapped razors in their rooms to prevent injuries. The Director of Nursing stated that residents should be offered a shave on shower days and acknowledged the risk of accidental cuts or injuries if razors were left in resident rooms.
Failure to Administer Oxygen at Ordered Rate
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician-ordered rate for a resident with chronic obstructive pulmonary disease, acute respiratory failure, and pulmonary emphysema. The resident was observed on multiple occasions receiving oxygen at a rate higher than the prescribed 2 liters per minute. Specifically, the resident was found to be on 3 liters of oxygen by nasal cannula and later observed with the concentrator set between 2.5 to 3 liters. These observations were confirmed by both the resident and the Licensed Practical Nurse (LPN) who verified the physician's order for 2 liters as needed. The Director of Nursing (DON) confirmed that nursing staff should check oxygen settings every shift, as some residents adjust their own oxygen levels. The DON also acknowledged that not adhering to the ordered oxygen dose could impact the resident's health, including their heart rate. The facility's policy on oxygen administration was reviewed, which stated that oxygen should be administered at the ordered rate unless otherwise specified. Despite this policy, the resident's oxygen was consistently set above the prescribed level, indicating a failure in following the physician's orders and facility protocols.
Failure to Provide Mechanical Soft Diet
Penalty
Summary
The facility failed to provide a mechanical soft diet to a resident during the lunch meal service, despite having a physician's order for such a diet due to the resident's difficulty chewing. The resident, who was diagnosed with type two diabetes, had an order for a mechanical soft texture diet dated 05/21/2024. However, the resident's care plan did not reflect the need for this diet, nor did it note the absence of upper teeth or dentures. A dietary progress note from 05/20/2024 recommended a mechanical soft diet for the resident, but this was not adhered to during the observed meal service. On 08/21/2024, the resident was observed with a lunch meal tray that included a slice of meatloaf, macaroni and cheese, green peas, and a cookie, none of which were prepared in a mechanical soft form. The resident expressed distress over the inability to eat due to the lack of top teeth. The dietary manager confirmed that the meatloaf should have been ground for a mechanical soft diet, as indicated on the facility's dietary spreadsheet. The facility's policy on therapeutic and modified diets, dated 05/25/2012, stated that diets should be prepared according to physician orders, which was not followed in this instance.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a pneumococcal vaccine was administered to a resident, despite having received consent for the vaccination. The resident, who had diagnoses of dementia and an irregular heartbeat, had an order dated February 23, 2024, indicating that they could receive the Pneumovax vaccine unless contraindicated. A subsequent order on August 20, 2024, specified that a dose of Prevnar 20 was to be administered intramuscularly. However, upon review of the resident's immunization screen on August 22, 2024, it was noted that the Prevnar 20 vaccine was listed as required but had not been administered. The Infection Preventionist, when interviewed, was unable to provide an explanation for the failure to administer the vaccine, despite the consent being given months earlier. The facility's Pneumococcal Vaccine policy, effective since March 2020, stated that all residents would be offered pneumococcal vaccines to prevent infections, yet this was not adhered to in this case.
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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) |
|---|---|---|---|---|
| The Blossoms At Cumberland Rehab & Nursing Center | 5.3 mi | ★★★★★ | 2 | 0 |
| The Springs Of Barrow | 7 mi | ★★★★★ | 4 | 0 |
| The Blossoms At Midtown Rehab & Nursing Center | 7.1 mi | ★★★★★ | 15 | 0 |
| The Green House Cottages Of Poplar Grove | 7.1 mi | ★★★★★ | 0 | 0 |
| Briarwood Nursing And Rehabilitation Center,inc | 7.3 mi | ★★★★★ | 0 | 0 |
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