Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pines Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident admitted with a diagnosis of upper extremity thrombosis did not receive prescribed blood thinning medication due to a transcription error by the admitting nurse. The oversight was not caught by the APRN, pharmacist, or nurse management team, leading to the resident's hospitalization and death from a stroke.
A resident with diabetes and other health issues experienced high blood sugar levels, an elevated white blood cell count, and developed a new pressure ulcer. The facility failed to notify the physician and the resident's family about these significant changes, contrary to their policy. Interviews with staff revealed confusion and inconsistencies in the notification process, and the resident's responsible party confirmed they were not informed of these changes.
The facility failed to follow physician's orders for wound care for two residents with pressure ulcers when the designated wound care nurse was out sick. A resident with a stage 4 pressure ulcer missed a treatment due to workload issues faced by an LPN, who did not inform the oncoming shift. Another resident with multiple pressure ulcers also missed treatments due to similar communication and delegation failures. The DON was aware of the need for assistance but did not ensure treatments were completed.
Failure to Administer Blood Thinner Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a newly admitted resident was free from significant medication errors, specifically related to the administration of a blood thinning medication. The resident, who had been diagnosed with upper extremity thrombosis and a necrotic ulcer, was admitted to the facility with an order for continued anticoagulation therapy. However, the admitting nurse did not transcribe the physician's order for the blood thinner into the resident's electronic health record (EHR). As a result, the resident did not receive the necessary medication from the time of admission until the resident was found unresponsive and later passed away from a stroke. The deficiency was compounded by multiple oversights from the facility's staff. The Advanced Practical Registered Nurse (APRN) and the pharmacist did not verify the resident's medication orders against the hospital discharge summary, and the blood thinning medication was not addressed during their reviews. The Assistant Director of Nursing (ADON), who was responsible for transcribing the orders, did not recall omitting any medication and was unaware of the missing order until after the resident's condition deteriorated. The Director of Nursing (DON) and the nurse management team also failed to catch the missing order during their daily startup meetings. Interviews with facility staff revealed a lack of communication and verification processes that contributed to the oversight. The pharmacist relied on the nursing staff to input correct orders into the EHR, and the APRN did not have access to the After Visit Summary during medication reviews. The ADON admitted to transcribing orders for multiple new admissions on the same day, which may have contributed to the error. The facility's failure to ensure the resident received the prescribed blood thinning medication ultimately led to the resident's hospitalization and subsequent death.
Removal Plan
- The admitting charge nurse will enter all orders from the discharge summary provided by the hospital.
- The admitting nurse will make a copy of the discharge summary and turn it over to the Medical Records Nurse or designee.
- The Medical Records Nurse or designee will provide a copy of the discharge summary to the Director of Nursing as well as the Advanced Practice Registered Nurse or Medical Doctor for review and recommendations.
- The nurse management team will jointly verify the accuracy of the orders against the hospital discharge summary at the nurse start up meeting.
- The RN supervisor will review the admission discharge summary and reconcile against entered orders. Any discrepancy will be reported to the Director of Nursing and on call provider for clarification and correction.
- All admissions will be reviewed again by the nurse management team at the nurse start up meeting.
Failure to Notify Physician and Family of Resident's Condition Changes
Penalty
Summary
The facility failed to notify the physician and/or the resident's representative of significant changes in the condition of a resident, identified as Resident #3. This resident had a history of type 2 diabetes, heart disease, and other health issues, and was cognitively intact with a BIMS score of 15. The facility's policy required immediate notification of the resident, their physician, and their legal representative in the event of a significant change. However, the facility did not adhere to this policy when Resident #3 experienced abnormal blood sugar levels, an elevated white blood cell count, and the development of a new pressure ulcer. On two occasions, Resident #3's blood sugar levels were recorded at 443 and 456, which were significantly higher than the normal range. Despite this, there was no documentation indicating that the physician or the resident's representative was notified. Additionally, a lab report showed an elevated white blood cell count, suggesting a possible infection, but again, there was no evidence of notification to the physician. Furthermore, a pressure ulcer developed on Resident #3's left buttock, which was not present upon admission, and there was no record of the family being informed about this new condition. Interviews with various staff members, including LPNs, RNs, the ADON, and the DON, revealed inconsistencies and a lack of clarity regarding the notification process. Some staff were unaware of the specific parameters for notifying physicians about blood sugar levels, and there was confusion about who was responsible for reviewing lab results. The APRN admitted that the elevated white blood cell count was not reviewed until several days after the lab results were received. The resident's responsible party confirmed that they were not informed about the pressure ulcer, elevated blood sugars, or abnormal lab values, highlighting a significant communication breakdown within the facility.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician's orders for wound care treatment were followed for two residents with pressure ulcers. Resident #2, who was admitted with a stage 4 pressure ulcer among other diagnoses, missed a scheduled wound care treatment on 08/26/2024. The designated wound care nurse, RN #10, was out sick, and LPN #3, who was responsible for the resident's care, was unable to complete the treatment due to workload. LPN #3 did not inform the oncoming shift about the missed treatment, and the Director of Nursing (DON) was unaware that assistance was needed. Similarly, Resident #4, who had multiple pressure ulcers, missed wound care treatments on 08/25/2024 and 08/26/2024. The resident's care plan included specific interventions for pressure ulcer management, but these were not followed due to the absence of the treatment nurse. LPN #3, who was responsible for the resident's care, did not complete the treatments and failed to communicate the lapse to the next shift. The DON was aware that the LPN needed assistance but did not ensure that the treatments were completed. Interviews with staff revealed a lack of communication and delegation of responsibilities when the treatment nurse was unavailable. The DON and the facility's administration expected the floor nurses to complete wound care treatments in the absence of the treatment nurse, but this expectation was not effectively communicated or managed, leading to missed treatments for both residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 27 citations issued within 25 miles in the last 12 months — 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 Hot Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Of Red Oak | 1 mi | ★★★★★ | 2 | 0 |
| The Blossoms At Hot Springs Rehab And Nursing Cent | 1.5 mi | ★★★★★ | 0 | 0 |
| Quapaw Care And Rehabilitation Center Llc | 4.1 mi | ★★★★★ | 0 | 0 |
| The Springs Of Park Ave | 4.8 mi | ★★★★★ | 0 | 0 |
| Belvedere Nursing And Rehabilitation Center, Llc | 6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Pines Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.