Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Springs Of Barrow during CMS and state inspections, most recent first.
Care Plan Missing Oxygen Therapy Interventions: A resident with moderate cognitive impairment and diagnoses including pneumonia, chronic respiratory failure, asthma, COPD, and chronic lung disease was observed receiving oxygen at 4 L/min via NC, but the care plan had no oxygen therapy interventions. The MDS indicated the resident continued to receive oxygen while in the facility, and staff including an LPN, MDS Coordinator, APRN, DON, and Administrator confirmed oxygen-related interventions should have been included.
Missing Physician Order for Oxygen Therapy: A resident with COPD and other significant respiratory diagnoses was observed receiving oxygen via nasal cannula, but the EHR contained no physician's order for oxygen therapy. An LPN confirmed the oxygen was in use and could not locate an order, and the APRN, MDS Coordinator, DON, and Administrator all acknowledged that an order should have been in place. The facility policy also required verification of a physician's order before oxygen administration.
The facility failed to maintain cleanliness and sanitation, with observations of unlined trash cans, stained walls, and unsanitary shower rooms. A resident's room had a dirty trash can and toilet, while hallways and smoking areas were not properly maintained. Staff interviews revealed unclear cleaning responsibilities, and the facility's cleaning policy lacked specific instructions for certain tasks.
A resident with Alzheimer's and a femur fracture had a fall mat removed from their care plan without notifying their emergency contact. The facility's policy requires informing the resident's representative of such changes, but this was not done, as confirmed by the DON.
A resident with hypertension and other conditions was admitted to a facility with a prescription for an angiotensin-converting enzyme inhibitor, which was not ordered or administered, leading to a hypertensive emergency. Interviews revealed a breakdown in the medication reconciliation process, despite procedures in place for reviewing discharge medication lists. The Director of Nursing acknowledged the importance of accurate medication reconciliation, but the failure resulted in a serious health event.
A facility failed to implement enhanced barrier precautions (EBP) for a resident requiring such measures. Two CNAs provided incontinence care without wearing gowns, despite a sign indicating the need for gloves and gowns during high-contact activities. The resident had a gastrostomy status and was on continuous enteral feeding, with a plan of care highlighting a risk for skin breakdown due to incontinence. The facility's EBP policy required gown and glove use for residents with medical devices, which was not followed in this instance.
The facility exhibited deficiencies in dietary hygiene and food storage practices. Dietary staff failed to wash hands and change gloves after contamination, and the ice machine was not maintained in a sanitary condition. Opened food items were not sealed, and expired products were not discarded promptly. Cold beverages were not held at the required temperature, and the facility's hand washing policy was not followed.
The facility failed to provide a safe, clean, and homelike environment for residents, with surveyors observing uncleanliness and disrepair in multiple rooms and bathrooms. Issues included sticky floors, unpleasant odors, exposed rough particle board, and broken furniture. Staff confirmed these conditions, raising concerns about potential safety hazards.
The facility did not secure areas containing hazardous equipment, such as the storage closet and water heater closet, which were found unlocked and accessible to residents. The Maintenance Supervisor acknowledged that the keypad locks were not functioning due to dead batteries, and these areas should have been locked to prevent resident access and potential harm.
The facility failed to properly document and reconcile refrigerated narcotics, leading to a deficiency in pharmaceutical services. An LPN reported missing documentation for narcotics, which were later found in the back of the narcotic book. Additionally, narcotics were not counted every shift as required, risking undetected disappearance. The ADON confirmed the need for proper documentation and shift counts.
The facility failed to ensure narcotics were clearly labeled, risking medication errors. An LPN found a faded label on an anti-anxiety medication in the narcotic box, which was later identified by an RN. Despite a request for a new label, the pharmacy had not sent one. The ADON confirmed staff should notify the DON or ADON and contact the pharmacy for new labels when needed.
Care Plan Missing Oxygen Therapy Interventions
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and implemented to include oxygen therapy interventions for Resident #67. During observations on 03/02/2026 and 03/04/2026, the resident was seen receiving oxygen at 4 liters per minute via nasal cannula through an oxygen concentrator, and an LPN was present at the bedside during one observation. Resident #67's admission MDS dated 01/25/2026 showed a BIMS score of 10, indicating moderate cognitive impairment, and listed diagnoses including pneumonia, chronic respiratory failure with hypoxia and hypercapnia, asthma, COPD, and chronic lung disease. The MDS did not include oxygen therapy, although the 5-day MDS dated 02/07/2026 indicated the resident had continued to receive oxygen therapy while in the facility. Review of the care plan showed no interventions related to oxygen therapy. During interview, the LPN confirmed the resident was on oxygen at 4 liters per minute and could not locate oxygen-related care plan interventions, stating they should be present for any resident receiving oxygen therapy. The MDS Coordinator stated they were responsible for creating and modifying care plans and that residents on oxygen should have oxygen therapy interventions listed; they also stated there were no oxygen therapy interventions on the care plan from admission through 03/03/2026. The APRN stated the resident was admitted on oxygen and had reported being on oxygen for 10 years. The DON and Administrator both stated oxygen therapy interventions should have been included in the care plan.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure a physician's order for oxygen therapy was in place before supplemental oxygen was administered to Resident #67. Resident #67 was admitted with a primary diagnosis of COPD and had additional diagnoses including pneumonia, chronic respiratory failure with hypoxia and hypercapnia, asthma, and chronic lung disease. The resident's MDS indicated moderate cognitive impairment and did not show that oxygen therapy was being received, while provider notes documented the resident had been hospitalized for acute on chronic hypoxic respiratory failure, sepsis secondary to influenza A, community-acquired bacterial pneumonia, and COPD exacerbation. During observations, Resident #67 was seen receiving oxygen at 4 liters per minute via nasal cannula through an oxygen concentrator. Review of the order summary showed no physician's orders for oxygen therapy. LPN #1, who was at the bedside, confirmed the oxygen was being administered and could not locate an order in the EHR, acknowledging that an order should have been in place. The APRN, MDS Coordinator, DON, and Administrator each confirmed that a physician's order for oxygen therapy should have been present for the resident, and the facility policy titled Oxygen Administration stated to verify that there is a physician's order for the procedure.
Facility Fails to Maintain Cleanliness and Sanitation
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in several areas, impacting both resident and public spaces. Observations revealed that a trash can in a resident's room lacked a liner and contained debris and stains, while the resident's toilet bowl had a brown ring. Hallways had brown stains on walls and baseboards, and the smoking area was littered with cigarette butts. Additionally, shower rooms were found with black stains on grout and walls, and trash cans without liners containing discolored liquids. Interviews with staff indicated a lack of clarity and execution in cleaning responsibilities, with the Laundry/Housekeeping Supervisor acknowledging daily cleaning duties but failing to ensure their completion. The facility's Daily Cleaning Procedures policy was reviewed and found to be lacking in specific instructions for cleaning walls and baseboards. The use of a one-step disinfectant was noted, but the contact time for mold and mildew was not specified, potentially contributing to the inadequate cleaning observed. The Maintenance Director mentioned shared responsibilities for maintaining the smoking area, but did not clearly define who was responsible, leading to the accumulation of cigarette butts. These deficiencies highlight a breakdown in the facility's cleaning protocols and oversight, resulting in unsanitary conditions for residents and staff.
Failure to Notify Emergency Contact of Care Plan Change
Penalty
Summary
The facility failed to notify a resident's emergency contact of a change in the resident's plan of care. The deficiency involved a resident with a severe cognitive impairment due to Alzheimer's disease and a history of a femur fracture. The resident's emergency contact was not informed when a fall mat, initially placed as a safety measure, was removed following a therapy evaluation. This decision was made during an interdisciplinary team meeting, but the emergency contact was not notified, contrary to the facility's policy. The Director of Nursing confirmed that the fall mat was removed because the resident was mobile and there was a concern about the resident tripping over it. Despite this change in the resident's care plan, there was no documentation indicating that the emergency contact or any other representative was informed of the removal of the fall mat. The facility's policy requires prompt notification of changes in a resident's condition or care plan to the resident, their physician, and their representative, which was not adhered to in this case.
Failure in Medication Reconciliation Leads to Resident's Hypertensive Emergency
Penalty
Summary
The facility failed to provide necessary care and services to a resident, resulting in a decline in the resident's physical well-being. The resident, who was cognitively intact and had a history of hypertension, end-stage renal disease, and hemiplegia, was admitted to the facility with a discharge summary from the hospital that included a prescription for an angiotensin-converting enzyme inhibitor to manage high blood pressure. However, the medication was not ordered or administered from the time of admission until the resident was hospitalized for a hypertensive emergency. Interviews with facility staff revealed a breakdown in the medication reconciliation process. The admission nurse and LPN described a procedure where discharge medication lists are entered into an electronic queue for review by floor nurses, with a final check by the admission nurse. Despite these steps, the medication was missed, indicating a failure in the process. The Director of Nursing confirmed that the orders are reviewed by multiple staff members, but the medication was still not administered, highlighting a gap in the system. The facility's procedure document for medication reconciliation on admission outlines steps to list and review medications for discrepancies, but there was no additional policy for handling orders when a resident returns from a hospital visit. The Director of Nursing acknowledged the importance of accurate medication reconciliation for resident health and safety, yet the failure to administer the prescribed medication led to a serious health event for the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to consistently implement enhanced barrier precautions (EBP) during resident care activities for a resident who required such precautions. On a specific date, two Certified Nursing Assistants (CNAs) were observed providing incontinence care to the resident without wearing gowns, despite the requirement to do so as indicated by a sign outside the resident's room. The sign specified that staff must wear gloves and a gown for high-contact resident care activities, including changing briefs. However, both CNAs only used gloves during the care activity. The resident in question had a medical diagnosis that included a gastrostomy status and was receiving continuous enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. The resident's plan of care indicated a self-care performance deficit in activities of daily living and a risk for skin breakdown due to incontinence. The facility's Enhanced Barrier Precautions policy required the use of gown and gloves during high-contact care activities for residents with medical devices such as a feeding tube, but this was not adhered to by the CNAs during the observed incident.
Deficiencies in Dietary Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper hygiene and sanitation standards in its dietary department, as observed through multiple incidents involving dietary staff and food storage practices. Dietary Aide #1 was observed contaminating his hands by handling his phone and then touching clean plates without washing his hands. Additionally, he failed to wash his hands after handling a carton of milk and before wrapping utensils for meals. The ice machine in the kitchen was found with a pink, slimy residue, indicating inadequate cleaning, and the dietary staff were unsure about the cleaning frequency. Furthermore, opened food items in the refrigerator and freezer, such as sausage, steak fritters, and corndogs, were not covered or sealed, posing a risk of cross-contamination. Expired food items, such as potato chips, were found in the medication room, and cold beverages were not maintained at the required temperature of 41 degrees Fahrenheit, with apple juice and strawberry shakes recorded at higher temperatures. Dietary staff also failed to change gloves and wash hands after handling potentially contaminated items, as seen with Dietary [NAME] #2, who did not wash hands after touching dirty objects before handling food. The facility's policy on hand washing was not adhered to, contributing to these deficiencies in maintaining food safety and hygiene standards.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents, as observed by surveyors. Multiple instances of uncleanliness and disrepair were noted in the rooms and bathrooms of residents on the 300 Hall. For instance, Resident #2's room and bathroom were consistently found with sticky floors, brown smears on the bathroom door, and a feeding pole with a dried brownish-white substance. The resident's wardrobe and over-the-bed table had exposed rough particle board, posing potential safety hazards. Resident #13's room and bathroom were observed to have a strong, unpleasant odor, with black substances on the floors and missing trim on the wainscoting, leaving rough edges exposed. The bathroom door was difficult to open, requiring force to access. Similarly, Resident #14's room had a strong odor of feces, a large hole in the footboard, and a plunger with a dark brown clumpy substance left in the bathroom. These conditions were consistent over multiple days of observation. Additional issues were noted in Resident #33's and Resident #65's rooms, including dark brown smears on privacy curtains, peeling paint and drywall, and gaps around the commode allowing urine to pool. The wardrobes and nightstands in these rooms were also in disrepair, with broken hinges and drawers. Staff interviews confirmed these observations, with concerns raised about the potential for residents to be scratched by rough surfaces and the presence of odors and mildew.
Failure to Secure Hazardous Areas
Penalty
Summary
The facility failed to ensure that certain areas were secured to prevent resident access to potentially hazardous equipment, leading to a deficiency. Specifically, the storage closet, janitor's closet near the dining area, and the water heater closet off the 100 Hall were not locked, allowing access to equipment that could result in accidents or injuries. During the survey, it was observed that the heating and cooling equipment was accessible through a set of white double doors. Additionally, the storage closet contained a large metal cabinet with coiling wires and a bucket with gray fluid under a humidifier. The water heater closet door was slightly open, exposing the hot water system. The Maintenance Supervisor confirmed that the keypad locks' batteries were dead, and the doors should have required a key to be unlocked, acknowledging that residents should not have access to these areas due to the risk of harm.
Deficiency in Narcotic Documentation and Reconciliation
Penalty
Summary
The facility failed to ensure proper documentation and reconciliation of refrigerated narcotics, leading to a deficiency in pharmaceutical services. On a specific date, an LPN reported that refrigerated narcotics from a medication room were not documented in the new narcotic book, and she was unable to find a narcotic page for a resident and two other non-sampled residents. Later, an RN showed the LPN that the narcotic pages were documented in the back of the narcotic book, which was questioned by a Nurse Consultant without receiving a response. Additionally, the facility did not adhere to the policy of counting refrigerated narcotics every shift. An LPN confirmed that narcotics were not being counted every shift, which could lead to narcotics disappearing without detection. The ADON stated that narcotics should be documented on the next corresponding page and counted at the beginning of each shift. An in-service provided by the ADON emphasized that all controlled substances should be counted by nursing during each shift, with both responsible parties verifying the medication card and narcotic page for accuracy.
Failure to Ensure Legible Medication Labels on Narcotics
Penalty
Summary
The facility failed to ensure that narcotics were clearly and legibly labeled, which is essential to prevent medication errors and misappropriation. During an observation, it was found that the refrigerated narcotic box contained several bottles of anti-anxiety medication, including one with a completely faded label. This unidentified bottle was marked with a red 'C' and was not immediately recognizable, posing a risk of medication errors. Licensed Practical Nurse (LPN) #3 acknowledged the issue and indicated that the unidentified medication should be reported to the Director of Nursing (DON) to prevent it from disappearing without a trace. Further investigation revealed that Registered Nurse (RN) #4 was able to identify the medication as belonging to a non-sampled resident. It was noted that a request for a new label had been made to the pharmacy approximately two weeks prior, but the pharmacy had not sent a replacement. The Assistant Director of Nursing (ADON) confirmed that staff are expected to notify the DON or ADON and contact the pharmacy for a new label when a medication label is worn and unreadable. This failure to ensure proper labeling could lead to the wrong medication being administered or the medication being taken improperly.
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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 Woodland Hills Rehab & Nursing Cen | 1 mi | ★★★★★ | 2 | 1 |
| The Green House Cottages Of Poplar Grove | 1 mi | ★★★★★ | 0 | 0 |
| Nursing And Rehabilitation Center At Good Shepherd | 1 mi | ★★★★★ | 4 | 0 |
| Presbyterian Village, Inc | 1.8 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Breckenridge Rehab & Nursing Cente | 2 mi | ★★★★★ | 4 | 0 |
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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 July 2026) and official state health department websites.