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 Springs Of Park Ave during CMS and state inspections, most recent first.
A facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) by not wearing required PPE during perineal care for a resident with a stage II pressure wound. The resident had multiple diagnoses and was incontinent. Two CNAs provided care without protective gowns and did not change gloves or perform hand hygiene after handling soiled items, risking cross-contamination. The DON confirmed the need for PPE and hand hygiene, but the facility's policies were not followed, leading to the deficiency.
A resident identified as an elopement risk left the facility without staff knowledge to visit their girlfriend, remaining away for about four hours. Despite being care planned not to leave without supervision, the incident was not reported to the state survey agency. The resident, diagnosed with non-Alzheimer's dementia, had previously been assessed as a moderate elopement risk and had a wander guard placed as a precaution. The facility's DON and Administrator did not consider the incident an elopement, as the resident was deemed capable of self-care. Consequently, no incident report was filed, and the event was not reported to the state, violating the facility's policies.
The facility failed to ensure proper food safety and sanitation practices, including leaving trash cans uncovered, storing dented canned goods and chemicals near clean dishes, and not adhering to handwashing protocols. Various food items were left uncovered, and the facility's walls, floors, and equipment were found to be in unsanitary conditions.
A facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate. An LPN administered incorrect medications to a resident, including enteric-coated aspirin instead of plain aspirin, B complex with vitamin B instead of B complex with vitamin C, and a multivitamin with minerals instead of a plain multivitamin. The DON confirmed that nurses are expected to follow physician orders and use the five rights of medication administration.
The facility failed to store controlled medications in a permanently affixed container and left medications at the bedside. Controlled medications were found unsecured in a refrigerator, and a resident with moderately impaired mental status had an inhaler and nebulizer left on the bedside table. Staff confirmed that no residents were assessed for self-administration of medications, and medications should not be left unattended.
The facility failed to ensure that an advanced directive was readily accessible in the EHR for a resident with dementia and type 2 diabetes mellitus. The resident's care plan indicated a DNR preference, but the directive was not found in the EHR. The Administrator later provided the document, which had not been scanned into the system.
The facility failed to complete a baseline care plan within 48 hours of a resident's admission, neglecting to address ADLs such as bathing, personal hygiene, and toileting for bowel incontinence. Observations noted the resident had visibly dry and cracked lips, and staff interviews confirmed that the necessary care plan was not completed.
The facility failed to update a resident's care plan to include necessary details regarding the use of insulin, a high-risk medication, despite the resident having a physician's order for insulin glargine and receiving insulin injections. The oversight was confirmed by the MDS Coordinator during an interview.
The facility failed to properly label enteral feeding and flush bags for a resident with a PEG tube, despite having a policy in place. Multiple observations revealed that the bags were either not labeled or improperly labeled, which was confirmed by an LPN familiar with the procedure.
The facility failed to ensure proper infection control measures, including covering a linen cart, performing hand hygiene, and using PPE for residents with C-Diff and chronic wounds. Staff were observed not following protocols, and new employees were not adequately trained on Enhanced Barrier Precautions.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure that staff adhered to Enhanced Barrier Precautions (EBP) by not wearing the required Personal Protection Equipment (PPE) during perineal care for a resident with a stage II pressure wound on the coccyx. The resident, who had diagnoses including chronic obstructive pulmonary disease, kidney disease, bipolar disorder, and heart failure, was observed to be incontinent of bowel and bladder. During the observation, two Certified Nursing Assistants (CNAs) provided perineal care without wearing protective gowns and failed to change gloves or perform hand hygiene after handling soiled items and before touching clean items, which posed a risk for cross-contamination and infection. The Director of Nursing confirmed that EBP signs should be posted outside the resident's door and that staff should wear gowns and gloves when providing personal care. The facility's policies on perineal care and hand hygiene were reviewed, revealing that while the hand hygiene policy emphasized the importance of hand hygiene when moving from contaminated to clean sites, the perineal care policy did not address this. Additionally, the facility's EBP policy required staff to be trained annually, and PPE should be readily available for use during high-contact care activities. Despite these policies, the CNAs did not follow the required procedures, leading to the deficiency.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an incident involving a resident who left the facility without staff knowledge to the state survey agency. The resident, who was identified as an elopement risk due to a history of attempts to leave the facility unattended, left the facility to visit their girlfriend and was gone for about four hours. Despite being care planned not to leave the facility without supervision, the incident was not reported as required by the facility's policy on abuse, exploitation, or misappropriation. The resident had a diagnosis of non-Alzheimer's dementia and was assessed as having a moderate risk for elopement. The facility had previously placed a wander guard on the resident as a precautionary measure. However, the Director of Nursing (DON) and the Administrator did not consider the incident an elopement because the resident was deemed capable of taking care of themselves and had not been exit-seeking. Consequently, an incident report was not filed, and the event was not reported to the state. Interviews with facility staff revealed that the resident had learned the door code, possibly by observing others, which allowed them to leave the facility. Although the facility conducted Senior Alert Drills and changed door codes following the incident, the lack of an incident report and failure to notify the state survey agency constituted a deficiency in the facility's adherence to its policies and regulatory requirements.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in the kitchen and food preparation areas. Observations revealed that trash cans were left uncovered near hand washing sinks and refrigerators, which could lead to cross-contamination. Additionally, various food items, including coffee filters, pitchers, and plates, were left uncovered, posing a risk of contamination. The facility also stored dented canned goods and chemicals near clean dishes, which could potentially harm residents if ingested or if the chemicals came into contact with food or food preparation surfaces. Stagnant water was found pooled under the dishwasher and sinks, creating a hazardous environment for both staff and residents. Further inspection showed that personal items, such as a staff water bottle, were stored near clean silverware, and various food items in the freezer were not properly sealed. The facility's walls, floors, and equipment, including light switches, plug outlets, and ceiling tiles, were found to be in unsanitary conditions, with visible grime, smudges, and stains. The outside alcove was cluttered with various items, which could attract pests and pose a safety risk. Additionally, the facility failed to cover food on the steam table and did not provide proper serving sizes to residents. Dietary staff did not adhere to proper handwashing protocols, as they were observed handling dirty items and then returning to food preparation without washing their hands. The facility's handwashing policy and cleaning guidelines were not followed, leading to potential cross-contamination and health risks for residents. The Registered Dietitian and Dietary Supervisor confirmed these deficiencies, highlighting the need for improved food safety and sanitation practices in the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in a medication error rate of 12%. During a medication pass observation, an LPN administered medications incorrectly to a resident. Specifically, the LPN gave enteric-coated aspirin instead of plain aspirin, B complex with vitamin B instead of B complex with vitamin C, and a multivitamin with minerals instead of a plain multivitamin. These errors were identified during a review of the medication administration record (MAR) and the medications given by the LPN. The Director of Nursing (DON) confirmed that nurses are expected to follow physician orders accurately and use the five rights of medication administration. The DON acknowledged that not following physician orders could lead to medication errors. The facility's policy on administering medications requires verifying the right medication and dosage by checking the label three times. Despite these protocols, the LPN failed to administer the medications as prescribed, leading to the identified errors.
Failure to Properly Store Controlled Medications and Secure Bedside Medications
Penalty
Summary
The facility failed to store controlled medications in a permanently affixed container and left medications at the bedside. During the survey, it was observed that the container used to store controlled medications in the medication room on Hall C was not permanently affixed inside the refrigerator. Additionally, the container could not be opened as no staff had the key, and the lock had to be broken by the Maintenance Director. Inside the container, Ativan 2 MG/ML was found, which belonged to a non-sample resident. This indicates a failure to properly secure controlled medications as required by regulations. Furthermore, a resident with a moderately impaired mental status was found to have an inhaler and a nebulizer with clear liquid left on the bedside table, visible from the doorway. The LPN confirmed that the resident was not assessed for self-administration of medications and acknowledged that medications should not be left at the bedside. The DON confirmed that no residents were assessed for self-administration and emphasized that medications should not be left unattended to prevent potential harm. This highlights a failure to ensure medications are securely stored and not left at the bedside, posing a risk to residents' safety.
Failure to Ensure Advanced Directive Accessibility in EHR
Penalty
Summary
The facility failed to ensure that an advanced directive was readily accessible in the electronic health record (EHR) for Resident #24, who had diagnoses of dementia and type 2 diabetes mellitus. The resident's care plan indicated a preference for no cardiopulmonary resuscitation (CPR) and to follow do not resuscitate (DNR) instructions as detailed in the advance directive. However, during the survey, the advance directive was not found in the EHR despite a resuscitation designation order indicating its existence. The Administrator later provided a copy of an advanced directive acknowledgment form and a General Durable Power of Attorney, both of which were stored in the Social Services Office and had not been scanned into the EHR. Licensed Practical Nurse (LPN) #4 confirmed that she relied on the resident's chart to determine the presence of an advanced directive, highlighting a gap in the facility's process for ensuring critical documents are accessible in the EHR.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure a baseline care plan was completed within 48 hours of a resident's admission to address activities of daily living (ADLs) and promote continuity of care and communication among nursing home staff. Resident #123, who had diagnoses of full incontinence of feces and adult failure to thrive, was admitted on 05/03/2024. However, the care plan dated 05/05/2024 did not address the resident's ADLs for bathing, personal hygiene, oral hygiene, mobility, dressing, grooming, or toileting for bowel incontinence. Additionally, an admission assessment contained questions for the care plan, but all sections were left blank. Observations on 05/05/2024 and 05/07/2024 noted that Resident #123 had visibly dry and cracked lips, indicating a lack of attention to personal hygiene needs. Interviews with staff revealed that the nurses did not complete the 48-hour baseline care plan. LPN #4 confirmed that while nurses answered questions about residents' transfers, diet, ambulation, and dental health, these did not trigger a care plan. The Director of Nursing also confirmed that nurses were capable of completing a baseline care plan during the admission assessment, but this was not done for Resident #123. This lack of a baseline care plan resulted in the resident's immediate needs not being addressed within the required timeframe.
Failure to Update Care Plan for Insulin Use
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised at least annually or when the residents' care needs changed. Specifically, the care plan for a resident with type 2 diabetes mellitus and severe cognitive impairment did not include necessary details regarding the use of insulin, a high-risk medication. The resident had a physician's order for insulin glargine, which was administered twice daily, but the care plan did not list any signs, symptoms, or side effects to monitor for insulin use. The deficiency was identified during an interview with the MDS Coordinator, who confirmed that the resident's care plan should have been updated to include insulin use after the annual MDS assessment documented insulin injections. The MDS Coordinator acknowledged the oversight and confirmed that the care plan should have included information about the insulin to ensure nursing staff were aware of the necessary care, assessments, and services required for the resident's diabetes management.
Failure to Properly Label Enteral Feeding and Flush Bags
Penalty
Summary
The facility failed to ensure that enteral feeding and flush bags were properly labeled with the necessary information for Resident #123, who had a percutaneous endoscopic gastrostomy (PEG) tube. The resident had a diagnosis of gastrostomy status and required continuous feeding and water flushes as per physician's orders. However, during multiple observations, it was noted that the enteral feeding and flush bags were either not labeled or improperly labeled. For instance, on 05/05/24, the enteral feeding bag was empty and not labeled, and the flush bag was labeled incorrectly. Similar issues were observed on 05/06/24 and 05/07/24, where the flush bags were not labeled despite containing clear liquid. These observations were confirmed by a Licensed Practical Nurse (LPN) who acknowledged the importance of proper labeling to ensure correct administration and continuity of care. The facility's Enteral Nutrition policy, provided by the Administrator, emphasized the need for proper labeling based on comprehensive nutritional assessments and current standards of practice. Despite this policy, the facility failed to adhere to these guidelines, leading to potential risks for Resident #123. The LPN confirmed that the enteral feeding and flush bags should include specific information such as date, milliliters per hour, name, room number, and time started to ensure proper administration and avoid complications. The lack of proper labeling was a clear deviation from the facility's policy and standard care practices, resulting in a deficiency in the care provided to Resident #123.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, leading to multiple deficiencies. A clean linen cart was observed uncovered and unsupervised on a resident hall, which was confirmed by Laundry Personnel #1. The linen cart should have been covered with a brown cover when not in use to prevent contamination. This lapse in protocol was observed on 05/05/24 at 10:35 AM and confirmed on 05/07/24 at 11:19 AM. Additionally, the facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) when caring for a resident with Clostridium Difficile (C-Diff). Multiple instances were observed where Certified Nursing Assistants (CNAs) and a Licensed Practical Nurse (LPN) did not follow proper procedures for handwashing and PPE usage. For example, CNA #1 did not wash her hands before entering the room of a resident with C-Diff and wore the same mask in and out of all rooms on the hall. Similar lapses were observed with other staff members, indicating a systemic issue with infection control practices. The facility also failed to consistently implement Enhanced Barrier Precautions (EBP) for a resident with chronic wounds. Despite a physician's order and care plan indicating the need for EBP, a CNA was observed not wearing an isolation gown while providing high-contact care. The CNA was also unaware of the EBP requirements and could not locate any gowns in the resident's room. The Infection Preventionist confirmed that new staff were not adequately trained on EBP, further highlighting the facility's failure to adhere to infection control protocols.
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What surveyors actually found near you
We read the 11 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.
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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) |
|---|---|---|---|---|
| Belvedere Nursing And Rehabilitation Center, Llc | 1.9 mi | ★★★★★ | 1 | 0 |
| The Blossoms At Hot Springs Rehab And Nursing Cent | 4.2 mi | ★★★★★ | 0 | 0 |
| The Blossoms At The Village Rehab & Nursing Center | 4.6 mi | ★★★★★ | 4 | 0 |
| The Pines Nursing And Rehabilitation Center | 4.8 mi | ★★★★★ | 0 | 0 |
| The Springs Of Red Oak | 5.7 mi | ★★★★★ | 2 | 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.