Deficiencies (last 3 years)
Deficiencies (over 3 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 5
Date: Sep 19, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication administration, treatment implementation, infection control, and resident care in a nursing home setting.
Findings
The facility was found deficient in multiple areas including allowing a resident to self-administer medications without clinical appropriateness, failure to consistently implement physician orders for position and mobility, medication administration errors including improper insulin pen use and incorrect medication given, and failure to follow proper infection control precautions during wound care.
Deficiencies (5)
Facility failed to ensure a resident was clinically appropriate to self-administer medications.
Facility failed to ensure physician orders were consistently implemented for position and mobility, including failure to apply handrolls or splints as ordered.
Facility failed to ensure medications were administered according to physician's orders for two residents, resulting in medication errors.
Facility failed to ensure insulin pen was prepared and administered according to manufacturer's instructions.
Facility failed to follow proper infection control precautions during wound care, including failure to gown and wash hands appropriately.
Report Facts
Residents sampled: 6
Residents cited: 1
Residents sampled: 1
Residents cited: 1
Residents sampled: 3
Residents cited: 2
Medication errors: 2
Error rate: 5.56
RNA task completion: 17
RNA refusals: 21
RNA not applicable: 48
Resident #30 HbA1c: 9.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Confirmed medications should not be left in residents' rooms |
| Assistant Director of Nursing | ADON | Stated medications should not be left with residents and nurses must ensure medications are taken |
| Director of Nursing | DON | Confirmed medication administration expectations and errors |
| Licensed Practical Nurse #3 | LPN | Observed medication administration and involved in medication error finding |
| Registered Nurse #4 | RN | Observed administering insulin pen incorrectly |
| Advanced Practice Nurse | APN | Provided expert opinion on insulin pen administration and medication administration expectations |
| Certified Nursing Assistant #10 | CNA | Assisted resident and provided information on resident's ability to open hand |
| Restorative Nursing Aide #5 | RNA | Reported on task completion and training related to handroll application |
| Restorative Nursing Aide #6 | RNA | Reported on task completion and training related to handroll application |
| Certified Nurse Assistant #11 | CNA | Reported on RNA task monitoring and training |
| Licensed Practical Nurse #1 | LPN | Observed failing to follow infection control precautions during wound care |
Inspection Report
Annual Inspection
Census: 107
Capacity: 130
Deficiencies: 2
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including coordination with the State Designated Authority for PASARR II evaluations and staffing requirements related to social work certification in a facility with over 120 beds.
Findings
The facility failed to notify the State Designated Authority and obtain a PASARR II evaluation for a sampled resident admitted from a psychiatric facility. Additionally, the facility did not employ a certified social worker despite having more than 120 beds, and lacked a policy for social worker staffing.
Deficiencies (2)
Failed to coordinate with the State Designated Authority and obtain PASARR II evaluation for Resident #3 admitted on 01/15/2025.
Failed to hire a certified social worker in a facility with more than 120 beds.
Report Facts
Number of beds: 130
Resident census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Director | Social Director | Responsible for obtaining PASARR II evaluation but had not been involved prior to survey |
| Administrator | Administrator | Provided information on PASARR II process and social worker staffing requirements |
| Business Office Manager | Business Office Manager | Discussed responsibility for obtaining PASARR II evaluation |
| Admissions | Admissions Staff | Discussed responsibility for obtaining PASARR II evaluation |
| Social Services staff member | Social Services staff member | Employed for two and a half years, not certified social worker |
| Minimum Data Set (MDS) Nurse | MDS Nurse | Interviewed regarding PASARR II evaluation and resident cognitive status |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
The inspection was conducted to investigate allegations of verbal abuse by staff towards residents, specifically regarding failure to report suspected abuse incidents in a timely manner.
Complaint Details
The complaint investigation focused on verbal abuse allegations involving Residents #2 and #3. The allegations were substantiated with evidence from interviews, staff disciplinary records, and policy reviews. Staff failed to report abuse immediately as required, and the alleged perpetrator was not removed promptly to protect residents.
Findings
The facility failed to ensure staff reported allegations of verbal abuse to the Administrator within two hours as required. Interviews and record reviews revealed incidents involving CNA #3 yelling at Residents #2 and #3, and failure by LPN #1 to immediately report the abuse. Staff received abuse training but failed to follow reporting protocols, resulting in disciplinary actions.
Deficiencies (1)
Failure to timely report suspected verbal abuse allegations to the Administrator for 2 of 3 sampled residents.
Report Facts
Dates of abuse training for CNA #3: 07/2024 (orientation), 11/01/2024, 11/15/2024, 01/07/2025
Dates of abuse training for LPN #1: 11/15/2024, 11/18/2024, 01/07/2025, 01/26/2025, 01/28/2025, 02/07/2025, 02/24/2025, 02/28/2025
Dates of abuse training for LPN #2: 01/26/2025, 01/28/2025, 02/07/2025, 02/28/2025
Disciplinary action dates for LPN #1: 01/31/2025 and 03/04/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in verbal abuse incidents involving Residents #2 and #3; received abuse training; left facility after incident. |
| LPN #1 | Licensed Practical Nurse | Witnessed abuse incident; failed to immediately report allegations; disciplined for failure to report abuse. |
| LPN #2 | Licensed Practical Nurse | Witnessed abuse incident; provided witness statement; received abuse training. |
| ADON | Assistant Director of Nursing | Received delayed reports of abuse incidents; provided statements on reporting expectations. |
| DON | Director of Nursing | Newly employed; described abuse reporting procedures and expectations. |
| Administrator | Facility Administrator | Defined abuse and reporting requirements; confirmed yelling at residents is abuse and must be reported immediately. |
Inspection Report
Routine
Deficiencies: 8
Date: Jan 8, 2025
Visit Reason
The inspection was conducted to assess compliance with resident rights, safety, care quality, and environmental standards at The Blossoms at Fort Smith Rehab & Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to provide toilet paper and paper towels in women's secured unit bathrooms, improper management of resident personal funds, unsafe wheelchair transport techniques, unsecured cigarettes accessible to residents, unsanitary conditions in the women's secure unit shower, lack of fitted sheets for beds, failure to provide perineal care during brief changes, improper medication administration by crushing non-crushable iron tablets, unsafe laundry cart transport causing resident injury, and failure to properly check feeding tube placement prior to medication and flush administration.
Deficiencies (8)
Failure to maintain dignity by supplying toilet paper and paper towels in women's secured unit bathrooms.
Failure to obtain written authorization to manage personal funds and ensure resident awareness of fund access and charges.
Failure to use safe wheelchair transport techniques, resulting in resident's foot hitting a door frame.
Failure to secure cigarettes from residents and failure to maintain a clean, sanitary women's secure unit shower room.
Failure to repair broken tile in resident room doorway and failure to provide adequate fitted sheets for beds.
Failure to provide perineal care during soiled brief change and failure to follow physician orders for medication administration (crushing iron tablets).
Failure to ensure safe laundry transport techniques, resulting in resident injury from collision with laundry cart.
Failure to properly check feeding tube placement prior to administering flushes and medications for residents with PEG tubes.
Report Facts
Residents reviewed for personal funds: 5
Residents reviewed for accidents and hazards: 11
Residents reviewed for Quality of Care: 11
Iron oral tablet doses administered: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #3 | CNA | Named in finding related to failure to provide toilet paper and paper towels and failure to perform perineal care. |
| Certified Nursing Assistant #4 | CNA | Named in finding related to unsafe wheelchair transport. |
| Licensed Practical Nurse #1 | LPN | Named in finding related to improper medication administration and feeding tube placement checks. |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including perineal care, medication administration, and facility management. |
| Business Office Manager | BOM | Interviewed regarding failure to obtain written authorization to manage personal funds. |
| Administrator | Facility Administrator | Interviewed regarding multiple deficiencies including cigarette access, paper product availability, and laundry cart safety. |
| Housekeeping Assistant Supervisor | Housekeeping AS | Interviewed regarding unsanitary conditions in women's secure unit shower and broken tile maintenance. |
| Laundry Tech #2 | Laundry Technician | Interviewed regarding laundry cart accident with resident. |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility environment at The Blossoms at Fort Smith Rehab & Nursing Center.
Findings
The facility was found deficient in ensuring residents had call lights within reach, providing adequate care for activities of daily living including incontinence care, and maintaining a safe environment by securing doors to rooms containing chemicals and sharps. Deficiencies were noted with minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failed to ensure residents call lights were within reach for 1 sampled resident.
Failed to ensure 1 resident reviewed for activities of daily living care was kept clean and dry.
Failed to ensure an accident/hazard free environment by not keeping doors locked on rooms containing chemicals and hazards.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Assessment Reference Date: Sep 6, 2024
Assessment Reference Date: Jul 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Confirmed call lights should be within reach before leaving resident's room | |
| Certified Nursing Assistant (CNA) #2 | Confirmed call lights should be within reach before leaving resident's room and stated hopper and shower room doors should be closed and locked | |
| Licensed Practical Nurse (LPN) #1 | Stated residents should always have call lights in reach when staff exit the room | |
| Certified Nurse Aide (CNA) #4 | Provided incontinent care and indicated Resident #13 should be checked every 2 hours | |
| Certified Nurse Aide (CNA) #5 | Provided incontinent care and indicated Resident #13 should be checked every 2 hours | |
| Licensed Practical Nurse (LPN) #3 | Confirmed hopper and shower room doors should be shut and locked to keep residents from accessing chemicals | |
| Administrator | Provided in-services and policies related to call lights and accident/hazard environment |
Inspection Report
Routine
Deficiencies: 6
Date: May 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, abuse prevention, supervision, medication management, food safety, and infection control at The Blossoms at Fort Smith Rehab & Nursing Center.
Findings
The facility was found deficient in maintaining resident dignity and privacy, protecting residents from abuse, ensuring adequate supervision to prevent accidents, proper medication storage and administration, food safety and sanitation practices, and infection prevention including hand hygiene during care and meal service.
Deficiencies (6)
Failure to ensure residents were not visually exposed during care to maintain dignity and privacy.
Failure to protect a resident from physical abuse by another resident with known behaviors.
Failure to provide adequate supervision to prevent accidents for a cognitively impaired resident at risk for choking.
Failure to ensure prescribed medications remain with the nurse for residents not assessed to self-administer medications.
Failure to procure, store, prepare, distribute, and serve food in accordance with professional standards, including expired food, unclean ice machines, improper hand hygiene, and improper food temperatures.
Failure to ensure proper hand hygiene during perineal care, medication pass, and meal and beverage service.
Report Facts
Residents affected: 104
MDS Assessment Reference Dates: Multiple dates including 04/10/2024, 04/26/2024, 03/01/2024, 02/15/2024, 02/22/2024, 02/27/2024
BIMS or SAMS scores: Scores indicating cognitive impairment for various residents (e.g., 1, 2, 3, 12)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #18 | Registered Nurse | Interviewed about resident privacy and dignity |
| Director of Nursing | Director of Nursing | Interviewed regarding resident care plans, abuse incident, medication self-administration, and infection control |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Observed and interviewed regarding perineal care and meal service hygiene |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Observed and interviewed regarding perineal care and meal service hygiene |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Observed during resident privacy and meal service |
| Registered Nurse #12 | Registered Nurse | Interviewed about hand hygiene and resident care |
| Registered Nurse #19 | Registered Nurse | Observed and interviewed about medication storage and facility policy |
| Speech Language Pathologist #20 | Speech Language Pathologist | Provided evaluation and treatment plan for resident with dysphagia |
| Dietary Supervisor | Dietary Supervisor | Interviewed about food safety and ice machine cleaning |
| Dietary Aide #15 | Dietary Aide | Observed handling food and equipment without proper hand hygiene |
Inspection Report
Routine
Deficiencies: 7
Date: Apr 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, discharge procedures, catheter care, trauma-informed care, and food safety in the nursing facility.
Findings
The facility was found deficient in ensuring accurate Minimum Data Set (MDS) assessments, comprehensive and timely care planning including trauma-informed care, completion of discharge summaries, notification of physicians regarding catheter complications, and proper food handling and storage practices. Several residents' care plans were incomplete or not updated to reflect current needs, and dietary staff failed to follow proper hygiene and food safety protocols.
Deficiencies (7)
Failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' status at time of assessment for 2 of 31 sampled residents.
Failed to develop and implement a comprehensive person-centered care plan including trauma histories, measurable objectives, and timeframes for 3 of 27 sampled residents.
Failed to revise care plans within 7 days of comprehensive assessment for 2 of 30 sampled residents.
Failed to ensure a written discharge summary with a recapitulation of the resident's stay for 1 sampled resident discharged in the past 120 days.
Failed to notify physician when 1 resident with an indwelling catheter had pus-like drainage from catheter insertion site.
Failed to provide trauma-informed and culturally competent care for 3 sampled residents with positive trauma histories, including failure to care plan potential triggers.
Failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including improper food covering, cross-contamination risks during meal transport, and dietary staff failing to wash hands or change gloves appropriately.
Report Facts
Residents sampled for MDS accuracy: 31
Residents sampled for trauma-informed care: 27
Residents sampled for care plan revision: 30
Residents affected by food safety deficiencies: 104
Total facility census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding MDS assessment inaccuracies and care plan updates | |
| Assistant Director of Nursing (ADON) | Provided facility policies and interviewed about catheter care and trauma-informed care | |
| Director of Nursing (DON) | Interviewed regarding discharge summary responsibilities and catheter drainage notification | |
| Social Services Director (SSD) | Interviewed regarding trauma-informed care assessments and discharge summaries | |
| Licensed Practical Nurse (LPN) #1 | Observed and interviewed regarding catheter care and drainage | |
| Dietary Employees (DE #1, DE #2, DE #3) | Observed failing to follow proper hand hygiene and food safety procedures | |
| Dietary Supervisor | Provided facility food safety policy and list of affected residents |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report an incident that resulted in serious bodily injury to the Office of Long-Term Care within 2 hours for one resident.
Complaint Details
The complaint investigation found that the facility did not report the incident involving Resident #1 within the required 2-hour timeframe. The incident involved positional asphyxia and death. The facility's Administrator stated the report was not completed after a meeting, and the coroner and detective initially suggested other causes of death such as cardiac-related events. The facility policy requires immediate reporting of suspected abuse or neglect resulting in serious bodily injury.
Findings
The facility failed to report an incident involving Resident #1 who was found unresponsive with positional asphyxia due to his neck positioned between the bottom rails of his mechanical bed. The facility did not complete the required report after the incident, despite policy requirements for timely reporting and investigation of abuse or neglect.
Deficiencies (1)
Failed to timely report an incident resulting in serious bodily injury to the Office of Long-Term Care within 2 hours for Resident #1.
Report Facts
Residents Affected: 1
Timeframe for reporting: 2
Inspection Report
Routine
Deficiencies: 3
Date: Mar 1, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care related to skin integrity, catheter care, and respiratory therapy in a nursing facility.
Findings
The facility failed to ensure appropriate treatment and physician notification for residents with skin abrasions and rashes, proper catheter care to prevent infections, and consistent administration of oxygen therapy at physician-ordered rates. Several residents had untreated skin issues, leaking catheters without proper orders, and oxygen/nebulizer equipment not properly managed.
Deficiencies (3)
Failure to ensure physician notification and treatment for residents with abrasions and skin rashes to prevent infection and deterioration of skin integrity.
Failure to provide appropriate care for residents with indwelling catheters, including ensuring catheter drainage bags were off the floor and physician notification for leaking catheters.
Failure to ensure oxygen was administered at the physician ordered flow rate and nebulizer masks/tubing were properly contained when not in use.
Report Facts
Residents sampled: 11
Residents affected by skin care deficiency: 4
Residents affected by catheter care deficiency: 2
Residents affected by respiratory care deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Described rash and catheter care issues for Resident #3 and Resident #10; discussed responsibilities for physician notification and oxygen therapy. |
| LPN #2 | Licensed Practical Nurse | Described rash and catheter care issues for Resident #3; discussed responsibilities for physician notification and catheter bag placement. |
| LPN #4 | Licensed Practical Nurse | Described rash on Resident #2 and discussed notification procedures. |
| LPN #5 | Licensed Practical Nurse | Discussed rash on Resident #7 and physician notification responsibilities. |
| LPN #3 | Licensed Practical Nurse | Documented progress note on Resident #3 with suprapubic catheter leakage. |
| CNA #1 | Certified Nursing Assistant | Observed with Resident #6 and discussed catheter bag placement and infection control. |
| Director of Nursing | Director of Nursing | Discussed expectations for staff compliance with policies and procedures related to skin and catheter care, and oxygen therapy. |
| Administrator | Administrator | Discussed expectations for staff compliance with policies and procedures related to skin and catheter care, and oxygen therapy. |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided facility policies on wound management, urinary catheter care, oxygen administration, and nebulizer medication administration. |
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