Skip to main content
Complaint Investigation

The Blossoms At Breckenridge Rehab & Nursing Cente

January 8, 2025 · Little Rock, AR · 800 Brookside Drive
Citations 4
CMS Rating 1/5
Beds 143
Provider ID 045458
Healthcare Facility
The Blossoms At Breckenridge Rehab & Nursing Cente
Little Rock, AR  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

The Blossoms at Breckenridge Rehab & Nursing Cente in LITTLE ROCK, AR — inspection on January 8, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical

regarding the incident. A full body assessment and body audit was done on Resident #3 and their

jeopardy to resident health or heard from LPN #2 loud [NAME] were heard at the nurses station. LPN #2 asked if CNA #1 hit safety Resident #3 and that CNA #1 stated that they clapped her hand but patted her buttocks.

045458 01/08/2025

The Blossoms at Breckenridge Rehab & Nursing Cente 800 Brookside Drive Little Rock, AR 72205

Review of a facility policy titled Prevention and Prohibition of Abuse indicated The facility administrator or designee shall complete a report to be made to the mandated state agency and may also be made to the local law enforcement agency after corporate approval or immediately if the abuse constitutes an emergency.

Administrator or designee will have 5 working days from the initial report of abuse to complete SIMS (Statewide Incident Management System) report.

Immediately means as soon as possible, in the absence of a shorter State time frame requirement, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

A review of an admission Record indicated the facility admitted Resident #3 with a diagnosis of schizoaffective disorder (combination of symptoms that affect a person's emotional state and a disorder that affects a person's ability to think, feel, and behave clearly).

A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had severe cognitive impairment.

A review of Resident #3 ' s Reportable, dated 12/18/2024, indicated Nurse was at nurse ' s station and heard a popping noise that they thought was a slap.

Upon entering the resident's room, Certified Nursing Assistant (CNA) #1 was getting resident up to go use the bathroom.

Licensed Practical Nurse (LPN) #2 asked CNA #1 if they hit the resident. CNA #1 answered back that she ' popped resident on the butt with the back of the hand ' trying to get her to go to the bathroom. LPN #2 dismissed CNA #1 from the room, assessment of resident completed with no negative findings.

Resident stable with no distress noted. CNA #1 immediately suspended with investigation started.

During an interview with the Administrator on 12/31/2024 at 12:05pm, the Administrator was familiar with Resident #3 ' s care and confirmed knowledge of alleged abuse on 12/18/2024.

The Director of Nurses (DON) notified the Administrator of the alleged abuse.

The Administrator confirmed the incident and accident was on 12/18/2024 at 6:00AM but notification was sent in on 12/19/2024 at 10:58AM. A body audit and assessment of Resident was completed, and the employee was suspended.

The Administrator confirmed a representative and the attending practitioner were both notified.

The Administrator confirmed the abuse was reported to the Office of Long-Term Care.

The Administrator confirmed that an investigation had been completed and was awaiting notice from the Office of Long-Term Care.

The Administrator confirmed the employee was suspended and removed from facility for their actions and to protect the alleged victim from further abuse during the investigation process.

The results of the investigation were founded, and the staff member was terminated.

The Administrator revealed there were no warning signs to facility to indicate prior to the incident and the facility tried to send in the reportable within a timely manner but had difficulty.

045458 01/08/2025

The Blossoms at Breckenridge Rehab & Nursing Cente 800 Brookside Drive Little Rock, AR 72205

reflect Resident #5's goals, preferences, needs, strengths and interventions for care.

resident.

The Administrator was asked what the policy and procedure for completing the care plan

upon admission within 48 hours and person-centered care based on RAI, reviewed with resident Inter-Disciplinary Team (IDT) team and responsible party and updated quarterly and as needed.

A review of the facility's undated policy titled Care Plan Policy and Procedure, provided by the Administrator on 01/03/2025, indicated Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches It is the policy of this facility to utilize an advanced care planning approach to review and determine patient centered care plans.

Review of Resident #3 Care Plan, initiated 10/23/2024, revealed the resident at risk for alteration psychosocial wellbeing related to living in skilled facility for long term care. No interventions in place at the time of review.

An OLTC Incident and Accident Report (I&A) dated 12/18/2024 revealed LPN #2 stated that CNA #1 confirmed that they popped the resident on the butt trying to get her to go the bathroom. LPN #2 revealed that they heard ouch with each of four swats. LPN #2 stated from the sound, it was not a clap that was heard. A witness statement from LPN #2 was included and read, This nurse was sitting at nurse ' s station . when [Resident #3] was screaming ouch, ouch from the swats from aide [CNA #1] x4 times.

This nurse then asked aide if she hit resident.

She [CNA #1] stated, No I was popping her on the butt.

During interview on 12/30/2024 at 1:50pm, Resident #3 stated that they (indicating CNA #1) hit me on the butt and I hit them back first.

During an interview on 12/30/2024 at 2:01pm, Human Resources (HR) stated CNA #1 was no longer with us.

045458

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 045458 B.

Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cottage Lane Health and Rehab of Little Rock 800 Brookside Drive Little Rock, AR 72205

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LITTLE ROCK, AR, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Blossoms at Breckenridge Rehab & Nursing Cente or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.