The Blossoms At Breckenridge Rehab & Nursing Cente
The Blossoms at Breckenridge Rehab & Nursing Cente in LITTLE ROCK, AR — inspection on September 12, 2025.
Found 1 citation. 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
During an interview on 09/09/2025 at 10:47 AM, LPN #1 indicated Resident #2 was put on one-to-one monitoring upon return to the facility.
Other immediate actions by the nursing staff included:
- A body audit was completed on 05/17/2025 at 5:50 PM for Resident #2.
- An Elopement Risk assessment with Care Plan was completed on 05/17/2025 at 10:12 PM, for Resident
#2, as well as all other residents in the facility During an interview at 09/09/2025 at 11:28 AM, the Maintenance Director indicated he came up the night of the incident and checked all doors, checked all alarms on the doors and changed all the codes for the doors.
The Maintenance Director also indicated that since there was nothing wrong with the doors, Resident #2 must have followed another person out of the door.
The facility provided timecard sheets to demonstrate the presence of the Maintenance Director at 8:00 PM on 05/17/2025 until 8:17 PM.
During an interview on 09/09/2025 at 12:48 PM, the DON indicated the Root Cause Analysis (RCA) Elopement Protocol and Root Cause Analysis, done between 05/17/2025 and 05/19/2025, revealed the only feasible way Resident #2 could have gotten out was the resident knew the codes to the door(s).
The interventions implemented were as follows:
- The process was changed immediately when taking Resident #2 out of the unit – the door was to
be opened first, then Resident #2 would be taken through the door.
This process change did not allow Resident #2 the opportunity to see the code being used.
- Doors on the secure unit were monitored three times per week, for June 2025 and July 2025, then
- Keypad covers were installed on 05/19/2025 to decrease visibility of the code entry
- In-services to all staff on elopement policy and procedure began 05/17/2025 with a completion date of
weekly, to ensure the doors were locked and the alarms were functioning correctly.
05/19/2025.
Education included in the training was to ensure doors are secure, not to allow residents to view the keypads when codes were entered, not to use exit doors on the secure unit unless it was an emergency.: Interviews with staff were conducted to verify they were in serviced on how to prevent elopement and the correct process if a resident eloped.
Staff interviewed were as follows: LPN #1, CNA #2, CNA #3, RN #4, CNA #5, LPN #6, Med Tech #7, LPN #8, Housekeeping #9, LPN #10, and CNA #11.
These interviews were conducted with staff that worked on all shifts.
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