The Blossoms At Breckenridge Rehab & Nursing Cente
Inspection Findings
F-Tag F0689
F 0689
- 1. The nurse was notified, doors were checked, and a unit and facility search began.
- 1. A body audit was completed on 05/17/2025 at 5:50 PM for Resident #2.
- 2. An Elopement Risk assessment with Care Plan was completed on 05/17/2025 at 10:12 PM, for Resident
- 1. The process was changed immediately when taking Resident #2 out of the unit – the door was to
- 2. Doors on the secure unit were monitored three times per week, for June 2025 and July 2025, then
- 3. Keypad covers were installed on 05/19/2025 to decrease visibility of the code entry
- 4. In-services to all staff on elopement policy and procedure began 05/17/2025 with a completion date of
Level of Harm - Actual harm
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.
Residents Affected - Few Other immediate actions by the nursing staff included:
#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:
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.
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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
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The Blossoms at Breckenridge Rehab & Nursing Cente in LITTLE ROCK, AR inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.