Below average — CMS composite of the measures below.
The next survey window likely opens 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 Blossoms At Berryville Rehab & Nursing Center during CMS and state inspections, most recent first.
Two residents with complex medical conditions and extensive medication regimens experienced significant medication errors when new LPNs, inadequately oriented and not fully competency-checked, misadministered drugs during med pass. In one case, a new LPN on her first day, unfamiliar with residents and the electronic system, gave another resident’s medications—including a hypoglycemic and an antihypertensive—to a cognitively intact resident with multiple cardiopulmonary and renal diagnoses, leading to hypotension, hypoglycemia, and hospital transfer. In the other case, an LPN in training and her preceptor pulled medications simultaneously from the same cart, and a resident requesting pain medication received an excessive dose of a controlled sleeping pill instead, a drug the pharmacist stated would definitely increase sedation and could depress CNS and breathing. Facility policy required verification of resident identity, triple-checking medication labels, and at least three days of accompanied med rounds for new personnel, but interviews showed these requirements were not fully implemented before the new nurses participated in or conducted medication administration alone or in a hurried, shared-cart process.
The facility failed to implement and complete its nurse orientation and competency validation process for new LPNs, resulting in two separate medication errors. One LPN, new to LTC and unfamiliar with the facility’s computer system, was left alone on the med cart after only partial observation-based training and without a completed competency checklist, and a resident received another resident’s medications. Another new LPN, also without documented competency sign-offs, was in joint med-pass with an untrained preceptor when a resident requesting pain medication was given sleeping pills after the preceptor pulled the wrong controlled medication and the trainee administered it. Preceptors were selected informally from floor nurses without preceptor training, and leadership interviews confirmed that required competency checklists and the facility’s own med-pass orientation policy were not consistently followed or documented.
Kitchen sanitation failure with dirty drip pans and fish fryer. Surveyors observed drip pans coated with a brown and black substance and visible charred noodles, along with a fish fryer grease layer covered in floating brown particles and cloudy grease. The DM said the drip pans had not been personally checked since starting in September and that the fryer was cleaned only every 2 weeks, while staff interviews did not identify these items as routine cleaning tasks. The facility cleaning schedule required daily drip pan cleaning and weekly fryer cleaning, but the records showed both were overdue.
A facility failed to maintain staffing levels required by its assessment, with multiple day, evening, and night shifts staffed below the required CNAs and nurses. Grievances and resident council minutes documented repeated complaints about delayed call-light response, and during observation a resident’s call light was sounding while staff walked past without stopping; the resident said they needed help with bed making and getting into bed and reported the facility was always shorthanded. Staff interviews described frequent short staffing, delayed or missed water passes, incomplete showers on weekends, and the Administrator and AD assisting with meal tray delivery and feeding during periods of short staffing.
Surveyors observed improper food storage and unsanitary conditions in a facility's kitchen and dining areas. Food was stored on the floor, and there was standing water in the walk-in refrigerator. In a dining room refrigerator, numerous food items were unlabeled, undated, and expired, with a sticky substance at the bottom. Staff interviews revealed unclear cleaning responsibilities, contributing to these deficiencies.
The facility failed to provide dignified meal assistance to residents, as an LPN was observed standing while feeding multiple residents with cognitive impairments, contrary to facility policy. Interviews revealed a misunderstanding among staff about the requirement to sit at eye level with residents during meal assistance, contributing to the deficiency.
A resident with cognitive and mood disorders did not receive regular showers as required, with only three showers documented over a month. Staff interviews revealed minimal staffing and improper documentation practices, with "Not Applicable" used instead of marking refusals. The facility's policy did not address missed showers, leading to a deficiency in care.
The facility failed to ensure staff performed hand hygiene while serving meals and providing assistance to residents, as staff moved between residents without sanitizing their hands. Additionally, an LPN did not follow Enhanced Barrier Precautions during catheter care for a resident with a history of infection, failing to wear a gown as required by policy.
A resident with moderate cognitive impairment was repeatedly observed with bleach and disinfectant wipes left accessible on their bedside table. Facility staff, including a CNA, RN, and DON, confirmed that these hazardous materials should not have been left in the resident's room and should be stored securely to prevent access.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors for two residents during medication administration. For the first resident, who had multiple complex diagnoses including pneumonia, COPD, CHF, atrial fibrillation, pulmonary hypertension, peripheral vascular disease, chronic kidney disease stage 3, hypertension, hyperlipidemia, and aortic valve stenosis, a nurse on her first day at the facility administered another resident’s medications in error. The resident was cognitively intact and receiving numerous scheduled medications, including diuretics, anticoagulants, antihypertensives, electrolyte replacements, and oxygen. A Medication Error Report documented that the resident was mistakenly given four incorrect medications intended for another resident, including a blood sugar–lowering medication, an antidepressant, a uric acid–lowering medication, and an antihypertensive with side effects of hypotension and hyperkalemia and label warnings related to diabetic medications. The error for the first resident occurred when an LPN, new to LTC and to the facility’s computer system, misidentified the resident and pulled the wrong medications. The LPN reported that it was her first day, she had limited orientation time with an RN preceptor that morning, and she had not been checked off as competent to administer medications independently. She stated she did not yet know the residents, found the electronic photos too small to distinguish individuals, and did not know how to enter orders into the computer. She described feeling overstimulated and attempting to work independently. The UM, who was simultaneously functioning as wound nurse, UM, and preceptor, left the LPN alone on the cart after the LPN stated she felt comfortable, despite the UM not having observed her passing medications and not having completed the medication portion of the competency checklist. The RN who precepted earlier in the day stated the LPN had only observed her, had not performed tasks independently, and had not been checked off to administer medications alone. Following the wrong-medication administration to the first resident, vital signs later showed hypotension and hypoglycemia, and the resident was sent to the hospital. Hospital records documented treatment for a medication error, hypotension, hypoglycemia, elevated heart enzymes, and acute kidney injury, with very low blood pressure on arrival and the resident reporting feeling like they were dying. Documentation from the hospital indicated facility staff reported the resident had been hypotensive for two hours. The pharmacist, after reviewing the resident’s scheduled medications and the medications given in error, stated she would have monitored for low blood pressure, low blood sugar, and oversedation, and identified multiple medications that could contribute to these effects. The NP stated it was difficult to determine whether the medication error caused the event, noting the resident’s existing pneumonia and kidney function issues. The resident’s representative reported being notified of a severe drop in blood pressure and stated that a physician advised seeking legal advice. The second resident involved in the deficiency had multiple diagnoses including critical illness myopathy, metabolic encephalopathy, cerebral edema, diabetes, morbid obesity, respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, cognitive communication deficit, dysphagia, hyperlipidemia, bipolar disorder, hypertension, and chronic kidney disease, and was cognitively intact. This resident was on a complex medication regimen including antipsychotics, antidepressants, anticoagulants, antibiotics, diuretics, opioids, and hypoglycemics. A Medication Error Report documented that the resident was accidentally given two sleeping pills instead of two pain pills. The error occurred while an LPN in training and her preceptor were both pulling medications from the same cart, with the trainee pulling non-controlled medications and the preceptor pulling narcotics. For the second resident, the trainee LPN reported that the resident had requested a pain pill but was given sleeping pills instead. She stated that the mistake was discovered later when controlled medications were counted and that the sleeping pill, a controlled medication, was stored in the narcotic box with other controlled medications. She reported that the preceptor punched the medication from the wrong card, that the pills were both small white tablets, and that they were trying to hurry. The trainee LPN stated she did not recall any specific competency check-offs and that her license had simply been verified. The pharmacist stated that the dose of sleeping medication given exceeded the recommended daily dose and would definitely increase sedation, with potential for amnesia, CNS depression, and breathing interruptions if the resident did not use a pressurized mask while sleeping, as well as possible sleepwalking episodes. The NP later reported there were no adverse side effects observed in this resident. The facility’s written Medication Administration policy required that medications be administered in accordance with orders, that the individual administering medications verify resident identity before administration, and that the label be checked three times to ensure the right resident, medication, dose, and route. The policy also stated that medications ordered for one resident may not be administered to another, and that new personnel authorized to administer medications would not be permitted to prepare or administer medications until oriented to the facility’s medication administration system. It further required that a charge nurse accompany new nursing personnel on medication rounds for a minimum of three days to ensure procedures were followed and proper resident identification methods were learned. Interviews with the UM, RN preceptor, and LPNs indicated that the new nurses involved in both medication errors were allowed to participate in or conduct medication passes without full completion of competency checklists, without consistent direct observation, and while preceptors were performing multiple roles or sharing the cart, contributing to the misadministration of medications to both residents.
Failure to Implement Effective Nurse Orientation and Competency Validation Leading to Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective nurse training and competency program for new LPN staff, resulting in incomplete orientation and unverified competencies for at least two nurses. The facility maintained a New Trainee Folder and a Licensed Nurse Competency Skills Check-off form intended to cover unit safety, communication, infection control, nursing care, emergency procedures, equipment, medication administration, pain management, resident rights, abuse, dementia care, QAPI, person-centered care, cultural competency, and HIPAA. Human Resources reported that the competency checklist was to be printed and placed in a staffing binder, completed by the preceptor over the first three days, and then signed off by leadership. However, for both reviewed LPNs, these competency checklists were not completed, and there was no documented verification that they had met medication administration or other required competencies before functioning independently. One LPN, on her first day working in the facility and with no prior LTC experience, was involved in a medication error in which a resident received another resident’s medications. This LPN reported that she had only been trained by an RN from 6 AM to 10 AM on how residents took their medications and who had swallowing issues, and that she did not know how to enter orders into the computer system and was unfamiliar with the software. The RN preceptor stated that the LPN had only observed her and had not performed any tasks independently before the RN left, and that she had not checked the LPN off to administer medications alone. The Unit Manager acknowledged that the LPN had no LTC experience, that she did not complete the medication portion of the competency checklist, and that she left the LPN alone on the cart after the LPN stated she felt comfortable, despite not having seen her pass medications. The facility’s Medication Administration policy required that new personnel not administer medications until oriented to the system and that a charge nurse accompany them on medication rounds for a minimum of three days, but this process was not followed or documented for this LPN. Another new LPN, also without a completed competency checklist, was involved in a separate medication error in which a resident requesting pain medication received sleeping pills instead. This LPN reported that she was in training with a preceptor, and that both nurses were pulling medications from the same cart, with the preceptor handling controlled substances. The error occurred when the preceptor punched a sleeping pill from the wrong card, and the trainee LPN administered it, noting that the pills were both small and white and that they were trying to hurry. The LPN stated she did not recall any specific competency check-offs being done beyond a license check. The Unit Manager and ADON both confirmed that preceptors were simply floor nurses who had been at the facility longer, with no formal preceptor training, and that the current training program had only recently started. Employee files for both LPNs lacked completed Licensed Nurse Competency Skills Check-off forms as of the survey date, and leadership interviews showed uncertainty about when competency checklists should be completed and how much training the LPNs had actually received before being allowed to function independently.
Kitchen sanitation failure with dirty drip pans and fish fryer
Penalty
Summary
The facility failed to ensure that food preparation equipment and the kitchen environment were maintained in a clean and sanitary condition to prevent contamination and the potential development of foodborne pathogens. During an initial kitchen tour, surveyors observed the drip pans covered with aluminum foil that was coated with a brown and black substance and visible charred curly noodles. At the same time, the fish fryer grease was observed to be mostly covered with floating brown particles, and the visible grease was cloudy. The Dietary Manager confirmed that the drip pans had not been cleaned or personally checked since starting employment in September, and stated that the fish fryer was used a couple of times per week and cleaned once every two weeks. Staff interviews did not identify cleaning of the stove, drip pans, or fish fryer as part of routine kitchen sanitation tasks, and one dietary aide could not recall the last in-service or its topic. The Administrator stated he made frequent daily visits to the kitchen and confirmed that infrequent cleaning of the drip pans could create a potential hazard of foodborne pathogens. The facility’s cleaning schedule required the fish fryer to be cleaned weekly and the drip pans daily, but the schedule showed the drip pans had not been cleaned since 11/28/2025 and the fish fryer had not been cleaned since the week of 11/24/2025-11/30/2025.
Inadequate staffing and delayed call-light response
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet residents’ needs for timely assistance, call-light response, and water pass in accordance with its facility assessment. The assessment revised 07/11/2025 required direct-care staffing for an average daily census of 64 residents of 6 CNAs and 3 nurses on days, 4 CNAs and 3 nurses on evenings, and 4 CNAs and 2 nurses on nights. Facility staffing records from 04/05/2025 through 11/23/2025 showed multiple shifts with staffing below those required, including shortages on day, evening, and night shifts across several dates and census levels. The facility’s grievance logs documented repeated complaints that call lights were not answered in a timely manner, and resident council meeting minutes also reflected complaints about delayed call-light response. During observation on 12/01/2025, multiple stripped bare, unmade beds were seen throughout the facility. Later that day, Resident #3’s call light was lit and sounding while several staff members walked by without stopping; the resident called out for help, and staff responded verbally without checking on the resident’s needs. Resident #3 was sitting in a wheelchair, their bed was stripped, and folded linen was in a chair in the room. The resident stated they wanted their bed made and to be assisted to bed and reported the facility was always shorthanded. Staff interviews supported the reported staffing concerns. The Administrator stated he frequently assisted with passing trays and feeding residents at mealtimes, and the AD said meal tray assistance was provided during short staffing, including on 12/01/2025. CNA interviews described staffing as not adequate, call lights not always being answered timely during busy care periods, water not always being passed as needed, showers not being completed on weekends, and a recent weekend day shift with only three CNAs that was not sufficient to assist residents with breakfast or lunch. The DON confirmed the facility had no policy regarding resident hygiene of answering call lights.
Improper Food Storage and Sanitation in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain proper food storage and sanitation standards in its kitchen and dining areas, as observed by surveyors. In the kitchen, food items such as potatoes were stored directly on the floor, and there was standing water in the walk-in refrigerator, which was being absorbed by towels and sheets. The area beneath the dishwasher was damp and stained, indicating a leak that had been recently addressed but not fully resolved. These conditions were acknowledged by the Dietary Manager, who noted that the maintenance issues had persisted for some time. In the dining areas, the surveyor found that the refrigerator in one of the dining rooms contained numerous food items that were not labeled, dated, or covered, including expired items and items without lids. The Director of Nursing confirmed that the refrigerator was used by both residents and staff, although it was intended only for resident use. The refrigerator was also found to be in an unsanitary condition, with a sticky brown substance at the bottom, and there was confusion about the ownership and status of the food items stored there. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities for the refrigerator, with the Housekeeping Supervisor stating that they had never cleaned it. The facility's housekeeping list did not include any duties related to cleaning the refrigerator in the dining room, and the dishwasher duties document did not address this area either. This lack of clear responsibility contributed to the unsanitary conditions and improper food storage practices observed by the surveyors.
Failure to Ensure Dignified Meal Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity during meal service, as observed with three residents who required assistance with eating. The facility's policy on resident assistance with meals emphasized that residents should be assisted with dignity, without staff standing over them. However, during an observation, an LPN was seen standing while feeding residents, moving from one resident to another, which contradicted the facility's policy and the guidance provided in the employee handbook. This action was noted during meal service for residents with severe and moderate cognitive impairments, who required assistance with eating due to conditions such as difficulty swallowing, muscle weakness, and central nervous system disorders. Interviews conducted with staff revealed a discrepancy in understanding the facility's expectations for meal assistance. A CNA stated that staff should be at the same level as residents to prevent intimidation, while the LPN involved believed that nurses were not required to sit due to the need to assist multiple residents. The Director of Nursing clarified that all staff, including nurses, should be sitting at eye level with residents to maintain dignity and prevent residents from feeling intimidated. This inconsistency in practice and understanding among staff members contributed to the deficiency in providing dignified care during meal service.
Failure to Ensure Regular Showers for Resident
Penalty
Summary
The facility failed to ensure that Resident #65 received regular showers or baths, as required for their activities of daily living. The resident, who was admitted with cognitive and mood disorders, anxiety, pain, and dizziness, had a moderate cognitive impairment and required assistance for bathing. Despite these needs, the facility's records showed that the resident had only received showers on three occasions over a 30-day period, with significant gaps between each instance. Interviews with staff revealed that the facility was operating with minimal staffing, and the Assistant Director of Nursing was on maternity leave, which may have contributed to the oversight. The Licensed Practical Nurse and Certified Nursing Assistants (CNAs) indicated that there was a system in place to document refusals of care, but there was no documentation of Resident #65 refusing showers. Instead, the term "Not Applicable" was used, which staff explained was meant to indicate that the resident did not receive a shower, either due to refusal or because the staff did not get to the shower. The Director of Nursing acknowledged that the documentation process was not being followed correctly, as "Not Applicable" was used instead of marking refusals. The facility's policy on showering residents did not address missed showers, and there was no follow-up documentation when Resident #65 refused a shower. This lack of proper documentation and adherence to procedures led to the resident not receiving the necessary care for their hygiene needs.
Inadequate Hand Hygiene and EBP Compliance
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff while serving meals and providing assistance to residents. Observations revealed that staff members, including CNAs and LPNs, moved between residents while feeding them without performing hand hygiene. Specific instances included a CNA rubbing hands on their thighs, touching their face, and adjusting glasses before feeding residents without sanitizing their hands. Another CNA and an LPN were observed feeding multiple residents consecutively without performing hand hygiene. Interviews with staff confirmed awareness of the need for hand hygiene, but it was not consistently practiced due to perceived time constraints or lack of sanitizer availability, despite sanitizer being present in the dining area. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) during indwelling catheter care for a resident with a history of infection and inflammatory reaction due to an indwelling urethral catheter. An LPN was observed inserting a new urinary catheter without wearing a gown, as required by the facility's EBP policy. The LPN acknowledged the oversight during an interview, confirming that the resident was on EBP but the gown was not utilized during the procedure.
Hazardous Wipes Left Accessible to Resident
Penalty
Summary
The facility failed to ensure that hazardous materials, specifically bleach wipes and disinfectant wipes, were not left at the bedside of a resident with moderate cognitive impairment. The resident, identified as having a Brief Interview of Mental Status (BIMS) score of 12, was observed multiple times over several days with these hazardous wipes accessible on their bedside table. This oversight was noted by a surveyor on four separate occasions, indicating a persistent issue with the storage of these materials. Interviews with facility staff, including a Certified Nursing Assistant (CNA), a Registered Nurse (RN), and the Director of Nurses (DON), confirmed that the wipes should not have been left in the resident's room due to their hazardous nature. The CNA and RN both acknowledged that the wipes could be mistakenly used for personal hygiene or with food, posing a risk to the resident. The DON further confirmed that these items should be stored securely, such as in a med cart or locked cabinet, to prevent resident access.
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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 Berryville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Blossoms At Eureka Springs Rehab & Nursing Cen | 10.6 mi | ★★★★★ | 1 | 0 |
| Meadowview Healthcare And Rehab | 21.3 mi | ★★★★★ | 2 | 0 |
| The Springs Of Mt Vista | 25.2 mi | ★★★★★ | 1 | 0 |
| The Springs Of Harrison | 25.3 mi | ★★★★★ | 0 | 0 |
| Hillcrest Home | 26.3 mi | ★★★★★ | 0 | 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.