Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Eureka Springs Rehab & Nursing Cen during CMS and state inspections, most recent first.
Inaccurate controlled medication records were found for three residents. A resident with chronic pain and psychiatric diagnoses, another resident with chronic pain syndrome and psychiatric diagnoses, and a third resident with pain-related care needs all had narcotic medications signed out in the narcotic book without matching eMAR documentation, and progress notes were missing for the documented events. Staff and leadership stated narcotics should be signed out, documented in the MAR, and supported by progress notes when held or refused, but the records did not consistently reflect administration.
Surveyors found that the ice machine was not maintained in a clean and sanitary condition, with visible dirt and discoloration present on internal surfaces despite regular cleaning schedules. Staff confirmed the presence of dirt and described the cleaning procedures, but contamination was still observed during the inspection.
Staff failed to follow infection control practices, including not performing hand hygiene during incontinent care for a resident, not cleaning a glucometer after use by an LPN, and improper wound care technique by a wound care nurse who used contaminated gloves and uncleaned scissors while handling dressings.
A resident with type 2 diabetes did not receive proper insulin pen administration due to an LPN priming the pen incorrectly by pointing the needle downward instead of upward, contrary to manufacturer guidelines. The DON confirmed a lack of recent staff education on insulin pen usage.
A resident's right to privacy in mail communication was violated when the facility's DON, with the Administrator's approval, routinely opened the resident's packages without consent. Despite the resident being cognitively intact and expressing that this was disrespectful and illegal, the facility justified the practice due to the resident's history of behavior problems and drug abuse. The DON maintained inventory lists of approved and unapproved items, with unapproved items kept locked in the office.
The facility failed to maintain secure doors in the Special Care Units, compromising resident safety. Observations showed that doors on the 300 and 500 Hall units could be pushed open without triggering alarms, and staff reported ongoing issues with the doors. The Maintenance Director identified a faulty hinge as the cause, but the Administrator was unaware of the problem, believing the units were secure.
The facility failed to report multiple resident-to-resident altercations to the state, despite incidents involving physical aggression and police involvement. Residents with severe cognitive impairments were involved in altercations, resulting in injuries such as abrasions and hematomas. The facility's policy requires immediate reporting of abuse, but the DON and Administrator did not report these incidents, citing a lack of malice and no serious injuries.
The facility failed to report several resident-to-resident altercations to the Office of Long-Term Care as required by policy. Incidents involved residents with severe cognitive impairments, resulting in physical aggression and injuries such as abrasions and hematomas. Although local authorities were notified, the state was not informed, contrary to regulations.
Inaccurate Controlled Medication Documentation
Penalty
Summary
The facility failed to maintain an accurate medication record system for controlled medications for three residents. Resident #1 was admitted with diagnoses including type 2 diabetes mellitus, anemia, recurrent depressive disorders, and schizoaffective disorder, bipolar type, and had a BIMS score of 13 indicating cognitive intactness. Resident #2 was admitted with chronic pain syndrome, major depressive disorder recurrent severe with psychotic symptoms, schizophrenia, bipolar disorder, and anxiety disorder, and had a BIMS score of 14. Resident #3 had a care plan for increased risk for alteration in pain/discomfort and an order for a narcotic pain medication as needed for pain. Review of the 200 Hall Narcotic Sign Out Book compared with the residents’ eMARs showed repeated instances where narcotic medications were signed out but not documented as administered in the eMAR. For Resident #1, one narcotic pain medication was signed out on 05/09/2026 but was not documented as given, and no progress note was present for that date and time. For Resident #2, a narcotic anti-anxiety medication was signed out eight times between 04/14/2026 and 04/30/2026 without corresponding eMAR documentation. For Resident #3, narcotic pain medication was signed out 48 times between 04/13/2026 and 05/14/2026 without documentation in the eMAR, and no progress notes were present for those dates and times. During interviews, LPN #1 stated he encouraged Resident #1 to take the prescribed as-needed narcotic pain medication. Other staff and leadership stated that when a narcotic is administered, it should be signed out of the narcotic book, documented in the MAR, and supported by a progress note if held or refused. The DON stated that if the MAR was blank, there was no way to know whether the narcotic signed out was actually given. The Medical Director also stated he expected documentation in the resident’s medical record showing the narcotic was administered, including the nurse, date, and time. The facility policy required the administering nurse to initial the MAR after giving each medication and to circle and initial the MAR if a drug was withheld, refused, or given at a different time.
Ice Machine Found Unclean During Survey
Penalty
Summary
Surveyors observed that the facility failed to maintain the ice machine in a clean and sanitary condition, as required for food service equipment. During an inspection, the Dietary Manager was asked to wipe various internal surfaces of the ice machine with white paper towels, which resulted in pink and brown discoloration transferring to the towels, indicating the presence of dirt and possible contamination. The Dietary Manager confirmed the substance was dirt and stated that the ice machine was sanitized monthly and thoroughly cleaned every three months by the Maintenance Director. However, the Maintenance Assistant reported that the machine had been cleaned the previous week and should not have shown any discoloration during the observation. Despite scheduled cleaning procedures, visible dirt and discoloration were present inside the ice machine at the time of the survey.
Infection Control Lapses in Hand Hygiene, Glucometer Cleaning, and Wound Care
Penalty
Summary
Staff failed to perform proper hand hygiene during incontinent care for a resident who was dependent on staff for toileting hygiene. During observation, a CNA did not perform hand hygiene before, during, or after providing care, nor before exiting the resident's room. The CNA later confirmed this lapse, and the Director of Nursing reported that the facility lacked both a handwashing policy and an incontinent care policy. Additionally, a LPN did not clean or disinfect a glucometer after performing a capillary blood glucose check on a resident, placing the used device back into the medication cart without cleaning. The LPN acknowledged the potential for contamination. In a separate incident, a wound care nurse used the same gauze to clean both around and inside a surgical incision, handled clean dressings with contaminated gloves, and used uncleaned scissors from his pocket during wound care. The nurse confirmed these lapses and the DON stated there was no wound care policy in place.
Improper Insulin Pen Priming Procedure
Penalty
Summary
The facility failed to ensure that an insulin pen was primed according to manufacturer recommendations before administration to a resident with type 2 diabetes mellitus. The resident had a physician's order for Insulin degludec, a long-acting insulin, to be administered subcutaneously twice a day. During a medication pass, an LPN was observed priming the insulin pen incorrectly by pointing the needle downward instead of upward, as recommended by the manufacturer. This incorrect technique could potentially lead to the resident not receiving the correct insulin dose. Upon questioning, the LPN acknowledged the mistake and confirmed that the pen should have been primed with the needle pointing up to effectively remove air and ensure the correct dose. The Director of Nursing (DON) confirmed that no recent education on insulin pen usage had been provided to the nursing staff, and any previous training materials were lost due to tornado damage. The manufacturer's instructions, which were later reviewed, clearly stated the correct priming procedure, which was not followed in this instance.
Violation of Resident's Privacy in Mail Communication
Penalty
Summary
The facility failed to uphold the resident's right to privacy in communication by mail, as evidenced by the actions taken with Resident #12. The facility's policy on Resident Rights, revised in November 2022, clearly states that residents have the right to communicate by mail in privacy. However, the facility's practice involved opening packages addressed to Resident #12 without her consent. Resident #12, who was cognitively intact with a BIMS score of 14, had a history of behavior problems and drug abuse, which the facility cited as justification for opening her packages. Despite this, the resident expressed that this practice was disrespectful and a violation of her rights. The Director of Nursing (DON), with the Administrator's approval, routinely opened all packages addressed to Resident #12 to inspect their contents. This was done under the pretext of preventing unauthorized items from being brought into the facility. During the survey, the DON was observed opening three packages addressed to Resident #12, which contained items such as baked beans, rings, and sunflower seeds. The DON maintained two inventory lists: one for approved items, which were given to the resident, and another for unapproved items, which were kept locked in the office. This practice was confirmed by both the DON and the Administrator, who stated that it was a measure to control what items Resident #12 ordered for her room.
Failure to Maintain Secure Environment in Special Care Units
Penalty
Summary
The facility failed to maintain a secure environment for residents in the Special Care Units, as evidenced by malfunctioning secure doors on both the 300 Hall and 500 Hall units. Observations revealed that the doors could be pushed open without triggering an alarm, compromising the safety of residents who were at risk due to cognitive impairments and behavioral symptoms. Maintenance staff and the Director of Nursing attempted to demonstrate the proper use of the doors, but the doors remained unsecured, with the magnetic locks failing to engage properly. The Maintenance Director later identified the issue as a faulty hinge on the 300 Hall door, which was unable to support the door's weight, preventing the magnetic lock from functioning correctly. Interviews with staff and the Ombudsman highlighted ongoing issues with the secure doors, including reports of doors being propped open or held shut by staff due to their malfunction. Despite these reports, the facility's Administrator was unaware of the need for a hinge replacement and believed the units were secure. The deficiency in maintaining a secure environment for residents in the Special Care Units was evident through multiple observations and staff interviews, indicating a failure to uphold the residents' right to a safe and comfortable living environment.
Failure to Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving resident-to-resident altercations. The facility's policy on abuse, neglect, and exploitation requires immediate reporting and investigation of all allegations of abuse. However, the facility did not report several incidents to the state, citing a lack of malice and no serious injuries as reasons for non-reporting. This failure to report is a deficiency in adhering to regulatory requirements for abuse reporting. Resident #6, who has severe cognitive impairment and a history of self-harm, was involved in an altercation with another resident who entered their room. Despite the incident being reported to the police and family, the facility did not notify the state, as the DON believed there was no malice involved. Similarly, Resident #7, with severe cognitive impairment and aggressive behaviors, was involved in multiple incidents, including attempting to choke another resident. These incidents were not reported to the state, despite police involvement and the presence of an abrasion on one resident. Resident #10, who also has severe cognitive impairment, was struck by another resident, resulting in a hematoma. The facility did not report this incident to the state, with the Administrator stating that resident-to-resident altercations are not reportable unless there are major injuries. The facility's failure to report these incidents to the state constitutes a deficiency in ensuring a safe environment and adhering to abuse reporting regulations.
Failure to Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report alleged abuse involving four residents, as required by their policy and regulations. The policy specifies that all complaints, concerns, or suspicions of abuse should be reported immediately to the Administrator and to the Office of Long-Term Care within two hours if the suspicion involves abuse. However, incidents involving residents were not reported to the state authorities as required. The incidents included physical altercations between residents, some of which resulted in injuries such as abrasions and hematomas. Resident #6, who had severe cognitive impairment and a history of self-harm, was involved in an altercation with another resident who entered their room. The incident was reported to the local police, but not to the Office of Long-Term Care. Similarly, Resident #7, who also had severe cognitive impairment, was involved in multiple incidents, including an attempt to choke another resident. These incidents were reported to the police but not to the state authorities. Resident #8, who had severe cognitive impairment and was a victim of physical aggression, sustained an abrasion during an altercation. Resident #10, who also had severe cognitive impairment, was struck by another resident, resulting in a hematoma. Despite these incidents being documented and reported to local authorities, the facility did not report them to the Office of Long-Term Care, as required by their policy and state regulations. The Administrator and DON acknowledged the failure to report these incidents to the state, citing misunderstandings about the reporting requirements for resident-to-resident altercations.
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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 Eureka Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Blossoms At Berryville Rehab & Nursing Center | 10.6 mi | ★★★★★ | 16 | 0 |
| Meadowview Healthcare And Rehab | 20 mi | ★★★★★ | 2 | 0 |
| Aspire Senior Living Roaring River | 21.7 mi | ★★★★★ | 5 | 0 |
| Cassville Health Care Center | 22.1 mi | ★★★★★ | 31 | 2 |
| Rogers Health And Rehabilitation Center | 22.4 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.