Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Berry Hill Nursing Home during CMS and state inspections, most recent first.
The facility failed to implement its abuse policy by not obtaining sworn statements or conducting timely criminal background checks for several employees. Additionally, the professional licenses or certifications of 11 nursing staff were not verified until after the survey began, with some staff working with residents before verification. This oversight in hiring and verification processes raises concerns about resident safety.
The facility failed to store food properly in the main kitchen and nourishment refrigerators, with items lacking proper sealing and labeling. Milk was stored above the recommended temperature, and nourishment refrigerators contained unlabeled and outdated items. The facility's policies did not adequately address these issues, leading to improper food handling and storage practices.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting their oral and dental status. One resident was observed with missing and decayed teeth, yet the MDS inaccurately reported no concerns. Another resident had multiple missing teeth and visible decay, but the MDS did not reflect these issues. A third resident, with a history of dental problems, was also inaccurately documented in the MDS. Interviews revealed a lack of awareness and thorough examination by the MDS coordinator.
The facility failed to complete the required PASARR for three residents with mental health diagnoses, including schizoaffective disorder and dementia. The PASARRs were only completed after surveyor inquiries, despite the facility's policy requiring them prior to admission.
A facility failed to develop a care plan for a resident's oxygen therapy, despite the resident's diagnoses of congestive heart failure and shortness of breath. The resident was using oxygen at 2 LPM, but the care plan did not include this therapy. The MDS coordinator admitted that the care plan was overlooked.
The facility staff failed to update care plans for two residents, resulting in deficiencies. One resident's care plan was not revised to reflect significant weight changes and a fall, while another resident's care plan did not reflect a change in code status from DNR to full code. The care plan coordinator and MDS coordinator acknowledged the oversights, and the facility's policy on interdisciplinary teams was not followed.
A resident was administered Breo Ellipta by an LPN without being instructed to rinse their mouth afterward, contrary to the physician's order and manufacturer's instructions. Interviews with the RN and DON confirmed that rinsing is a required procedure to prevent complications, highlighting a deficiency in the standard of care.
A resident was discharged without a complete discharge plan of care and recapitulation of stay. The discharge documentation lacked essential information such as medications, treatments, and diet. The resident had a complex medical history, but the discharge summary did not provide a comprehensive overview of their status. The facility's discharge planning policy was not followed, and the necessary information was not communicated to the resident or care providers.
A resident with multiple health conditions, including cognitive communication deficit, experienced tooth pain but was unaware of an existing physician's order for Orajel due to its omission from the MAR. Despite the order being faxed to the pharmacy and the medication being available, staff were not informed, leading to a lapse in pain management.
A resident did not receive a physician-ordered nutritional supplement during lunchtime meals, as observed on two consecutive days. The resident confirmed the absence of the supplement, which was supposed to be included on the meal tray according to the meal ticket. The dietary manager acknowledged the oversight but could not explain why the supplement was not provided, despite having a physician's order and recommendation from a dietician.
During a medication pass observation, a facility failed to accurately label three medications, including Provera, Phenytoin Sodium Extended Release, and Atenolol/Chlorthalidone, with dosages and complete names. The LPN and RN involved were unaware of the missing information, assuming the pharmacy-provided medications were correct. The issue was identified as a software problem affecting label printing.
Two residents in the facility did not receive necessary dental services, leading to deficiencies in their care. One resident, with multiple health conditions, experienced ongoing tooth pain and was prescribed antibiotics but did not see a dentist due to difficulties in finding a provider who could accommodate a stretcher. Another resident, with cognitive impairments, was recommended for extractions by an oral surgeon but did not receive follow-up dental care. Facility staff struggled to secure dental services due to provider availability issues.
A resident with significant weight loss did not receive the physician-ordered therapeutic diet of double portions. Despite the order for a regular diet with pureed texture and honey consistency, the resident was observed receiving only half portions. Both a CNA and an LPN confirmed the discrepancy, and the dietary manager acknowledged the error, noting that the resident should have received two scoops of all food items.
A resident with multiple diagnoses and severely impaired cognitive skills had a clinical record discrepancy. The resident's plan of care listed a DNR order, but the interventions inaccurately required CPR, indicating a Full Code status. The RN MDS coordinator acknowledged updating the care plan but not the intervention column, leading to the error.
Failure to Implement Employee Pre-Screening Procedures
Penalty
Summary
The facility staff failed to implement the abuse policy regarding the pre-screening of employees, affecting 15 out of 25 employee records reviewed. Specifically, the facility did not obtain sworn statements or conduct criminal background checks within 30 days of employment for several employees. For instance, a Licensed Practical Nurse (LPN) was hired without a sworn statement on file, and the criminal background check was delayed by several months. Additionally, two Certified Nursing Assistants (CNAs) had unsigned sworn statements. This lack of timely and complete documentation raises concerns about the facility's ability to ensure the safety of its residents. Furthermore, the facility did not verify the professional licenses or certifications of 11 nursing department employees until after the survey began. This included Registered Nurses (RNs), LPNs, and CNAs, whose licenses or certifications were not checked to confirm they were active and unencumbered. Two CNAs were allowed to work with residents before their certifications were verified. The Human Resources Manager acknowledged the responsibility for verifying licenses and stated that the sworn statements and background checks are crucial for resident safety. However, the facility's failure to adhere to these procedures indicates a significant oversight in their hiring and verification processes.
Improper Food Storage and Temperature Control
Penalty
Summary
The facility staff failed to store food in accordance with professional standards for food service safety in the main kitchen and the nourishment refrigerators on two nursing units. In the main kitchen, several food items were improperly stored, lacking proper sealing and labeling. For instance, graham cracker crumbs were secured with a binder clip without any date marking, and various frozen items like crab cakes, chicken tenders, and french fries were not properly sealed or dated. Additionally, a container of chicken noodle soup was inadequately covered, exposing it to potential contamination, and other items like boiled eggs and cherry cheesecakes lacked proper labeling and dating. The facility also failed to maintain milk at the appropriate temperature. During an observation, the temperature of a milk carton was recorded at 45.7 degrees Fahrenheit, which is above the recommended temperature of less than 40 degrees. The dietary manager acknowledged the discrepancy and instructed the staff to return the milk to the cooler. However, the facility's policies did not address the specific temperature requirements for dairy products, although a general temperature range for refrigerators was noted. On two nursing units, the nourishment refrigerators contained items that were not labeled or dated correctly, and some were stored beyond their use-by dates. Observations revealed unlabeled applesauce cups, coleslaw, and various other food items without proper identification or dating. The temperature log for one unit's refrigerator was incomplete, missing recordings for several days. The director of nursing confirmed that the refrigerators were intended for resident food storage, but many items appeared to belong to staff. The facility's policies on food storage and leftovers did not adequately address these issues, leading to improper food handling and storage practices.
Inaccurate MDS Assessments for Oral/Dental Status
Penalty
Summary
The facility staff failed to complete accurate Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in documenting their oral and dental status. Resident #3 was admitted with multiple diagnoses, including dementia and depression, and was observed with missing and decayed lower front teeth. Despite a denture consultation noting dental caries and residual teeth roots, the MDS inaccurately documented no oral or dental concerns. Interviews with the MDS coordinator and a registered nurse revealed a lack of awareness of the resident's dental issues. Resident #5, diagnosed with conditions such as multiple sclerosis and diabetes, was observed with multiple missing teeth and visible decay. The resident's care plan noted poor oral health, yet the MDS inaccurately reflected no dental concerns. The MDS coordinator acknowledged the resident's missing teeth but was uncertain about the decay status. This discrepancy highlights a failure to accurately assess and document the resident's dental condition. Resident #21, with a history of psychosis and vascular dementia, was observed with missing and decayed teeth. An oral surgeon consultation had previously identified cavities and the need for extractions, but the MDS failed to document these issues. The MDS coordinator admitted to not observing broken teeth during the assessment. The facility's failure to conduct thorough oral examinations and accurately document findings in the MDS led to these deficiencies, as outlined in the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual.
Failure to Complete PASARR for Residents
Penalty
Summary
The facility failed to complete the required Pre-Admission Screening and Resident Review (PASARR) for three residents, leading to deficiencies identified during a survey. Resident #46, diagnosed with schizoaffective disorder and anxiety disorder, was admitted without a PASARR, which was only completed after the surveyor's inquiry. Similarly, Resident #21, with multiple diagnoses including psychosis, mood disorder, and vascular dementia, did not have a PASARR completed either before or after admission. The social worker confirmed the absence of the PASARR and was unsure of the process prior to her employment. Resident #17, with diagnoses of schizoaffective disorder, depression, and dementia, also lacked a PASARR upon admission. The resident's clinical record and the PASARR log book did not contain the necessary documentation, and the social worker completed the PASARR only after the surveyor's review. The facility's policy mandates that a PASARR must be completed for all new residents prior to admission, but this was not adhered to in these cases.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a care plan for a resident's oxygen therapy, which was necessary due to the resident's diagnoses of congestive heart failure and shortness of breath. The resident was observed using oxygen at 2 liters per minute, but the care plan did not include this therapy. The clinical record showed an order for continuous oxygen at 2 LPM, but it lacked a start date. The MDS coordinator acknowledged that a care plan should have been developed when the order originated, but it was overlooked.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility staff failed to review and revise the care plan for two residents, leading to deficiencies in their care. For one resident, the care plan was not updated to reflect significant weight changes and a fall. The resident experienced multiple instances of weight loss, as noted by the registered dietician, but the care plan was not revised to address these changes. Additionally, after the resident experienced a fall, the care plan was not updated to include new preventative interventions. The care plan coordinator acknowledged the oversight, attributing it to their absence due to surgery. For another resident, the facility staff did not update the care plan to reflect a change in code status from do not resuscitate (DNR) to full code. Although the resident expressed a desire to be a full code and the medication administration record reflected this change, the care plan still listed the resident as DNR. The MDS coordinator was unaware of the change in code status and acknowledged the need to investigate the oversight. The facility's policy on interdisciplinary teams requires regular meetings to develop and review care plans, but these deficiencies indicate a failure to adhere to this policy. The facility administrator and nurse consultant were informed of these issues during end-of-day meetings, but no additional information or corrective actions were provided in the report.
Failure to Instruct Resident to Rinse Mouth After Medication Administration
Penalty
Summary
The facility staff failed to adhere to professional standards of care during medication administration on one of the units. During a medication pass observation, a Licensed Practical Nurse (LPN) administered Breo Ellipta to a resident without instructing or assisting the resident to rinse their mouth afterward, as recommended by the manufacturer and per the physician's order. The resident's clinical record included a physician's order that specifically instructed rinsing the mouth after using the Breo Ellipta inhaler, which was not followed during the observed administration. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the standard procedure required nurses to prompt and ensure residents rinse their mouths after inhaling medications like Breo Ellipta. The manufacturer's instructions also emphasized the importance of rinsing to reduce the risk of oropharyngeal candidiasis. Despite these guidelines, the LPN did not provide the necessary instruction, leading to a deficiency in the standard of care provided to the resident.
Incomplete Discharge Planning and Documentation for a Resident
Penalty
Summary
The facility staff failed to develop a comprehensive discharge plan of care and recapitulation of stay for a resident, identified as R43, who was discharged from the facility. The discharge documentation was incomplete, lacking critical information such as medications released, treatments, diet, and other educational needs. The social worker had initiated the discharge instructions and plan of care, noting follow-up appointments and home health agency information, but the nursing staff did not complete the remaining sections. The discharge summary was also deficient, as it did not include a detailed recapitulation of the resident's stay, vital signs, or mention of any wounds or treatments to the leg. The resident, R43, had a complex medical history, including hypertension, sacral fracture, chronic diastolic congestive heart failure, chronic hypoxic respiratory failure, chronic atrial fibrillation, history of transcatheter aortic valve replacement, recurrent gastrointestinal blood loss anemia, chronic kidney disease stage 3b, hypothyroidism, and blindness in both eyes. Despite these conditions, the discharge summary failed to provide a comprehensive overview of the resident's status at discharge. The facility's policy on discharge planning was not adhered to, as the necessary information was not communicated to the resident, continuing care provider, or other authorized persons. The facility administrator and corporate nurse consultant were informed of these deficiencies, but no additional information was provided before the survey concluded.
Failure to Implement Physician's Order for Pain Management
Penalty
Summary
The facility staff failed to implement a physician's order for a resident, identified as Resident #5, who was part of a survey sample. The deficiency involved the omission of a physician's order for as-needed Orajel topical gel from the resident's medication administration record (MAR). This oversight meant that nurses were not aware of the order and did not offer or administer the medication for tooth or gum pain as needed. Resident #5, who was assessed as cognitively intact, reported experiencing tooth pain during an interview but was unaware of the Orajel order. The clinical record showed that the physician's order for Orajel was dated several days prior to the survey, but it was not listed on the MAR. Interviews with the resident and staff, including a licensed practical nurse and a nurse consultant, revealed that the order was faxed to the pharmacy, and the medication was available in the cart. However, the failure to record the medication on the MAR resulted in the staff being unaware of its availability for the resident's pain management. This finding was discussed with the facility's administrator and nurse consultant, with no additional information provided before the survey concluded.
Failure to Provide Physician-Ordered Nutritional Supplement
Penalty
Summary
The facility staff failed to provide a physician-ordered nutritional supplement for a resident, identified as R64, during lunchtime meals. Observations on two consecutive days revealed that the supplement was missing from R64's lunch tray. The resident confirmed that the supplement was not provided by the facility, although it was sometimes brought in by her daughter. A Certified Nursing Assistant (CNA) verified the absence of the supplement and noted that it was listed on the meal ticket. Interviews with the dietary manager confirmed that there was an order for the supplement to be included on the lunch tray, but it was not executed. The dietary manager was unable to provide an explanation for the oversight, as the dietary aide responsible was not available for comment. A review of the clinical records showed a physician's order for the supplement, which was recommended by a registered dietician. Facility documents emphasized the importance of adhering to physician orders for nutritional needs, yet the supplement was not provided as required.
Medication Labeling Deficiency
Penalty
Summary
The facility staff failed to accurately label medications during a medication pass observation, resulting in three instances of non-compliance with labeling requirements. The medication Provera, administered to a resident, was not labeled with a dosage. During the observation, the LPN administering the medication confirmed the absence of the dosage on the multi-medication pill pack and verified the correct dosage with the physician's order. The issue was identified as a labeling error, with the dosage missing from the packaging due to a software issue. Additionally, two other medications, Phenytoin Sodium Extended Release and Atenolol/Chlorthalidone, administered to two different residents, were also found to be improperly labeled. The pharmacy pouches for these medications did not include the dosage or complete medication names. The LPN and RN involved in the medication administration were unaware of the missing information, assuming the pharmacy-provided medications were correct. The facility's consultant pharmacy supervisor confirmed the labeling issue was due to a software problem, which resulted in incomplete prescribing information on the labels.
Failure to Provide Dental Services for Residents
Penalty
Summary
The facility staff failed to provide necessary dental services for two residents, leading to deficiencies in their care. Resident #5, who was admitted with multiple health conditions including multiple sclerosis and diabetes, was assessed as cognitively intact. Despite a physician's order for dental services due to a right lower molar abscess, the resident did not receive a referral or visit to a dentist. The resident experienced ongoing tooth pain and was prescribed antibiotics twice, but no dental appointment was scheduled due to difficulties in finding a dentist who could accommodate the resident's need for a stretcher during transport. Resident #21, with diagnoses including psychosis, stroke, and vascular dementia, was assessed with moderately impaired cognitive skills. An oral surgery consultation recommended extractions and a restorative plan by a general dentist. However, no dental services were provided following this consultation. The social worker was unaware of the need for a dental appointment, and the facility struggled to secure dental services due to provider availability issues. Interviews with facility staff, including the social worker, administrator, and nurse practitioner, revealed ongoing challenges in securing dental care for residents requiring special accommodations. Despite attempts to contract a provider, the facility was unable to arrange necessary dental appointments for the residents, resulting in unresolved dental issues.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
The facility staff failed to provide a physician-ordered therapeutic diet for a resident who had experienced significant weight loss. The resident had an active physician order for a regular diet with pureed texture, honey consistency, and double portions as part of an enriched meal program. Despite this order, the resident was not provided with the double portions as prescribed. A clinical record review showed a weight loss of 7.2 pounds over one month, and the care plan indicated a focus on nourishment due to weight loss, with an intervention specifying double portions. During an observation, the resident was seen being fed by a CNA, and the food portions were not double as ordered. Both the CNA and an LPN confirmed that the portions did not appear to be double. The dietary manager also confirmed that the resident should have received two scoops of all food items, but only one scoop was provided, resulting in half-full bowls. The facility's policies on therapeutic diets and menu adjustments were reviewed, indicating that diets should be served as prescribed by the attending physician.
Inaccurate Clinical Record for Resident with DNR Order
Penalty
Summary
The facility staff failed to maintain an accurate clinical record for a resident, leading to a deficiency. The resident, who was admitted with multiple diagnoses including cancer, atrial fibrillation, deep vein thrombosis, hypertension, and schizoaffective mood disorder, was assessed with severely impaired cognitive skills. The resident's clinical record documented a current do not resuscitate (DNR) order, and the plan of care indicated the resident was on hospice with a DNR order. However, the care plan interventions inaccurately documented a requirement for cardiopulmonary resuscitation (CPR), indicating a Full Code status. During an interview, the registered nurse MDS coordinator admitted to updating the care plan's problem/focus area but failing to change the intervention column, resulting in the discrepancy. This issue was discussed with the facility's administrator and nurse consultant, but no additional information was provided before the survey concluded.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 9 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near South Boston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Boston Health & Rehab Center | 2.5 mi | ★★★★★ | 1 | 1 |
| Clarksville Health & Rehab Center | 19.8 mi | ★★★★★ | 0 | 0 |
| Roxboro Healthcare & Rehab Center | 20.3 mi | ★★★★★ | 3 | 0 |
| Person Memorial Hospital | 20.5 mi | ★★★★★ | 5 | 1 |
| Heritage Hall - Brookneal | 23.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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