Inspection Reports for
Care Manor Nursing and Rehab
804 Burnett Drive, Mountain Home, AR, 72653
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 29, 2025
Visit Reason
The inspection was conducted to assess the accuracy of Minimum Data Set (MDS) assessments and the completeness of resident care plans at Care Manor Nursing and Rehab.
Findings
The facility failed to ensure accurate completion of MDS assessments for five residents, incorrectly coding psychotic disorders. Additionally, the facility failed to develop and implement a complete care plan addressing intravenous therapy, primary diagnoses, and antibiotic therapy for one resident.
Deficiencies (2)
Failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for five residents, with incorrect coding of psychotic disorders.
Failed to develop and implement a complete care plan addressing intravenous therapy, primary diagnoses, and antibiotic therapy for one resident.
Report Facts
Residents reviewed for MDS accuracy: 10
Residents with inaccurate MDS assessments: 5
Residents reviewed for care plan completeness: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #13 | Registered Nurse | Responsible for developing and implementing care plans; named in care plan deficiency |
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding care plan responsibilities and deficiencies |
| Administrator | Administrator | Interviewed regarding care plan responsibilities |
| MDS Coordinator | Interviewed regarding inaccurate MDS assessments |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide a written bed hold notification prior to transferring a resident to the hospital.
Complaint Details
The complaint investigation found that the facility did not provide the required written bed hold notification for Resident #1 prior to hospital transfer. The resident's representative was unaware of the bed hold policy and expressed confusion. Staff interviews indicated lack of knowledge and inconsistent procedures regarding bed hold notifications.
Findings
The facility failed to ensure a written bed hold notification was issued prior to a hospital transfer for one resident. Interviews with staff revealed lack of knowledge and inconsistent practices regarding bed hold notifications, and the facility did not provide written notification as required.
Deficiencies (1)
Failure to notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Report Facts
Residents Affected: 1
Date of hospital transfer: Nov 18, 2024
Date of admission agreement: Jul 27, 2021
Brief Interview of Mental Status score: 12
Date of survey completion: Jan 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Stated lack of knowledge about bed hold notification |
| Business Office Manager | Business Office Manager | Stated no bed hold notifications generated since 11/01/2024 |
| Director of Nursing | Director of Nursing | Unaware how bed hold worked or who was responsible |
| Administrator | Administrator | Unaware of bed hold notification requirement and misunderstood questions about bed holds |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 16, 2024
Visit Reason
The inspection was conducted as part of a regulatory survey to assess compliance with nursing home regulations, including resident care preferences, infection prevention and control, and staffing requirements.
Findings
The facility was found deficient in honoring a resident's preference for bed making, proper disinfection of a multi-resident glucometer to prevent infection spread, and employing a qualified Infection Preventionist during a COVID-19 outbreak. These deficiencies were associated with minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failed to ensure that a resident's expressed preference for having their bed made was honored.
Failed to ensure a multi-resident use glucometer was disinfected after use to prevent potential spread of infection.
Failed to ensure that an Infection Preventionist was employed during a COVID-19 outbreak.
Report Facts
Residents Affected: 1
Residents Affected: 1
Timeframe without Infection Preventionist: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Performed blood glucose test without disinfecting glucometer |
| CNA #2 | Certified Nursing Assistant | Reported bed making practices and staffing issues |
| CNA #3 | Certified Nursing Assistant | Reported bed making practices and timing |
| Director of Nursing | Director of Nursing | Provided statements regarding infection control policies and staffing |
| Administrator | Administrator | Commented on the requirement for a trained and certified Infection Preventionist |
Inspection Report
Routine
Deficiencies: 6
Date: May 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility policies at Care Manor Nursing and Rehab.
Findings
The facility was found deficient in honoring resident preferences for bed making, updating comprehensive care plans, limiting PRN psychotropic medication orders to 14 days without physician justification, securing narcotic medications properly, disinfecting multi-use glucometers, and employing a qualified infection preventionist during a COVID-19 outbreak.
Deficiencies (6)
Failed to honor a resident's expressed preference for having their bed made daily.
Failed to revise or update the comprehensive care plan within 7 days of a significant change for a resident.
Failed to limit PRN orders for psychotropic drugs to 14 days without physician documentation for two residents.
Failed to ensure narcotic medications were stored in a permanently affixed compartment and multi-use vials were dated when opened.
Failed to disinfect a multi-resident use glucometer after use to prevent potential spread of infection.
Failed to employ a qualified infection preventionist during a COVID-19 outbreak.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 2
Residents Affected: 1
Timeframe: 7
Timeframe: 14
Dates: Jan 2, 2024
Dates: Feb 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding PRN medication monitoring, narcotic storage, infection control, and Infection Preventionist absence |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed performing blood glucose test without disinfecting glucometer |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Observed handling narcotic box and medication storage |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed about bed making schedule |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed about bed making schedule |
| MDS Coordinator | MDS Coordinator | Interviewed about care plan update requirements |
| Administrator | Administrator | Interviewed about importance of trained Infection Preventionist |
Inspection Report
Routine
Census: 45
Deficiencies: 6
Date: Mar 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, bathing services, respiratory care, food preparation, and food safety in the nursing facility.
Findings
The facility failed to ensure accurate Minimum Data Set (MDS) assessments, comprehensive care plans for medication monitoring, consistent bathing services for dependent residents, proper storage of respiratory equipment, preparation of pureed food to appropriate consistency, and adherence to food safety and hygiene standards in the kitchen.
Deficiencies (6)
Failed to ensure Minimum Data Set (MDS) assessments were accurate and complete for 1 of 11 residents reviewed.
Failed to develop and implement a comprehensive, person-centered care plan addressing medication monitoring for multiple residents.
Failed to provide regular bathing services to maintain hygiene for 2 of 13 residents dependent on staff for bathing.
Failed to ensure oxygen/updraft mouthpiece/mask was stored in a bag or closed container when not in use for 2 residents with oxygen orders.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for 2 meals observed.
Failed to ensure dietary staff washed hands before handling clean equipment; food items were not properly dated, covered, or discarded when expired; and hot foods were not maintained at safe temperatures.
Report Facts
Residents affected: 45
Residents dependent on staff for bathing: 14
Residents reviewed for MDS accuracy: 11
Residents reviewed for medication care plan: 7
Pureed diet residents: 4
Food temperature: 123
Food temperature: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding MDS accuracy and respiratory equipment storage |
| RN #1 | Registered Nurse | Accompanied surveyor to resident rooms to assess oxygen/updraft mask storage |
| RN #1 | Registered Nurse | Interviewed about care plan development and medication monitoring |
| LPN #1 | Licensed Practical Nurse | Interviewed about resident assistance needs and bathing frequency |
| CNA #1 | Certified Nurse Assistant | Interviewed about resident assistance needs and bathing frequency |
| Director of Nursing | Director of Nursing | Interviewed about resident assistance needs and bathing frequency |
| Dietary Employee #1 | Dietary Employee | Observed preparing pureed food and interviewed about food consistency |
| Dietary Employee #2 | Dietary Employee | Observed handling food and tested food temperatures |
| Dietary Employee #3 | Dietary Employee | Observed handling food and interviewed about handwashing |
| Dietary Supervisor | Dietary Supervisor | Interviewed about pureed food consistency and food safety policies |
| Administrator | Administrator | Provided facility policies and lists of residents |
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