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)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
100% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
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
Routine
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 MDS assessments for five residents, incorrectly coding psychotic disorders that were not supported by medical diagnoses. 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)
Failure to ensure accurate Minimum Data Set (MDS) assessments for five residents, with incorrect coding of psychotic disorders.
Failure 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 sampled for care plan review: 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 Nursing | Confirmed RN #13's responsibilities and care plan requirements |
| Administrator | Administrator | Confirmed RN #13's role in care plan completion and updates |
| MDS Coordinator | Confirmed incorrect coding of MDS documents and lack of facility policy for MDS |
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
Census: 2
Capacity: 2
Deficiencies: 1
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding bed hold notification procedures when residents are transferred to a hospital.
Findings
The facility failed to ensure a written bed hold notification was issued prior to a hospital transfer for one resident. Interviews revealed staff and administration were unaware or inconsistent about bed hold notification responsibilities and procedures.
Deficiencies (1)
Failure to ensure a written bed hold notification was issued prior to a hospital transfer for Resident #1.
Report Facts
Residents Affected: 1
Census: 2
Total Capacity: 2
Bed hold duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding bed hold knowledge and transfer procedures |
| Business Office Manager | Business Office Manager | Interviewed regarding bed hold notification generation and procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding knowledge of bed hold procedures |
| Administrator | Administrator | Interviewed regarding resident education and bed hold notification procedures |
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
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 care planning 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-resident 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 for a resident within 7 days of a significant change.
Failed to limit PRN psychotropic medication orders 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
Residents affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding PRN medication monitoring, narcotic storage, glucometer disinfection, and infection preventionist staffing |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Observed during narcotic medication storage inspection |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed performing blood glucose test without disinfecting glucometer |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed about bed making practices |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed about bed making practices |
| MDS Coordinator | MDS Coordinator | Interviewed about care plan update requirements |
| Administrator | Administrator | Interviewed about importance of having a trained and certified Infection Preventionist |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 16, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to honor a resident's preference for bed making, improper disinfection of a multi-resident use glucometer, and lack of a qualified Infection Preventionist during a COVID-19 outbreak.
Complaint Details
The complaint investigation found substantiated issues including failure to honor resident preferences, infection control lapses, and staffing deficiencies related to infection prevention during a COVID-19 outbreak.
Findings
The facility failed to ensure Resident #32's preference for daily bed making was honored, failed to disinfect a multi-resident glucometer after use for Resident #45, and did not employ a qualified Infection Preventionist during a COVID-19 outbreak from January to February 2024.
Deficiencies (3)
Failure to honor Resident #32's expressed preference for having their bed made daily.
Failure to disinfect a multi-resident use glucometer after use, risking potential spread of infection for Resident #45.
Failure to employ a qualified Infection Preventionist during the COVID-19 outbreak from 01/02/2024 to 02/08/2024.
Report Facts
Assessment Reference Date: Apr 29, 2024
Inspection Date: May 16, 2024
Dates without Infection Preventionist: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed performing blood glucose test without disinfecting glucometer |
| CNA #2 | Certified Nursing Assistant | Interviewed about bed making schedule and practices |
| CNA #3 | Certified Nursing Assistant | Interviewed about bed making schedule and practices |
| Director of Nursing | Director of Nursing | Provided information on infection control policies and staffing during COVID-19 outbreak |
| Administrator | Administrator | Commented on requirement for trained and certified 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 |
Inspection Report
Routine
Census: 45
Deficiencies: 6
Date: Mar 10, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident assessments, care planning, activities of daily living, respiratory care, food preparation, and food safety.
Findings
The facility was found deficient in ensuring accurate Minimum Data Set assessments, comprehensive care plans for medication monitoring, consistent bathing services for dependent residents, proper storage of respiratory equipment, preparation of pureed foods to appropriate consistency, and adherence to food safety and hygiene standards in the dietary department.
Deficiencies (6)
Failure to ensure accurate and complete Minimum Data Set (MDS) assessments for residents, affecting care planning.
Failure to develop and implement comprehensive, person-centered care plans addressing medication monitoring for multiple residents.
Failure to provide regular bathing services to maintain good hygiene for residents dependent on staff assistance.
Failure to store oxygen/updraft masks in a bag or closed container when not in use, risking contamination.
Failure to ensure pureed food items were blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failure to ensure dietary staff washed hands before handling clean equipment; improper food storage and labeling; expired foods not discarded; and hot foods not maintained at safe temperatures.
Report Facts
Residents affected: 45
Residents sampled for MDS accuracy review: 11
Residents dependent on staff for bathing: 14
Residents receiving pureed diets: 4
Food temperature: 123
Food temperature: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding MDS assessment accuracy and respiratory equipment storage |
| RN #1 | Registered Nurse | Accompanied surveyor to residents' 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 foods with improper consistency |
| Dietary Employee #2 | Dietary Employee | Observed handling food and testing food temperatures |
| Dietary Employee #3 | Dietary Employee | Observed handling food and equipment without proper handwashing |
| Dietary Supervisor | Dietary Supervisor | Interviewed about pureed food preparation and food safety policies |
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