Inspection Reports for
Heather Manor Nursing and Rehabilitation Center
400 West 23rd Street, Hope, AR, 71801
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 6
Date: Feb 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, notification of hospital transfers, bed hold policies, psychotropic medication use, medication storage, infection control, and other care standards at Heather Manor Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during incontinence care, incomplete written notifications for hospital transfers, failure to provide bed hold notifications, inadequate management of psychotropic medications, improper medication storage, and lapses in infection prevention and control practices including improper use of PPE and hand hygiene during wound care.
Deficiencies (6)
Failed to ensure privacy was protected and dignity maintained during incontinence care for Resident #70.
Failed to provide timely and complete written notification to residents and representatives regarding hospital transfers for Residents #69, #76, and #49, missing appeals process and Ombudsman contact information.
Failed to provide written bed hold notification prior to hospital transfer for Resident #76.
Failed to ensure gradual dose reductions and proper documentation for psychotropic medications for Resident #11.
Failed to ensure medications were properly stored to prevent unauthorized access; medications left unattended on medication cart.
Failed to ensure staff used infection control measures including proper PPE use and hand hygiene during care of residents on Enhanced Barrier Precautions and during wound care.
Report Facts
Residents reviewed for hospitalizations: 3
Hospital transfers for Resident #69: 4
Sample residents reviewed for unnecessary medications: 5
Sample residents reviewed for pressure ulcer care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | Observed providing incontinence care without privacy | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding privacy, medication management, infection control, and bed hold policies |
| Administrator | Interviewed regarding hospital transfer notifications and bed hold policies | |
| Business Office Manager | Responsible for sending bed hold notices; confirmed no notice sent for Resident #76 | |
| Licensed Practical Nurse #3 | LPN | Observed leaving medications unattended and not wearing PPE during medication administration |
| Certified Nursing Assistant #1 | CNA | Observed transferring Resident #11 without proper PPE |
| Certified Nursing Assistant #2 | CNA | Observed transferring Resident #11 without proper PPE |
| Treatment Nurse | Observed wound care with improper hand hygiene |
Inspection Report
Routine
Deficiencies: 7
Date: Apr 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, meal service, accident hazards, respiratory care, medication storage, food safety, and infection control at Heather Manor Nursing and Rehabilitation Center.
Findings
The facility failed to treat residents with dignity during meal service, served residents food they disliked, failed to secure combustible equipment, improperly stored oxygen therapy equipment, failed to affix medication storage containers, had multiple food safety and sanitation violations, and failed to ensure safe intravenous medication administration practices.
Deficiencies (7)
Failed to treat residents with respect and dignity during meal assistance, including inappropriate staff comments and lack of timely feeding assistance.
Failed to ensure residents were not served disliked foods, risking weight loss or nutritional deficits.
Failed to ensure combustible equipment was safely locked away from residents who could self-propel in wheelchairs.
Failed to ensure humidifier bottles and nasal cannula tubing were dated and stored properly to prevent infection.
Failed to ensure storage container for refrigerated controlled medications was permanently affixed as required.
Multiple food safety and sanitation violations including improper hand hygiene, unclean kitchen equipment, expired and improperly stored food, and dirty cleaning supplies.
Failed to ensure intravenous medications were administered in a safe and non-contaminated manner, risking infection for a resident with a PICC line.
Report Facts
Residents affected: 8
Residents affected: 79
Residents affected: 8
Residents affected: 5
Syringes of Lorazepam: 3
Meal times: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed removing medication storage box and discussing storage requirements |
| LPN #2 | Licensed Practical Nurse | Observed administering intravenous medications improperly to Resident #68 |
| CNA #1 | Involved in meal service to Resident #25 and made inappropriate comments | |
| CNA #2 | Referred to Resident #25 as a feeder during meal service | |
| CNA #3 | Discussed meal tray procedures for Resident #50 | |
| RN #1 | Registered Nurse | Assisted Resident #25 with meal service and was interviewed about meal service procedures |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding policies and procedures on meal service, equipment storage, and infection control |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding meal service complaints and food safety issues |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding oxygen therapy equipment care |
Inspection Report
Routine
Census: 88
Deficiencies: 9
Date: Mar 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, nutrition, infection control, and safety at Heather Manor Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including inconsistent bathing and hygiene care for residents, improper medication storage and labeling, failure to change oxygen tubing as ordered, inadequate meal preparation and serving practices, failure to maintain proper food temperatures, poor hand hygiene during meal service, and failure to ensure pureed food consistency.
Deficiencies (9)
Failure to provide consistent showers/baths to residents dependent on assistance, leading to skin issues.
Medications left at bedside without assessment for self-administration, posing risk of misuse or theft.
Oxygen tubing not changed weekly as ordered, with tubing dated several months old.
Medications in carts and rooms were expired, unlabeled, or improperly stored, with dirty medication carts.
Meals served did not follow planned menus, including incorrect diet textures and missing items.
Meal trays left sitting out unrefrigerated while residents were sleeping, with food served at unsafe temperatures.
Pureed food items were thick and not smooth, risking choking hazards.
Food items in storage were expired, uncovered, or undated; staff failed to wash hands before food handling; ice cream served melted.
Staff failed to perform hand hygiene between residents during meal service, increasing infection risk.
Report Facts
Residents affected: 2
Residents affected: 88
Medication carts reviewed: 3
Medication carts with deficiencies: 2
Residents receiving oxygen: 14
Meal trays observed: 12
Residents eating in main dining room: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Provided information on bathing schedules and medication storage practices |
| Director of Nursing | Director of Nursing | Provided responses regarding bathing protocols, medication storage, oxygen tubing changes, and hand hygiene importance |
| Infection Control Nurse | Infection Control Nurse | Provided responses regarding bathing and medication storage practices |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Provided information on oxygen tubing change frequency and medication storage |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Accompanied surveyor during medication cart inspection |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Observed with meal trays left in medication room and assisted resident |
| Dietary Supervisor | Dietary Supervisor | Provided information on menu compliance, food temperatures, and food preparation |
| Dietary Employee #1 | Dietary Employee | Observed pureeing food items |
| Dietary Employee #2 | Dietary Employee | Provided information on pureed diets and food temperatures |
| Dietary Employee #3 | Dietary Employee | Observed handling food without handwashing |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Delivered breakfast trays on 400 Hall |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Provided information on hand hygiene during meal service |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided hand hygiene policy document |
| Infection Preventionist | Infection Preventionist | Provided information on hand hygiene importance during meal service |
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