Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Oak Manor Nursing And Rehabilitation Center Inc during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed rate after surveyors observed 31 medication opportunities and found four errors, resulting in a 12% error rate. An LPN gave a resident the wrong dose of an oral chewable gas medication, and an MA-C crushed extended-release oral meds that should not have been crushed while also administering a nasal spray in a manner that did not match the order. The resident involved in the first error was cognitively intact, while the second resident had moderate cognitive impairment; both errors were documented as administered.
A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls had a care plan requiring two-person assistance with a gait belt for transfers. Despite this, a CNA attempted to transfer the resident alone from a shower chair to a w/c, during which the resident’s knees gave out and the CNA lowered the resident to the floor, causing minor knee scratches documented by an LPN. The administrator later verified that both the care plan and the posted closet care plan specified two-person transfers, while the CNA reported believing the resident was a one-person transfer and admitted not reviewing the closet care plan recently. Other CNAs and a MA-C stated they routinely checked closet care plans, which were updated as needed, to determine residents’ transfer needs.
The facility failed to discard three expired medications from a medication cart, including multivitamins, a fiber laxative, and fast-acting insulin. An LPN stated that nurses are responsible for removing expired medications, and insulin should be discarded 28 days after opening. The DON confirmed the facility follows the 28-day rule and that nurses check carts daily, with a pharmacy consultant checking monthly. However, the facility lacked a policy on dating multi-dose and expired medications.
The facility failed to ensure safe food preparation by not adequately cleaning the deep fryer and grease traps. During a kitchen tour, the Dietary Manager revealed grease traps with a dark brown substance and crumbs, and a deep fryer with dark brown liquid and crumbs. The DM stated that cleaning occurs every two weeks but acknowledged the need for more frequent cleaning to prevent foodborne illness. The facility lacked a policy or staff competencies for food preparation and equipment cleaning.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent during a medication administration observation. Surveyors observed 31 opportunities for medication administration and identified four medications that were not administered in accordance with the Physician's Orders, resulting in a 12 percent medication error rate. The deficiency involved two residents during the observation and record review process. For one resident with a BIMS score of 15 and intact cognition, an LPN administered an oral chewable gas medication that was ordered at 80 mg, but the eMAR reflected a 125 mg chewable tablet. The medication was documented as given, and during interview the LPN stated she had missed the difference between the ordered dose and the bottle label. She also stated she normally tried to match the MAR with the medication, and acknowledged that the dose, route, and other order details should be checked before administration. For another resident with moderate cognitive impairment and a BIMS score of 09, an MA-C crushed all oral medications even though the orders included extended-release blood pressure and chest congestion medications that should not be crushed. The MA-C also administered a nasal steroid spray, but the order and observed administration did not match the documented directions. The MA-C stated she had been crushing the resident's medications after being told the resident requested it, but she did not know whether the provider had been informed. The MD stated no extended-release medication should be crushed, and the DON stated staff were expected to follow the Physician's Order and verify any doubt before administering medications.
Failure to Follow Two-Person Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a certified nurse aide followed an existing care plan requiring two-person assistance for transfers, resulting in a fall for one resident. The resident had multiple diagnoses, including type 2 diabetes, atrial fibrillation, congestive heart failure, peripheral vascular disease, difficulty walking, and a history of falling. An annual MDS showed the resident had severe cognitive impairment and required partial/moderate assistance for showering/bathing and was dependent on staff for tub/shower transfers. The resident’s care plan, initiated several months earlier, identified an ADL self-care performance deficit related to repeated falls and specified that the resident required a mechanical lift and two staff for transfers. A later revision documented that the mechanical lift was discontinued, but the resident remained dependent on two staff with a gait belt for transfers. On the date of the incident, the CNA involved transferred the resident alone from a shower chair to a wheelchair, contrary to the care plan requirement for two-person assistance. During this transfer, the resident’s knees became weak, and the CNA lowered the resident to the floor in the shower room. Subsequent assessment by an LPN documented superficial scratches with scabbed areas below both knees, with no bruising and no reported pain from the resident, who stated, "I am fine." During the facility’s internal review, the administrator confirmed that the resident’s care plan and the posted closet care plan both indicated a two-person transfer requirement. In a phone conversation with the administrator, the CNA stated he thought the resident was a one-person transfer and acknowledged he had not reviewed the closet care plan "in a while." Other CNAs and a medication assistant reported in interviews that they routinely relied on the closet care plan to determine transfer needs and that these plans could be updated frequently, underscoring that staff were expected to check them regularly.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to discard three expired medications from one of the two medication carts observed for medication labeling and storage standards. During an observation and interview, three expired medications were found in the Northwest cart, including a bottle of multivitamins that expired in June 2024, a vial of fiber laxative that expired in August 2024, and a vial of fast-acting insulin with an opened date of August 1, 2024. An LPN stated that nurses are responsible for ensuring medications are removed before they expire, and insulin should be discarded 28 days after being opened and dated. The Director of Nursing confirmed that the facility follows the 28-day rule for opened multi-use medications and that nurses are responsible for checking the medication carts daily for expired medications. Additionally, the facility's pharmacy consultant checks the carts monthly for expired medications. However, the facility did not have a policy related to dating multi-dose medication and expired medication.
Inadequate Cleaning of Kitchen Equipment
Penalty
Summary
The facility failed to ensure food was prepared in a safe manner to prevent foodborne illness by not adequately cleaning the deep fryer and grease traps. During an initial tour of the facility kitchen, the Dietary Manager (DM) revealed grease traps covered in aluminum foil with a dark brown substance, small light brown crumbs, and hollow tubular shaped noodles that were light brown but black on top. Additionally, the deep fryer contained dark brown liquid with numerous small round crumbs gathered on top and around the edges. The DM stated that the grease traps and fish fryer are cleaned every two weeks, but acknowledged that they should be cleaned more frequently to prevent attracting bugs and to protect residents from foodborne illness. The facility was unable to provide a policy or staff competencies related to food preparation and cleaning of equipment when requested.
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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 Booneville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenhurst Nursing Center | 12.3 mi | ★★★★★ | 0 | 0 |
| Paris Health And Rehabilitation Center | 14.7 mi | ★★★★★ | 7 | 0 |
| The Springs Of Waldron | 19.6 mi | ★★★★★ | 0 | 0 |
| Pink Bud Home For The Golden Years | 20 mi | ★★★★★ | 0 | 0 |
| Ozark Nursing And Rehab | 25.1 mi | ★★★★★ | 6 | 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.