Above 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 Beare Manor during CMS and state inspections, most recent first.
The facility inaccurately submitted RN staffing data to CMS for FY Quarter 2 2024. The PBJ Staffing Data Report showed missing RN hours for several dates, which the DON confirmed were days they worked. The error occurred because the previous business office staff failed to input the data before submission. Updated reports confirmed RN coverage on those days.
The facility did not ensure that residents were offered the choice to formulate advanced directives, affecting several residents. Clinical records lacked documentation that residents or their representatives were given the opportunity to establish an advanced directive upon admission or thereafter. The DON acknowledged this deficiency, which involved residents with both 'Do Not Resuscitate' (DNR) and 'Resuscitate' code statuses.
The facility failed to accurately measure and verify liquid controlled drugs for four residents receiving Lorazepam Con 2mg/ml. The 'Controlled Substances' policy requires accurate drug inventory, but discrepancies were found in records. Observation revealed that Lorazepam bottles lacked markings for accurate measurement beyond 22mls. A CMA could not confirm the remaining medication amount without the controlled drug sheet, and the DON acknowledged the issue, stating the pharmacy would need to dispense differently.
The facility failed to follow its food storage and handling policies, with unlabeled and undated food items found in refrigerators and freezers. Freezers were not cleaned regularly, and the dishwasher did not reach the required temperature, yet dishes were still put away. Additionally, inappropriate utensils were used for serving meals, and infection control protocols were violated during silverware wrapping.
The facility did not ensure that binding arbitration agreements included an acknowledgment that residents or their representatives understood the agreements they were signing. This affected sixteen residents, as confirmed by the Administrator upon review.
The facility did not inform residents or their representatives of their right to have arbitration at a convenient venue in the binding arbitration agreements. This affected sixteen residents, and the Administrator acknowledged the omission upon review.
The facility did not implement a water management program to minimize Legionella risk, despite having a policy in place. The DON, also the IP, admitted to not following the policy, relying instead on corporate instructions. This deficiency potentially affected all 35 residents.
Inaccurate RN Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate Registered Nurse (RN) staffing data to the Centers for Medicare & Medicaid Services (CMS) for the fiscal year Quarter 2 of 2024. A review of the Payroll-Based Journal (PBJ) Staffing Data Report for the period from January 1, 2024, to March 31, 2024, revealed that the facility did not report RN hours for numerous specific dates within this timeframe. Upon inquiry, the Director of Nursing (DON) confirmed that RN coverage was indeed provided on all the days listed as missing in the PBJ report. The DON explained that the previous business office personnel failed to manually input the RN hours into the system before submitting the data to the state, resulting in the inaccurate submission. The DON provided updated time reports showing RN coverage for each of the days in question, confirming that the initial submission to the state was not accurate.
Failure to Offer Advanced Directives
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate advanced directives, affecting seven out of twelve sampled residents. These residents, identified as #7, #10, #20, #21, #24, #26, and #30, did not have documentation in their clinical records indicating that they or their representatives were offered the opportunity to establish an advanced directive upon admission or at any time thereafter. The Director of Nursing acknowledged the absence of established advanced directives or signed acknowledgments for these residents, despite their varying code statuses, which included both 'Do Not Resuscitate' (DNR) and 'Resuscitate'. This oversight was identified during a review of the clinical records and confirmed through an interview with the Director of Nursing.
Inaccurate Measurement of Liquid Controlled Drugs
Penalty
Summary
The facility failed to ensure accurate measurement and verification of liquid controlled drugs for four residents receiving Lorazepam Con 2mg/ml. The facility's 'Controlled Substances' policy, effective since July 2015, mandates accurate accountability of controlled drug inventory at all times. However, discrepancies were found in the 'Controlled Drug Receipt Record/Disposition Form' for four residents, where the recorded amounts left did not match the expected quantities based on the dates and amounts received. For instance, Resident #15's record showed a discrepancy in the amount left compared to the quantity received. During an observation, it was noted that the Lorazepam bottles lacked markings to measure the medication accurately beyond 22mls. When asked, a Certified Medication Aide (CMA) admitted they could not confirm the remaining amount of medication without referring to the controlled drug sheet. The Director of Nursing (DON) acknowledged the inability to verify the accuracy of the liquid narcotics count due to the lack of markings on the bottles and stated that the pharmacy would need to dispense the medication differently.
Deficiencies in Food Storage, Handling, and Portion Control
Penalty
Summary
The facility failed to adhere to its food storage and handling policies, as observed during a survey. In multiple refrigerators and freezers, food items such as cheese, milk, rice crispy bars, and pound cake were found without proper labeling or dating, contrary to the facility's policy that requires all stored foods to be covered, labeled, and dated. Additionally, opened bags of frozen cookies were found without labels or dates, and a dietary aide was observed wrapping silverware on a dirty surface without a barrier, violating infection control protocols. The facility also did not maintain proper cleaning practices for its freezers, as evidenced by the presence of ice and frozen red liquid in one of the freezers, which had not been cleaned recently. The facility's policy requires freezers to be cleaned regularly, but this was not followed. Furthermore, the dishwasher was not reaching the required temperature of 120 degrees Fahrenheit, with readings of only 100 and 105 degrees, and the temperature log had not been completed for several days. Despite this, dishes were still being put away without being re-washed, as required by the facility's policy. Portion control was also inadequately managed, with inappropriate utensils being used for serving meals. A purple spoon, identified as a one tablespoon measure, was used to serve a pureed main entree instead of the required #12 scoop, which is 1 1/2 cups. This discrepancy was acknowledged by the dietary manager, who noted that the puree had already been served. The facility lacked a clear policy on portion sizes, and the portion size chart was only displayed on the wall without further guidance.
Failure to Ensure Understanding of Binding Arbitration Agreements
Penalty
Summary
The facility failed to provide a binding arbitration agreement that included an acknowledgment that the resident or their representative understood the agreement they were signing. This deficiency affected sixteen out of twenty-six residents who had signed such agreements. The Director of Nursing identified that there were 35 residents in the facility, with 26 having signed binding arbitration agreements. Upon review, it was found that the agreements for these sixteen residents did not contain the necessary acknowledgment of understanding. The Administrator confirmed this omission after reviewing the agreements.
Failure to Inform Residents of Arbitration Venue Rights
Penalty
Summary
The facility failed to provide a binding arbitration agreement that informed residents or their representatives of their right to have the arbitration held at a venue convenient to both parties. This deficiency affected sixteen out of twenty-six residents who had signed such agreements. During a review, the Administrator was unable to identify any statement in the agreements that informed the residents or their representatives of this right. The Director of Nursing identified that there were 35 residents in the facility, with 26 having signed binding arbitration agreements. The lack of this necessary information in the agreements was acknowledged by the Administrator upon review.
Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement a comprehensive water management program to minimize the risk of Legionella and other opportunistic pathogens in its water systems, as required for infection control. The deficiency was identified through a review of records and interviews, revealing that the facility did not have a documented water management program in place, despite having a Legionnaires' Disease policy dated September 2019. This policy outlined the need for a facility risk assessment, development of water management strategies, and documentation of the program, including a facility description and water system description. However, the building diagram attached to the policy was blank, and the facility did not follow the policy and procedure for Legionella management. The Director of Nursing (DON), who also served as the Infection Preventionist (IP), acknowledged the absence of Legionellosis cases in the facility but admitted to not following the policy. The DON indicated that they were following instructions from their corporate office, which had received an email from the CMS DNH Triage Team emphasizing the need for a documented water management program. The email highlighted the necessity of an assessment to identify potential growth and spread of Legionella and other pathogens, as well as control measures and monitoring. Despite these directives, the facility did not have a water management program in place, potentially affecting all 35 residents residing in the facility.
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 13 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hartshorne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Walnut Grove Care & Rehab Center | 12.6 mi | ★★★★★ | 0 | 0 |
| New Hope Retirement & Care Center | 13.2 mi | ★★★★★ | 8 | 0 |
| Mcalester Nursing & Rehab | 13.7 mi | ★★★★★ | 2 | 0 |
| Tidwell Living Center | 14.2 mi | ★★★★★ | 0 | 0 |
| Latimer Nursing Home | 14.3 mi | ★★★★★ | 0 | 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.