Cycle 1
Health 2025-05-06 · Fire 2025-05-06
23 health deficiencies
Top issue: Administration (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Bella Vista, AR
Concordia Nursing & Rehab, LLC
1-star overall rating with 1-star inspections with Special Focus status with $121,855 in total fines with 23 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
7 Professional Drive, Bella Vista, AR
(479) 855-3735
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
30
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bradford Montgomery
Operator or chain grouping
Approved since
1989-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.29
Registered nurse staffing · state 0.40 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.33
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
2.70
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.27 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
100%
Annual nurse turnover · state 51% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,599
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9854
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.58
Performance 53.12% · Measure score 2.58 · Achievement 2.58 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.28
Baseline 2.83 hours · Performance 3.95 hours · Measure score 3.28 · Achievement 3.06 · Improvement 3.28
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 28 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.0
1 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.2
1.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.7 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
94.9%
3.1 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.3% · Q4 96.3% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.9%
3.9 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.7% |
1.4%
6.3 pts worse
|
11.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 10.0% · Q3 8.3% · Q4 4.0% · 4Q avg 7.7% |
| Percentage of long-stay residents who lose too much weight | 11.3% |
4.9%
6.4 pts worse
|
5.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · 4Q avg 11.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.7% |
21.8%
3.9 pts worse
|
19.6%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · 4Q avg 25.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
12.5%
0.7 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.4% |
10.4%
9 pts worse
|
14.9%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.0% |
0.7%
4.3 pts worse
|
1.0%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.5% · Q4 11.3% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
1.1%
4 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 9.1% · Q3 3.8% · Q4 3.8% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.2% |
14.6%
2.4 pts better
|
19.8%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 4.7% · Q3 0.0% · Q4 22.7% · 4Q avg 12.2% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.6%
2.7 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.3% |
81.8%
3.5 pts better
|
81.7%
3.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 78.4% · Q2 93.1% · Q3 85.7% · Q4 86.4% · 4Q avg 85.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.4%
1.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.5% |
77.9%
4.4 pts worse
|
79.7%
6.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
10 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-10-27 · Fire 2022-10-27
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-06
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-30
F · Potential for more than minimal harm
2024-02-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-02-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-27
F · Potential for more than minimal harm
2022-10-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-11-25
F · Potential for more than minimal harm
2022-10-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-25
Inspection history
Recent health citations
L · Immediate jeopardy
2025-05-06
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-10-07
L · Immediate jeopardy
2025-05-06
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-06-06
K · Immediate jeopardy
2025-05-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-06
K · Immediate jeopardy
2025-05-06
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-06-06
K · Immediate jeopardy
2025-05-06
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-06-06
J · Immediate jeopardy
2025-05-06
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-05-06
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-05-06
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2025-10-07
F · Potential for more than minimal harm
2025-05-06
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-05-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-05-06
F844 · Administration Deficiencies
Health
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-05-06
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-05-06
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-06
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-07
E · Potential for more than minimal harm
2025-05-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-06
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-10-07
E · Potential for more than minimal harm
2025-05-06
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2025-10-07
E · Potential for more than minimal harm
2025-05-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-06
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-06
G · Actual harm
2024-02-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-02-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-01
F639 · Resident Assessment and Care Planning Deficiencies
Health
Maintain 15 months of resident assessments in the resident's active clinical record.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-01
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-01
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-01
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-01
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-02-29
F · Potential for more than minimal harm
2022-10-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-25
E · Potential for more than minimal harm
2022-10-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-25
D · Potential for more than minimal harm
2022-10-27
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-11-25
B · Minimal harm
2022-10-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-27
Penalties and ownership
What sits behind the stars
$111,647
2025-05-06
Fine
Fine · fine $111,647
Fine
$0
2025-05-06
Payment Denial
Payment Denial · denial start 2025-08-06 · 62 days
62 day denial
$10,208
2024-02-01
Fine
Fine · fine $10,208
Fine
Ownership
Huddleston, Nadine
W-2 Managing Employee · Individual
Montgomery, Bradford
5% Or Greater Direct Ownership Interest · Individual
Montgomery, Bradford
Corporate Director · Individual
Nearby options
Other facilities in reach
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Highlands Of Bella Vista Health & Rehab, LLC
Bella Vista, AR
2-star overall rating with 2-star inspections with $8,055 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
The Green House Cottages Of Northwest Arkansas
Bentonville, AR
5-star overall rating with 5-star inspections with $705 in total fines with 1 recent health deficiencies
#3
Apple Creek Health And Rehab, LLC
Centerton, AR
3-star overall rating with 3-star inspections with $8,410 in total fines with 3 recent health deficiencies
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