Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Care Manor Nursing And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of threatening behavior repeatedly verbally threatened and ultimately physically assaulted their cognitively impaired roommate, resulting in injury. Despite staff awareness of ongoing threats and verbal aggression, effective interventions such as room changes or psychiatric evaluation were not consistently implemented, and documentation of monitoring was lacking. The facility failed to protect residents from abuse as required by policy.
A facility failed to accurately complete MDS assessments for five of 10 residents reviewed. Quarterly MDSs for multiple residents incorrectly coded psychotic disorder or psychotic disorder other than schizophrenia despite the medical record showing no such diagnosis; one resident’s record also lacked PASRR information. The MDS Coordinator confirmed the coding errors and stated the facility used the RAI 3.0 manual and did not have an MDS policy.
A resident admitted with diagnoses including brain dysfunction caused by liver damage and bacteria in the blood had IV access and received two IV antibiotics, but the comprehensive care plan did not address the resident’s diagnoses, IV therapy, or antibiotic therapy. RN stated she overlooked adding these items, and the DON confirmed that infections, antibiotic therapy, and IV therapy should be included in care plans.
A facility failed to issue a written bed hold notification to a resident before a non-emergent hospital transfer, as required by their admission agreement. The resident's representative was informed of a five-day bed hold without prior written notice, causing confusion. Interviews revealed that staff, including the LPN, BOM, DON, and Administrator, were unaware or misinformed about the bed hold process, leading to the deficiency.
A resident with a terminal diagnosis was admitted to hospice care, but the facility failed to update the care plan to reflect this change. The MDS Coordinator acknowledged the oversight, stating that the care plan should have been updated when the resident was admitted to hospice.
The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days without proper documentation. Two residents received PRN medications consistently for several months without documented justification for their continued use. The DON explained that the IDT monitors PRN medication use, but there was no evidence of required evaluations and documentation.
The facility failed to ensure narcotic medications were stored in a permanently affixed compartment, leading to potential misappropriation. Surveyors found expired Ativan vials and undated multi-use vials of Tuberculin. The LPN confirmed all nurses had access to the medication room, and the DON acknowledged the risk of misappropriation due to improper storage and documentation practices.
A facility failed to disinfect a multi-resident use glucometer after use, potentially spreading infection. An LPN performed a blood glucose test on a resident with type II diabetes and returned the glucometer to the cart without sanitizing it. The DON confirmed that staff are trained to clean the glucometer before and after each use.
The facility failed to ensure an Infection Preventionist (IP) was employed during a COVID-19 outbreak. The DON confirmed that the acting IP had quit, leaving the facility without an IP for about a month. The DON managed infection control without an IP license or certification, and the Administrator acknowledged the requirement for a trained and certified IP.
The facility failed to honor a resident's preference for having their bed made daily. The resident, who is cognitively intact and has type 2 diabetes mellitus and bipolar disorder, reported that their bed was frequently left unmade due to staff shortages. Interviews with CNAs revealed inconsistencies in bed-making routines, and the facility's policy on maintaining a homelike environment was not followed.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse between residents, specifically involving a resident with severe cognitive impairment who repeatedly threatened and ultimately physically assaulted their roommate, who also had severe cognitive impairment and decreased physical mobility. The first incident involved verbal threats and aggressive language directed at the roommate, with staff intervention and short-term monitoring, but no room change or psychiatric consultation was initiated at that time. Staff and CNA interviews revealed that threatening behavior and verbal aggression from the resident continued over a period of weeks, with multiple reports made to nursing staff. Despite ongoing threats and escalating behaviors, the residents continued to share a room. Staff were aware of the repeated threats and verbal altercations, but interventions such as room changes or psychiatric evaluations were not consistently implemented. The facility's Director of Nursing and Administrator cited a lack of available beds and did not recall or act upon all reported incidents. Documentation of one-on-one monitoring after the second incident was not provided, and there was no evidence of consistent or effective measures to separate the residents or address the aggressive behaviors. The situation culminated in a physical assault, where the aggressive resident struck their roommate on the forehead with a remote control, resulting in visible injury and bleeding. Staff responded to the incident, provided treatment, and initiated neuro checks, but the failure to act on prior threats and to implement protective interventions contributed to the occurrence of abuse. The facility's policy required protection from abuse and management of aggressive behaviors, but these measures were not adequately followed, leading to the cited deficiency.
Inaccurate MDS Coding for Psychotic Disorder
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately completed for five of 10 residents reviewed for MDS accuracy. For Resident #7, the medical record showed diagnoses including depression, generalized anxiety disorder, altered mental status, and cognitive communication deficit, and there was no PASRR information available in the electronic medical record. However, the quarterly MDS with an ARD of 07/28/2025 indicated a psychotic disorder even though the resident had no diagnosis of a psychotic disorder requiring a PASARR. A modification made after surveyor inquiry removed the psychotic disorder from the MDS. The resident’s care plan documented psychotropic medication related to depression. Similar MDS coding errors were identified for Resident #4, Resident #69, Resident #34, and Resident #58. Each resident’s quarterly MDS indicated a psychotic disorder or psychotic disorder other than schizophrenia, but review of the medical diagnoses showed no such diagnosis for any of them. After surveyor inquiry, modified MDS entries were completed to remove the psychotic disorder coding. During interview, the MDS Coordinator stated the admission records were completed by an admission LPN, that she completed the MDS documents, and that the MDSs had been coded incorrectly because the residents did not have a diagnosis of other psychotic disorder when the MDS was completed. She also stated the facility did not have a policy for the MDS and used the RAI 3.0 manual.
Care Plan Did Not Address Diagnoses, IV Therapy, or Antibiotics
Penalty
Summary
The facility failed to address intravenous therapy, primary diagnoses, and antibiotic therapy in the comprehensive care plan for one resident. Resident #52 was admitted with diagnoses including brain dysfunction caused by liver damage and bacteria in the blood. The admission MDS dated 08/01/2025 showed the resident had a BIMS score of 13, indicating cognitive intactness, and also indicated that the resident received antibiotics and had IV access. The resident’s order summary dated 07/29/2025 showed two IV antibiotics were ordered for the resident’s diagnoses. However, the care plan did not address the resident’s medical diagnoses, antibiotic therapy, or IV therapy. During interview, RN #13 stated she adds diagnoses, IV therapy, and antibiotic therapy to care plans for residents who receive them, but she overlooked doing so for Resident #52. The DON stated that infections, antibiotic therapy, and IV therapy should be addressed in care plans, and the Administrator stated that RN #13 was responsible for completing and updating care plans.
Failure to Provide Bed Hold Notification Before Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notification to a resident prior to their transfer to a hospital, as required by the facility's admission agreement. The agreement, signed by the resident's authorized representative, stipulated that written information regarding the duration of the bed hold and any associated charges would be provided before a hospital transfer, except in emergent situations. However, when the resident was transferred to the hospital for a non-emergent condition, a fracture to the right femur neck, no such notification was issued. The resident's representative was informed by the facility that the bed would only be held for five days, leaving them uncertain about the next steps. Interviews with facility staff revealed a lack of understanding and communication regarding the bed hold process. The LPN involved in the transfer process was unaware of the bed hold requirements, and the Business Office Manager, who had recently assumed her role, had not been instructed on generating bed hold notifications. The Director of Nursing also expressed unfamiliarity with the bed hold procedure. The Administrator initially misunderstood the bed hold requirements, believing that information provided upon admission sufficed, and later acknowledged that the Business Office Manager had not been properly guided on this responsibility. This lack of clarity and communication among staff led to the deficiency in providing the required bed hold notification to the resident and their representative.
Failure to Update Care Plan Following Hospice Admission
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident with a diagnosis of malignant neoplasm of the brain was revised or updated following a significant change in the resident's condition. The resident, who was severely cognitively impaired and required substantial assistance with personal hygiene, was admitted to hospice care on 03/27/2024. Despite this significant change, the resident's care plan still indicated that the resident had not elected hospice care as of 05/15/2024. This discrepancy was identified during a review of the resident's electronic medical record and care plan. The MDS Coordinator acknowledged that the care plan should be updated when changes occur, including admission to hospice care. However, the MDS Coordinator admitted to forgetting to remove the
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days without proper documentation from the attending physician or prescribing practitioner. Resident #11, diagnosed with unspecified dementia, depression, cerebral infarction, and anxiety disorder, had a PRN order for Clonazepam 0.5 mg every 6 hours for anxiety. The medication was administered consistently from January to April 2024 without any documented justification for its continued use past 14 days. The medical records and monthly pharmacy reviews did not provide a rationale for the ongoing administration of Clonazepam. Similarly, Resident #42, diagnosed with vascular dementia, cerebral infarction, and anxiety disorder, had a PRN order for Ativan 1 mg every 6 hours for behaviors. This medication was also administered consistently from January to May 2024 without documented justification for its continued use past 14 days. When questioned, the Director of Nursing (DON) explained that the Interdisciplinary Team (IDT) monitors the use of PRN medications and meets weekly to discuss whether the medication should be discontinued or scheduled. However, there was no evidence that the required evaluations and documentation were completed for these residents.
Failure to Secure Narcotic Medications and Properly Date Multi-Use Vials
Penalty
Summary
The facility failed to ensure that narcotic medications were stored in a permanently affixed compartment, leading to the potential for misappropriation of resident property. During an inspection, surveyors observed that the facility's narcotic box could be easily removed from the refrigerator and placed on the counter. Inside the box, expired vials of Ativan and other medications intended for facility use were found. Additionally, multi-use vials of Tuberculin were observed without opened dates, which is against proper medication management protocols. The Licensed Practical Nurse (LPN) confirmed that all nurses had access to the medication room and that the narcotic box had always been removable from the refrigerator. The Director of Nurses (DON) acknowledged that the current practice could lead to misappropriation of medications and confirmed that narcotics were surrendered monthly without a proper counting process when keys were handed over to another nurse. The report highlights that the facility did not appropriately account for and secure medications from discharged residents, further increasing the risk of misappropriation. The DON admitted that expired or discontinued medications should be tagged, counted, and locked up, but this process was not consistently followed. The lack of proper storage and documentation practices for narcotic medications and multi-use vials indicates a significant lapse in the facility's medication management system, potentially compromising resident safety and medication integrity.
Failure to Disinfect Glucometer After Use
Penalty
Summary
The facility failed to ensure a multi-resident use glucometer was disinfected after use, which could potentially spread infection. Resident #45, who had a diagnosis of type II diabetes mellitus and a physician's order for fast-acting insulin based on capillary blood glucose (CBG) monitoring, was involved in the incident. On 05/15/2024 at 7:36 AM, an LPN performed a blood glucose test on Resident #45 using a glucometer taken from a medication cart. After the test, the LPN returned the glucometer to the cart without sanitizing it. The LPN later acknowledged that the glucometer should have been wiped down with a sanitizer cloth before and after use to prevent the spread of germs and infections. The Director of Nursing confirmed that the glucometer should be cleaned before and after each use and stated that staff are trained on this procedure during new hire orientation and retrained annually. The facility's policy also indicated that staff should use a disinfected blood glucose meter or a single-resident use device for obtaining a fingerstick glucose level.
Failure to Employ an Infection Preventionist During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that an Infection Preventionist (IP) was employed during the period from 01/02/2024 to 02/08/2024, during which a COVID-19 outbreak occurred. On 05/15/2024, the Director of Nursing (DON) confirmed that the nurse who was acting as the IP had quit either during or before the outbreak, leaving the facility without an IP for roughly a month. The DON reported that they personally managed the infection control by following the facility's policies and procedures, despite not having an IP license or certification. The Administrator acknowledged that having a trained and certified IP is a requirement.
Failure to Honor Resident's Preference for Bed-Making
Penalty
Summary
The facility failed to honor a resident's expressed preference for having their bed made daily. Resident #32, who has diagnoses of type 2 diabetes mellitus and bipolar disorder, was observed and interviewed, revealing that their bed was frequently left unmade. The resident, who scored 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive intactness, expressed feeling ignored by the CNAs due to staff shortages. The resident reported that their bed had not been made for the entire week and had stopped asking for it to be made. Interviews with CNAs revealed inconsistencies in bed-making routines, with no assigned time for making beds and varying practices depending on how busy the staff were. CNA #2 mentioned that beds are typically made before lunch but could not recall if Resident #32's bed had been made that week. CNA #3 stated that beds are made after breakfast but could only recall making the resident's bed on Monday. The facility's policy on providing a homelike environment was reviewed, which emphasized maintaining a clean, sanitary, and orderly environment, but this was not adhered to in the case of Resident #32.
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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 Mountain Home
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hiram Shaddox Health And Rehab | 0.7 mi | ★★★★★ | 0 | 0 |
| Lake Forest Senior Living At Mountain Home | 3.1 mi | ★★★★★ | 0 | 0 |
| Gassville Therapy And Living | 6.9 mi | ★★★★★ | 4 | 0 |
| Twin Lakes Therapy And Living | 12.5 mi | ★★★★★ | 0 | 0 |
| Gainesville Nursing | 16.2 mi | ★★★★★ | 2 | 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.