Cycle 1
Health 2025-08-29 · Fire 2025-08-29
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Mountain Home, AR
Care Manor Nursing And Rehab
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
804 Burnett Drive, Mountain Home, AR
(870) 424-5030
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Anthony & Bryan Adams
Operator or chain grouping
Approved since
1999-08-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 4 overall / 3 health / 3 staffing / 4 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
0.39
Registered nurse staffing · state 0.40 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
3.91
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.27 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
4.64
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 51% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,167
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.02% · Performance 22.14% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.76
Baseline 5.03% · Performance 7.61% · Measure score 0.76 · Achievement 0.76 · Improvement 0
Total nurse turnover
1.33
Baseline 59.61% · Performance 58.23% · Measure score 1.33 · Achievement 1.33 · Improvement 0
Adjusted total nurse staffing
3.34
Baseline 3.82 hours · Performance 4.03 hours · Measure score 3.34 · Achievement 3.34 · Improvement 0.57
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.33% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 124 · Observed rate 7.26% · Lower 95% interval 6.73% |
| Discharge to community | 45.52% |
50.57%
5 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 39.32% · Lower 95% interval 37.48% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 63 · Denominator 63 |
| Falls with major injury | 1.59% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 63 |
| Discharge self-care score | 70.59% |
53.69%
16.9 pts better
|
Numerator 36 · Denominator 51 |
| Discharge mobility score | 64.71% |
50.94%
13.8 pts better
|
Numerator 33 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 63 · Adjusted rate 2.73% |
| Healthcare-associated infections requiring hospitalization | 7.61% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 7.32% · Lower 95% interval 4.04% |
| Staff COVID-19 vaccination coverage | 3.33% |
8.2%
4.9 pts worse
|
Numerator 3 · Denominator 90 |
| Staff flu vaccination coverage | 73.15% |
42%
31.2 pts better
|
Numerator 109 · Denominator 149 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 34 · Denominator 51 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 43 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · 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 | 1.8 |
2.0
0.2 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
94.9%
1 pts better
|
93.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 92.3% · Q4 91.7% · 4Q avg 95.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
96.1%
0.5 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.9%
2.5 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
1.4%
3.7 pts worse
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 11.9% · Q3 4.0% · Q4 3.8% · 4Q avg 5.1% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
4.9%
3.9 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 1.8% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.2% |
21.8%
11.4 pts worse
|
19.6%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 40.0% · Q3 31.9% · Q4 26.8% · 4Q avg 33.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.1% |
12.5%
9.4 pts better
|
16.7%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.7% · Q3 2.4% · Q4 2.0% · 4Q avg 3.1% · 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 ability to walk independently worsened | 14.9% |
11.4%
3.5 pts worse
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q4 3.4% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
10.4%
6.6 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.7% · Q3 2.2% · Q4 5.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.1%
1.1 pts better
|
1.7%
1.7 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 with new or worsened bowel or bladder incontinence | 24.8% |
14.6%
10.2 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 32.1% · Q3 18.8% · Q4 21.0% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.6%
1.4 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.5% · Q3 2.4% · Q4 5.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.2% |
81.8%
3.6 pts worse
|
81.7%
3.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.0% · Q2 84.8% · Q3 77.9% · Q4 65.9% · 4Q avg 78.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.9% |
13.8%
3.1 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 16.1% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.4%
1 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.6% · Q3 1.7% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.9% |
77.9%
7 pts better
|
79.7%
5.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.8% |
25.2%
4.6 pts worse
|
23.9%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.8% · Observed 23.2% · Expected 18.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-03-10 · Fire 2023-03-10
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-22
F · Potential for more than minimal harm
2024-05-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-15
F · Potential for more than minimal harm
2023-03-10
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 2023-04-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-08-29
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 2025-09-22
D · Potential for more than minimal harm
2025-01-17
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-03-03
E · Potential for more than minimal harm
2024-05-16
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 2024-06-15
E · Potential for more than minimal harm
2024-05-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-15
E · Potential for more than minimal harm
2024-05-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-06-15
E · Potential for more than minimal harm
2024-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-15
E · Potential for more than minimal harm
2024-05-16
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-06-15
D · Potential for more than minimal harm
2024-05-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-15
F · Potential for more than minimal harm
2023-03-10
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 2023-04-09
E · Potential for more than minimal harm
2023-03-10
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 2023-04-09
E · Potential for more than minimal harm
2023-03-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-09
E · Potential for more than minimal harm
2023-03-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-09
E · Potential for more than minimal harm
2023-03-10
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 2023-04-09
D · Potential for more than minimal harm
2023-03-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-09
Penalties and ownership
What sits behind the stars
Ownership
Eagle Health Systems Inc
5% Or Greater Direct Ownership Interest · Organization
Adams, Anthony
5% Or Greater Indirect Ownership Interest · Individual
Adams, Bryan
5% Or Greater Indirect Ownership Interest · Individual
Adams, Anthony
Corporate Officer · Individual
Adams, Bryan
Corporate Officer · Individual
Dvorak, Nora
Corporate Director · Individual
Ellis, John
Corporate Officer · Individual
Koehler, Tobey
Corporate Officer · Individual
Sutterfield, Randy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Hiram Shaddox Health And Rehab
Mountain Home, AR
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Lake Forest Senior Living At Mountain Home
Mountain Home, AR
3-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Gassville Therapy And Living
Gassville, AR
5-star overall rating with 4-star inspections with 4 fire-safety deficiencies in the latest cycle
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