Inspection Reports for
Hiram Shaddox Health and Rehab
1100 Pinetree Ln, Mountain Home, AR 72653, United States, AR, 72653
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 2
Date: May 15, 2025
Visit Reason
The inspection was conducted to evaluate compliance with medication administration and food safety standards at the nursing home.
Findings
The facility failed to ensure medications were administered without errors, resulting in a medication error rate of 5.56% during the 8:00 AM medication pass. Additionally, the facility failed to prepare and serve food in a safe and sanitary manner, as staff were observed eating in the kitchen preparation area and not performing proper hand hygiene, potentially affecting 71 of 73 residents.
Deficiencies (2)
Medication error rate exceeded 5%, with errors including under-dosing Vitamin B12 and crushing enteric coated delayed release medication.
Staff eating in the kitchen preparation area and failing to perform hand hygiene after touching personal items and before serving residents.
Report Facts
Medication administration error rate: 5.56
Residents potentially affected by food safety issue: 71
Total residents in facility: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Observed administering medications incorrectly and crushing enteric coated medication |
| Advance Practice Registered Nurse (APRN) | Advance Practice Registered Nurse | Interviewed regarding medication orders and confirmed medication administration standards |
| Director of Nursing | Director of Nursing | Confirmed expectations for medication administration according to physician orders and facility policies |
| Administrator | Administrator | Confirmed expectations for medication administration and kitchen operations policies |
| Dietary Manager | Dietary Manager | Confirmed staff training on safe food handling and hand hygiene |
Inspection Report
Routine
Deficiencies: 2
Date: May 15, 2025
Visit Reason
The inspection was conducted to evaluate medication administration practices and food safety procedures at the facility, including observation, interviews, record and policy reviews.
Findings
The facility failed to ensure medications were administered without errors, resulting in a medication error rate of 5.56% during the 8:00 AM medication pass. Additionally, the facility failed to prepare and serve food in a safe and sanitary manner, as staff were observed eating in the kitchen preparation area and not performing proper hand hygiene, potentially affecting 71 of 73 residents.
Deficiencies (2)
Medication error rate exceeded 5%, with errors including administering only 1 tablet instead of 2 for Resident #126 and crushing enteric coated medication for Resident #227.
Staff eating in the kitchen preparation area and failing to perform hand hygiene after touching personal items and before serving residents.
Report Facts
Medication administration error rate: 5.56
Residents potentially affected by food safety issue: 71
Total residents in facility: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Observed administering medications with errors and crushing enteric coated medication |
| Advance Practice Registered Nurse (APRN) | Interviewed regarding medication orders and administration | |
| Director of Nursing | Director of Nursing (DON) | Confirmed expectations for medication administration |
| Administrator | Administrator | Confirmed expectations for medication administration and kitchen operations |
| Dietary Manager | Dietary Manager (DM) | Confirmed staff training on safe food handling and hand hygiene |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Feb 23, 2024
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements, including medication self-administration, notification of Medicare coverage and liability, catheter care, and quality assurance processes.
Findings
The facility was found deficient in ensuring proper assessment and physician orders for residents self-administering medications, providing Advance Beneficiary Notices to residents discharged from Medicare services, maintaining catheter privacy shields, and implementing effective Quality Assurance and Performance Improvement (QAPI) plans to prevent repeated deficiencies.
Deficiencies (5)
Failed to ensure that before a resident was allowed to self-administer bronchodilator medication via nebulizer, the interdisciplinary team conducted an assessment, obtained a physician order, and developed a care plan.
Failed to provide Advance Beneficiary Notice to inform residents and/or responsible parties of financial liability after Medicare coverage was discontinued for 5 sampled residents.
Failed to ensure staff covered the catheter bag with the privacy shield for 1 resident, affecting dignity.
Failed to develop and implement appropriate QAPI plans to prevent repeated deficiencies related to self-administration of medications.
Failed to ensure assessment and physician orders for residents self-administering topical analgesic and albuterol inhaler medications.
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 75
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding resident self-administration of medications and medication orders |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding knowledge of residents self-administering medications |
| Director of Nursing | Director of Nursing | Interviewed regarding catheter care training and self-administration policies |
| Nurse Consultant | Provided policy and information regarding self-administration assessments | |
| Administrator | Administrator | Interviewed regarding QAA Committee and quality assurance processes |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication self-administration, notification of Medicare/Medicaid coverage and liability, catheter care and privacy, and quality assurance and performance improvement activities at the nursing facility.
Findings
The facility was found deficient in ensuring proper assessment and physician orders for residents self-administering medications, providing Advance Beneficiary Notices to residents discharged from Medicare skilled services, maintaining catheter privacy for residents, and implementing effective Quality Assurance and Performance Improvement (QAPI) plans to prevent repeated deficiencies.
Deficiencies (5)
Failure to ensure that before a resident was allowed to self-administer bronchodilator medication via nebulizer, the interdisciplinary team conducted an assessment, obtained a physician order, and developed a care plan.
Failure to provide Advance Beneficiary Notice (ABN) to inform residents and/or responsible parties of financial liability after Medicare coverage was discontinued for 5 sampled residents.
Failure to ensure staff covered the catheter bag with the privacy shield for 1 resident, compromising resident dignity.
Failure to develop and implement appropriate Quality Assurance and Performance Improvement (QAPI) plans to prevent repeated deficiencies related to self-administration of medications.
Failure to ensure assessment and physician orders for residents self-administering topical analgesic and Albuterol inhaler medications.
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 75
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding resident self-administration of medications and medication presence at bedside | |
| Licensed Practical Nurse (LPN) #2 | Interviewed regarding knowledge of residents self-administering medications | |
| Nurse Consultant | Provided policy and statements regarding self-administration assessments | |
| Director of Nursing (DON) | Interviewed regarding staff training, catheter care, and resident self-administration policies | |
| Administrator | Interviewed regarding Quality Assurance and Performance Improvement (QAPI) activities and awareness of repeated deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 11, 2023
Visit Reason
The inspection was conducted due to concerns about infection prevention and control practices at the facility, specifically related to failure to follow proper hand hygiene and glove use protocols during incontinent care for a sampled resident.
Complaint Details
The visit was complaint-related, focusing on infection prevention and control practices. The report documents observations, interviews, and record reviews confirming failures in infection control procedures.
Findings
The facility failed to ensure staff followed proper infection prevention and control practices, including failure to change gloves between dirty and clean tasks, failure to perform hand hygiene after handling contaminated surfaces, and failure to sanitize equipment prior to resident use. These deficiencies were observed during care of Resident #2, who had dementia and urinary tract infections.
Deficiencies (2)
Failure to change gloves between dirty to clean tasks during incontinent care and failure to perform hand hygiene after handling contaminated surfaces.
Failure to ensure equipment was sanitized and clean of contamination prior to resident use.
Report Facts
Residents sampled: 3
Resident BIMS score: 8
Assessment Reference Date: Apr 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Observed walking through feces, failing to change gloves or perform hand hygiene. | |
| Certified Nursing Assistant (CNA) #2 | Observed failing to change gloves and perform hand hygiene during incontinent care. | |
| Certified Nursing Assistant (CNA) #3 | Assisted in transferring Resident #2 from bed to contaminated wheelchair. | |
| Infection Control Prevention (ICP) Nurse | Interviewed regarding hand hygiene and glove use protocols. | |
| Director of Nursing (DON) | Interviewed regarding expectations for staff compliance with infection control policies. | |
| Administrator | Interviewed regarding facility policies and staff expectations for infection control. |
Inspection Report
Routine
Deficiencies: 2
Date: May 11, 2023
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control practices, specifically related to proper hand hygiene, glove use, and sanitation procedures during resident care.
Findings
The facility failed to ensure staff followed proper infection prevention and control practices, including failure to change gloves between dirty and clean tasks, failure to perform hand hygiene after handling contaminated surfaces, and failure to sanitize equipment prior to resident use, affecting one sampled resident.
Deficiencies (2)
Failure to change gloves between dirty to clean tasks during incontinent care and failure to perform hand hygiene after handling contaminated surfaces.
Failure to ensure equipment was sanitized and clean of contamination prior to resident use.
Report Facts
Residents Affected: 1
Assessment Reference Date: Apr 17, 2023
Inspection Report
Deficiencies: 0
Date: Feb 8, 2023
Visit Reason
The inspection was conducted as a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Feb 8, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Hiram Shaddox Health and Rehab, summarizing the findings from the survey completed on 02/08/2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 65
Deficiencies: 11
Date: Dec 1, 2022
Visit Reason
Routine inspection of Hiram Shaddox Health and Rehab to assess compliance with regulatory requirements including resident care, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to involve residents in care planning, inadequate medication self-administration assessments, incomplete significant change assessments, inaccurate Minimum Data Set (MDS) documentation, failure to provide adequate assistance with activities of daily living, improper oxygen administration, lack of informed consent and assessment for side rail use, failure to monitor anticoagulant therapy adequately, improper medication storage, failure to administer pneumococcal vaccines after consent, and failure to timely notify residents and families of COVID-19 positive cases.
Deficiencies (11)
Failed to offer invitation to participate in care plan meetings for 1 resident.
Failed to ensure assessment before allowing residents to self-administer medications for 2 residents.
Failed to complete significant change in status MDS upon discharge from hospice for 1 resident.
Failed to ensure accurate and complete MDS assessments for 1 resident.
Failed to provide adequate assistance with activities of daily living for 6 residents.
Failed to administer oxygen as ordered for 1 resident.
Failed to obtain informed consent and properly assess use of side rails for 1 resident.
Failed to ensure adequate medication monitoring for anticoagulant therapy for 1 resident.
Failed to ensure medication flushes were not left at bedside for 1 resident receiving IV therapy.
Failed to administer pneumococcal vaccine after consent for 4 residents.
Failed to notify residents, representatives, and families timely of confirmed COVID-19 positive cases for 2 residents.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Total residents: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in findings related to medication self-administration and medication flushes |
| Director of Nursing | Director of Nursing | Named in findings related to care plan meetings, medication self-administration, oxygen administration, side rail use, anticoagulant monitoring, medication storage, vaccination, and COVID-19 notification |
| Administrator | Administrator | Named in findings related to care plan meetings, vaccination, and COVID-19 notification |
| Certified Nurse Aide #4 | Certified Nurse Aide | Named in findings related to assistance with ADLs and side rail use |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Named in findings related to assistance with ADLs, medication monitoring, and side rail use |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Named in findings related to assistance with ADLs, medication monitoring, and side rail use |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in findings related to assistance with ADLs, medication monitoring, and side rail use |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in findings related to anticoagulant medication monitoring |
| Infection Preventionist | Infection Preventionist | Named in findings related to vaccination and COVID-19 notification |
| Social Service Director | Social Service Director | Named in findings related to vaccination and COVID-19 notification |
| Certified Nurse Aide #8 | Certified Nurse Aide | Named in findings related to assistance with ADLs |
Inspection Report
Routine
Census: 65
Deficiencies: 11
Date: Dec 1, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to invite a resident to care plan meetings, inadequate assessment for self-administration of medications, incomplete significant change in status assessments, inaccurate Minimum Data Set (MDS) documentation, failure to provide adequate assistance with activities of daily living, improper oxygen administration, lack of informed consent and assessment for side rail use, inadequate monitoring of anticoagulant therapy, improper medication storage, failure to administer pneumococcal vaccines after consent, and failure to timely notify residents and families of confirmed COVID-19 cases.
Deficiencies (11)
Failed to offer an invitation to participate in care plan meetings for 1 resident.
Failed to ensure assessment before allowing residents to self-administer medications.
Failed to complete a significant change in status Minimum Data Set (MDS) upon discharge from hospice.
Failed to ensure accurate and complete Minimum Data Set (MDS) assessments.
Failed to provide adequate assistance with activities of daily living for 6 dependent residents.
Failed to administer oxygen as ordered for 1 resident.
Failed to obtain informed consent and properly assess the use of side rails for 1 resident.
Failed to ensure adequate medication monitoring for anticoagulant therapy for 1 resident.
Failed to ensure medication flushes were not left at bedside for 1 resident receiving IV therapy.
Failed to administer pneumococcal vaccine after consent for 4 residents.
Failed to notify residents, representatives, and families timely of confirmed COVID-19 positive cases for 2 residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 19
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Total residents: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to medication flushes and oxygen administration |
| LPN #6 | Licensed Practical Nurse | Named in findings related to shower refusals and anticoagulant monitoring |
| LPN #7 | Licensed Practical Nurse | Named in findings related to shower refusals and anticoagulant monitoring |
| CNA #4 | Certified Nurse Aide | Named in findings related to shower assistance and side rail use |
| CNA #5 | Certified Nurse Aide | Named in findings related to shower assistance and side rail use |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding care plan meetings, medication monitoring, and resident care |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in interviews regarding shower schedules, side rail assessments, and anticoagulant monitoring |
| Administrator | Administrator | Named in interviews regarding care plan meetings, vaccination policies, and COVID-19 notifications |
| Social Services Director | Social Services Director | Named in interviews regarding care plan meetings and vaccination consents |
| Infection Preventionist | Infection Preventionist | Named in interviews regarding vaccination administration and COVID-19 notifications |
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