Hiram Shaddox Health and Rehab

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure medications were administered without errors resulting in an error rate of more than 5% for 2 (Resident #126 and Resident #227) of 7 residents who were observed during the 8:00 AM medication administration.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined that the facility failed to prepare and serve food in a safe and sanitary manner as evidenced by staff eating in the kitchen's preparation area and not performing hand hygiene after touching personal items and before serving residents. The failed practice had the potential of affecting 71 of 73 residents. On 5/12/2025 at 5:52 PM, upon entrance to the facility's kitchen, [NAME] #1 was observed eating food out of a small dish while standing on the serving line. [NAME] #1 picked up a cellphone from the top shelf of the steam table that was playing music, turned the music off, and sat the phone back down. [NAME] #1 then picked up a spoon handle and stirred the food on the steam table. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advance Beneficiary Notice [ABN] was provided to inform the residents and/or their responsible parties of financial liability for continued care and services after their Medicare coverage was discontinued for 5 Residents (#6, #19, #32, #42, and #276) sampled residents who were discharged from Medicare Skilled services in the last 6 months and remained in the facility and/or discharged home. This failed practice had the potential to affect 41 residents who received a Beneficiary Notice and were discharged or remained in the facility the last 6 months after they were released from Medicare Services.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program [QAPI] Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for F554, which referenced Self Administer of Medications. These failed practices had the potential to affect 75 residents

Inspectors wroteBased on observation, record revie, and interview, the facility failed to ensure that before a resident was allowed to self-administer Bronchodilator medication via nebulizer, the Interdisciplinary Team [IDT] conducted an assessment to determine if this practice was safe, to ensure a physician order [PO] was obtained and a care plan was developed to address self-administration of medication via nebulizer, to prevent potential errors in administration for 1 Resident #2 sampled residents. who had PO for Bronchodilator nebulizer treatments [tx].

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff covered the catheter bag with the privacy shield for 1(Resident #13) of 5 (Residents #13, #40, #66, #68, and #273) privacy shield was not pulled down over the catheter bag, assuring residents privacy. This lack of privacy care had the potential to affect the resident's dignity.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure before a resident was allowed to self-administer medications, the interdisciplinary team (IDT) conducted an assessment to determine if this practice was safe, to prevent potential complications for 1 (Resident #5) of 1 sampled resident who had a Topical Analgesic at the bedside and for 1 (Resident #18) of 1 sampled resident who had an Albuterol Inhaler at the bedside.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to provide assistance with activities of daily living (ADLs) for 6 (Resident #172, Resident #26, Resident #19, Resident #21, Resident #34, and Resident #122) of 6 dependent residents reviewed for ADLs. Specifically, the facility failed to: - Provide showers for Resident #26, Resident #19, Resident #21, Resident #34, and Resident #122. - Shave Resident #21 when needed. - Transfer Resident #172 out of bed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication (heparin flush and a normal saline flush) were not left at the bedside to prevent a potential accident/hazard for 1 (Resident #221) of 1 sampled resident who received Intravenous (IV) therapy in the last 30 days.

Inspectors wroteBased on record review and interview, the facility failed to ensure a pneumococcal vaccine was administered after consent was obtained to minimize the potential for contracting pneumonia for 4 (Residents #11, #20, #39 and #61) of 5 (Residents #1, #11, #20, #39 and #61) sampled residents whose immunization records were reviewed. This failed practice had the potential to affect 39 residents who had not received a pneumococcal vaccine as determined by the total census of 65, minus the 26 residents who had received a pneumococcal vaccine, according to the Resident Census and Conditions of Residents form dated 11/28/22.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Residents, Resident Representatives and Families were notified by 5:00 PM the next calendar day following the occurrence of a confirmed positive COVID-19 of 2 (Residents #22 and #51) of 3 (Residents #22, #51 and #225) sampled residents who had a confirmed COVID-19 positive case in the last 4 weeks. This failed practice had the potential to affect 64 residents according to the Census Report provided by the Administrator on 11/28/22.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to offer an invitation to participate in care plan meetings for 1 (Resident #122) of 2 residents reviewed for care plan meetings. This had the potential to affect the newly admitted resident's participation in the care meetings.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a significant change in status Minimum Data Set (MDS) was completed upon discharge from hospice services for 1 (Resident #59) of 2 residents reviewed for resident assessments.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #23) of 19 (Residents #5, #10, #19, #20, #21, #23, #26, #31, #32, #34, #38, #41, #51, #54, #59, #68, #122, #172, and #221) sampled residents whose MDS was reviewed. This failed practice had the potential to affect all 65 residents who resided in the facility as documented on the Resident Census and Conditions of Resident provided by the Administrator on 11/28/22.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered by the physician for 1 (Resident #23) of 11 (Residents #5, #10, #18, #19, #23, #26, #32, #38, #41, #59 and #122 I put in ascending order) sampled residents who had physician orders for oxygen.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to obtain informed consent and properly assess the use of side rails for 1 (Resident #41) of 1 resident reviewed for the use of side rails.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to ensure adequate medication monitoring for 1 (Resident #10) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to obtain lab tests (to measure blood clotting times) as ordered for Resident #10 who was receiving anticoagulation medication.