Cycle 1
Health 2025-05-15 · Fire 2025-05-15
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mountain Home, AR
Hiram Shaddox Health And Rehab
5-star overall rating with 5-star inspections with 2 recent health deficiencies
1100 Pinetree Lane, Mountain Home, AR
(870) 232-0320
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Anthony & Bryan Adams
Operator or chain grouping
Approved since
2020-01-29
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
0.48
Registered nurse staffing · state 0.40 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.72 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.35 · national 1.54
Weekend hours
2.64
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.27 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 51% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,942
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9912
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.86
Baseline 25.61% · Performance 18.43% · Measure score 7.86 · Achievement 6.47 · Improvement 7.86
Healthcare-associated infections
5.98
Baseline 7.23% · Performance 6.05% · Measure score 5.98 · Achievement 5.98 · Improvement 4.79
Total nurse turnover
0
Baseline 59.42% · Performance 65.71% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.37
Baseline 3.33 hours · Performance 3.47 hours · Measure score 1.37 · Achievement 1.37 · Improvement 0.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.45% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 235 · Observed rate 12.77% · Lower 95% interval 9.16% |
| Discharge to community | 51.79% |
50.57%
1.2 pts better
|
No Different than the National Rate · Eligible stays 201 · Observed rate 49.25% · Lower 95% interval 46.32% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.48% |
95.27%
2.2 pts better
|
Numerator 116 · Denominator 119 |
| Falls with major injury | 0.84% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 119 |
| Discharge self-care score | 48.15% |
53.69%
5.5 pts worse
|
Numerator 39 · Denominator 81 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 36 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 3.36% |
2.29%
1.1 pts worse
|
Numerator 4 · Denominator 119 · Adjusted rate 4.45% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 3.48% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 2.35% |
8.2%
5.8 pts worse
|
Numerator 2 · Denominator 85 |
| Staff flu vaccination coverage | 88.64% |
42%
46.6 pts better
|
Numerator 117 · Denominator 132 |
| Discharge function score | 46.91% |
56.45%
9.5 pts worse
|
Numerator 38 · Denominator 81 |
| Transfer of health information to provider | 98.82% |
95.95%
2.9 pts better
|
Numerator 84 · Denominator 85 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 6.25% |
25.2%
18.9 pts worse
|
Numerator 4 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.0
About the same
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
94.9%
3.5 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 98.4% · Q3 98.3% · Q4 100.0% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
96.1%
0.9 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.9%
1 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 6.6% · Q3 8.3% · Q4 3.6% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.4%
1.4 pts better
|
11.4%
11.4 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 who lose too much weight | 4.5% |
4.9%
0.4 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.9% · Q3 5.8% · Q4 0.0% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.6% |
21.8%
0.2 pts better
|
19.6%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 19.2% · Q3 25.0% · Q4 19.0% · 4Q avg 21.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
12.5%
8.8 pts better
|
16.7%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.5% · Q3 2.4% · Q4 3.1% · 4Q avg 3.7% · 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 | 6.3% |
11.4%
5.1 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
10.4%
0.8 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 13.0% · Q3 8.3% · Q4 10.0% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.1%
0.7 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.8% |
14.6%
4.8 pts better
|
19.8%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 10.9% · Q3 13.4% · Q4 2.0% · 4Q avg 9.8% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.6%
About the same
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.5% · Q3 8.2% · Q4 1.6% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.0% |
81.8%
2.2 pts better
|
81.7%
2.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 65.1% · Q2 80.0% · Q3 89.9% · Q4 95.7% · 4Q avg 84.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.9% |
13.8%
4.1 pts worse
|
12.0%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 16.5% · Expected 10.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
77.9%
5.4 pts better
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.6% |
25.2%
9.4 pts worse
|
23.9%
10.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.6% · Observed 32.0% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2024-02-23
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-12-01 · Fire 2022-12-01
12 health deficiencies
Top issue: Infection Control (3 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-22
F · Potential for more than minimal harm
2022-12-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-29
F · Potential for more than minimal harm
2022-12-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-12-01
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 2022-12-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-09
E · Potential for more than minimal harm
2025-05-15
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 2025-06-09
E · Potential for more than minimal harm
2024-02-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-03-23
E · Potential for more than minimal harm
2024-02-23
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-02-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-02-23
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-23
E · Potential for more than minimal harm
2023-05-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-10
E · Potential for more than minimal harm
2022-12-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-12-01
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 2022-12-29
E · Potential for more than minimal harm
2022-12-01
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 2022-12-29
E · Potential for more than minimal harm
2022-12-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-29
E · Potential for more than minimal harm
2022-12-01
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-01
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-01
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-12-01
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 2022-12-29
D · Potential for more than minimal harm
2022-12-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-12-29
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
Lockard, Tiffany
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Care Manor Nursing And Rehab
Mountain Home, AR
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#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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