Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Pruitthealth - Holly Hill, Llc during CMS and state inspections, most recent first.
Smoking Supervision and Oxygen Safety Failures: Two residents with COPD and oxygen needs were allowed to smoke with inadequate oversight and inaccurate smoking assessments. One resident was observed smoking unsupervised while wearing nasal cannula oxygen and keeping cigarettes and a lighter in his oxygen bag, while another resident was observed smoking with a portable O2 tank still attached to her wheelchair and no staff present. Staff interviews confirmed smoking materials were not consistently secured and that the smoking assessments were completed incorrectly.
A facility failed to enforce its smoking policy when two cognitively intact residents were allowed to smoke while using portable O2. One resident with COPD and chronic respiratory failure was observed smoking with a nasal cannula on and the portable O2 machine still attached to his rollator, while another resident with chronic respiratory failure and COPD was observed smoking with her O2 tank attached to her wheelchair. The policy prohibited smoking where O2 was used or stored and required smoking materials to be kept secure by staff.
Failure to Address Vision Impairment in Care Plan: A resident with impaired vision and no glasses had a CAA trigger for vision impairment, but the care plan did not identify or address the issue. The MDSC acknowledged the omission, and the Administrator and DON confirmed the vision CAA should have been reflected in the resident’s care plan.
A resident with vision impairment and little to no cognitive impairment did not receive ordered eye care. An optometrist recommended daily lid hygiene with a warm washcloth for chronic blepharitis and later ordered eye ointment and eye drops for dry eye, but the orders were not transcribed into the EMR or documented on the MAR. An LPN confirmed the orders were not carried through, and the SSD and DON described the facility's process for receiving and reviewing the optometrist's orders.
Medication Error Rate Exceeded Threshold During Insulin Pen Administration: Surveyors found an eight percent medication error rate after observing two insulin administration errors involving two residents with DM receiving Humalog KwikPen insulin by sliding scale. An RN and a CMA each administered insulin without priming the pen after attaching the needle, and both confirmed the omission during interview. The DON and CCC stated staff training included priming the insulin pen to ensure proper function and accurate dosing.
Missing food safety policy and refrigerator oversight. The facility had no policy for food brought in by visitors and no defined cleaning schedule or assigned staff for resident refrigerators. A cognitively intact resident’s personal refrigerator contained multiple expired items and an unlabeled bowl with visible mold growth, and the freezer compartment lacked a thermometer, so freezer temps were not recorded. Staff interviews confirmed the expired food, the lack of a cleaning/documentation process, and that the missing freezer thermometer had not been identified until surveyors observed it.
The facility did not ensure dietary staff wore beard guards as required by policy, risking food contamination. The Dietary Manager was observed preparing and serving food without a beard cover, contrary to the facility's hygiene standards. Interviews confirmed the expectation for all staff to use hair nets and beard guards, with the DM admitting to not wearing one and being unsure of the policy's application in the dining room.
The facility failed to prevent personal food items from being stored in the medication room, risking contamination of medications and supplies. Observations revealed items like hot dog buns and condiments next to medical supplies. Staff interviews confirmed that such storage is unsanitary and could lead to contamination and infection. The facility lacked a policy on this issue.
A resident with visual impairment and multiple health issues was not cleaned promptly after meals, and the call light was repeatedly found out of reach. Staff interviews confirmed that care plan interventions were not consistently followed, leading to a deficiency in maintaining the resident's dignity and rights.
Three residents in the facility were found with unauthorized medications at their bedside, posing a risk of unauthorized access and potential harm. One resident had unauthorized nasal spray and Advair Diskus, another had 23 bottles of medications without a self-administration order, and a third had nitroglycerin tablets for chest pain without proper authorization. Facility staff were unaware of these situations, highlighting a failure in monitoring and ensuring compliance with medication storage policies.
The facility failed to accommodate the needs of two residents: one morbidly obese resident was not provided with a suitable bed, causing fear of falling, and a visually impaired resident did not have a call light within reach and was not assisted with eating and cleaning. Staff interviews confirmed that care plans were not followed, leading to these deficiencies.
The facility failed to provide residents and their representatives with written information about their right to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified through interviews and record reviews, revealing that the Admission Packet lacked necessary language. Three residents were specifically noted, with varying cognitive statuses, and staff confirmed the absence of required documentation.
The facility failed to maintain a safe, clean, and homelike environment on the 100 hall. Observations revealed stained toilet bases and caulking, rusty light fixtures, and protruding wall trim in several rooms. These conditions were confirmed by the Maintenance Director, posing potential risks to residents' safety and quality of life.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. A resident assessed to self-administer medications lacked a supporting care plan. Another resident received oxygen therapy at an incorrect rate, contrary to physician orders. Additionally, a resident's care plan for nutrition was not followed, as they were not weighed weekly as required. Further discrepancies were noted in oxygen therapy management for two other residents, with incorrect flow rates administered compared to physician orders.
A resident with multiple contractures and muscle weakness did not receive the prescribed splints as ordered, which were essential for managing their condition. Despite clear medical orders and a care plan requiring daily application of orthoses, observations revealed the resident was without splints over several days. Interviews with CNAs, LPNs, and the Director of Health Services confirmed the lapse in care, highlighting a failure to adhere to the prescribed treatment plan.
The facility failed to prevent accident hazards for two residents. One resident was exposed to harmful chemicals when bleach was found in their bathroom, contrary to facility policy. Another resident had a free-standing oxygen tank in their room, which was not secured in a rack or cart as required. Staff confirmed that such practices were against policy and posed potential risks.
A resident with urinary retention and neurogenic bladder had their catheter tubing improperly positioned, coiled, and hung at bed height instead of below the bladder, contrary to care plan instructions. Observations revealed staff placed the catheter bag on a dresser knob based on the resident's preferences, and the CMA admitted to not receiving proper instructions. The DHS confirmed the improper positioning and corrected it.
The facility failed to complete timely nutrition assessments for two residents, as required by its policy. One resident, with conditions like dysphagia and acute kidney failure, and another with atrial fibrillation and end-stage renal disease, did not receive assessments until months after admission. The Registered Dietitian confirmed the oversight, and the facility's administration was unaware of the delay, potentially risking the residents' nutritional health.
A LTC facility failed to follow physician orders for oxygen administration for four residents, leading to potential respiratory complications. One resident received oxygen at an incorrect rate, confirmed by a nurse who adjusted it. Another resident received oxygen at a higher rate than prescribed, with no humidifier attached. A third resident's oxygen rate was incorrect, and equipment was not dated. A fourth resident's oxygen masks were not stored properly, posing an infection risk. Staff interviews confirmed these deficiencies.
The facility failed to lock a medication cart, remove expired medications, and label open dates on medications, posing risks of unauthorized access and ineffective treatment. An LPN confirmed the cart couldn't be locked, and expired medications were found on various carts. The DHS emphasized the importance of locking carts and labeling medications to prevent harm.
Smoking Supervision and Oxygen Safety Failures
Penalty
Summary
The facility failed to protect residents from smoking-related accident hazards for two residents reviewed for smoking, including one resident with chronic respiratory failure, COPD, nicotine dependence, and continuous oxygen therapy, and another resident with chronic respiratory failure with hypoxia and COPD. The deficiency involved inaccurate smoking assessments, inadequate supervision during smoking, failure to secure smoking materials, allowing smoking in proximity to portable oxygen equipment, and failure to follow the facility’s smoking policy. The report states that these actions and inactions created conditions during smoking times that could result in bodily injury to residents smoking and those nearby. For one resident, the smoking observation form was not completed accurately because it did not reflect all answers as “NO,” even though the form showed yes responses for medical diagnosis/condition, medication hazards when smoking, poor judgment/non-compliance regarding safety, and a physician order for oxygen. The resident’s care plan stated he was a smoker and should comply with the nonsmoking policy, leave smoking items at the front desk, sign out before leaving, and return items to the nurse upon re-entry. Despite this, he was observed smoking unsupervised while wearing oxygen via nasal cannula, with the portable oxygen machine attached to his rollator, and later was observed retrieving a cigarette and lighter from the zipper pocket of his oxygen machine bag. For the other resident, the smoking observation form also was not completed accurately and indicated she was a supervised smoker, physically unable to light her own cigarette, and had a physician order for oxygen. Her care plan stated she was non-compliant in the use of oxygen and was re-educated to go off the facility grounds when smoking after turning her oxygen off. However, she was observed signing out to smoke, taking her oxygen tank outside, and later smoking in the parking lot with the oxygen tank still attached to her wheelchair, with no staff observing her. Staff interviews confirmed that the resident would retrieve cigarettes from the front desk and that staff did not go out to supervise residents who smoked. The Administrator and DON stated the smoking assessments were completed incorrectly due to staff misunderstanding the questions and that residents who signed out were considered on leave of absence.
Smoking Policy Not Enforced Around Residents Using Oxygen
Penalty
Summary
The facility failed to enforce its smoking policy by allowing residents to smoke near others who were using portable oxygen. Surveyors identified this issue for two residents reviewed for smoking out of a sample of 24 residents. The deficiency was cited under 483.90 Smoking Policies at scope and severity J, and the report states that the noncompliance created conditions that posed a risk of serious injury for the residents. One resident had diagnoses including chronic respiratory failure, COPD, and nicotine dependence. His quarterly MDS showed a BIMS score of 14 out of 15, indicating he was cognitively intact, and that he received oxygen therapy. His smoking observation form dated 01/22/26 showed multiple yes responses, including medical diagnosis/condition, medication creating a hazard when smoking, poor judgment/non-compliance regarding safety, and a physician’s order for oxygen. Progress notes documented that he and his representative were educated about the risk of fire related to smoking with oxygen and that noncompliance could result in discharge. On 02/23/26, he was observed sitting on his rollator and smoking a cigarette while wearing oxygen via nasal cannula in the upper parking lot, with the portable oxygen machine still attached to the rollator. The second resident had diagnoses including chronic respiratory failure with hypoxia and COPD with acute exacerbation. Her MDS showed a BIMS score of 15 out of 15, indicating she was cognitively intact. She stated she signed out to smoke and had been educated about using oxygen while smoking. On 02/24/25, she was observed in the parking lot near the front door smoking while her oxygen tank remained attached to the back of her wheelchair, and staff were not present to observe her smoking. The facility policy stated smoking was prohibited in areas where oxygen was used or stored and that smoking materials were not to be kept in a resident’s possession, with igniting and smoking materials maintained in a secure area by staff.
Failure to Address Vision Impairment in Care Plan
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for one resident, R60, after the resident’s MDS assessment identified impaired vision and no use of glasses. Review of the resident’s face sheet showed admission to the facility on 07/30/2021, and the MDS with an ARD of 07/01/2025 documented impaired vision with a BIMS score of 14 out of 15, indicating the resident was cognitively intact. The CAA triggered for vision impairment and directed staff to develop an appropriate care plan. Review of R60’s care plan showed no evidence that the resident’s impaired vision had been identified or addressed in the plan of care. During interview, the MDSC stated that because the CAA triggered for impaired vision, a corresponding care plan should have been developed, and acknowledged that this had been overlooked. The Administrator and DON also confirmed that the CAA for the resident’s vision had triggered and should have been addressed in the resident’s care plan.
Failure to Transcribe and Implement Optometrist Eye Care Orders
Penalty
Summary
The facility failed to ensure eye care was provided according to orders for one resident with vision impairment and a BIMS score of 14, indicating little to no cognitive impairment. The resident was admitted on 07/30/2021 and had been seen by an optometrist for dry eyes and blepharitis. In an eye care chart note dated 08/19/2025, the optometrist recommended daily lid hygiene with a warm washcloth for chronic blepharitis affecting the ocular surface. In a later eye care chart note dated 12/09/2025, the optometrist ordered Refresh Lacri-Lube eye ointment daily for dry eye and Refresh Liquigel eye drops four times per day. Review of the physician orders showed no documented order for the eye care or medications from the optometrist's chart note, and review of the MAR showed no documentation of the warm washcloth hygiene or the eye drops. During interviews, an LPN confirmed the optometrist's orders were not transcribed into the clinical record and had not been carried through. The SSD stated the optometrist typically printed the orders and gave them to the SSD, and the nursing team was responsible for reviewing them. The DON and LPN later stated the orders should have been provided to the facility and transcribed into the resident's EMR.
Medication Error Rate Exceeded Threshold During Insulin Pen Administration
Penalty
Summary
The facility failed to ensure a medication error rate below five percent. Surveyors observed two medication errors out of 25 opportunities, resulting in an eight percent medication error rate. The errors involved two residents with type 2 diabetes mellitus who were receiving Humalog KwikPen insulin by sliding scale order. For one resident, an RN retrieved the insulin pen, attached a needle, and administered the dose without priming the pen after attaching the needle. During interview, the RN confirmed she had been trained to prime the pen but did not do so and stated she forgot. For the second resident, a CMA retrieved the insulin pen, attached a needle, and administered the dose without priming the pen with two units to ensure the needle worked and the resident received the correct dosage. The CMA confirmed she did not prime the pen and stated insulin pen administration had been reviewed during training. The DON stated the facility’s annual skills fair included insulin pen administration and that staff were expected to prime the pen by dialing to two units and pushing insulin into the air before administration. The CCC also stated staff were instructed to prime the pen to ensure the needle functioned properly so the resident would receive an accurate dose.
Missing Food Safety Policy and Poor Refrigerator Maintenance
Penalty
Summary
The facility failed to establish a policy governing food brought in by visitors and failed to ensure a resident’s personal refrigerator was maintained free of expired items and had completed temperature logs for the freezer. R7 was admitted to the facility on [DATE] and had a quarterly MDS with an ARD of 01/20/2026 showing a BIMS score of 15 out of 15, indicating the resident was cognitively intact. During an interview, R7 stated that food was stored in the personal refrigerator and that staff had not cleaned it recently, although temperatures had been taken. On observation, R7’s personal refrigerator contained multiple expired food items, including almond milk dated 01/04/2026, Silk Almond Milk Vanilla from December 2025, an unlabeled bowl with a yellow substance and black furry growth, Ensure Clear dated December 2024, pre sliced cheese dated 05/27/2025, and Greek yogurt dated September 2025 and 07/02/2025. The freezer compartment did not have a thermometer. CNA 5 confirmed the expired items required disposal and stated she was not aware of any cleaning schedule or designated location for documenting completion of the task. The Maintenance Director stated he entered refrigerator temperatures into his maintenance program after they were documented on the personal refrigerator log, and that he had not been informed the freezer lacked a thermometer. The Administrator acknowledged the facility had no policy for food brought in by visitors, no defined cleaning schedule, and no assigned staff responsible for maintaining residents’ refrigerators, and confirmed freezer temperatures had not been taken because a thermometer was not in place until surveyors identified the issue.
Failure to Use Beard Guards by Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff adhered to the policy requiring the use of hair nets and beard guards during food preparation and service. Observations revealed that the Dietary Manager (DM) was preparing and serving food trays without wearing a beard cover, which is a violation of the facility's policy titled 'Dietary Partner Hygiene and Dress Code' dated 11/10/2020. This policy mandates that all dietary partners must cover their hair and facial hair with appropriate coverings to prevent contamination. Interviews with the DM, Director of Health Services (DHS), and Infection Preventionist (IP) confirmed the expectation that all staff, including the DM, should wear hair nets and beard guards while handling food. The DM admitted to not wearing a beard guard and expressed uncertainty about the policy's application in the dining room. Both the DHS and IP emphasized the risk of food contamination if facial hair is not covered, highlighting the potential impact on 80 out of 83 residents receiving an oral diet.
Inappropriate Storage of Personal Food Items in Medication Room
Penalty
Summary
The facility failed to ensure that personal food items were not stored in the medication storage room, which could lead to contamination of medications and supplies. During an observation, personal food items such as hot dog buns, mustard, and ketchup were found on a shelf in a cupboard next to medical supplies in the medication room. The Director of Health Services (DHS) was present during this observation and confirmed the presence of these items, acknowledging that the medication room should only contain residents' medications and supplies to prevent contamination. Interviews with staff, including the DHS and a Licensed Practical Nurse (LPN), confirmed that food items should not be stored in the medication room as it is unsanitary and could lead to contamination and possible infection to residents. The Infection Preventionist (IP) also stated that food items could cause bacterial growth, further contaminating the medications. The facility lacked a policy regarding the storage of personal food items in the medication room, as no such policy was provided upon request.
Failure to Maintain Resident Dignity and Rights
Penalty
Summary
The facility failed to maintain or enhance the rights, dignity, and respect of its residents, specifically in the case of a resident identified as R70. R70 was admitted with multiple diagnoses, including head injury, aneurysm of the heart, muscle weakness, and visual impairment. Observations revealed that the resident was not cleaned promptly after eating, and the call light was not within reach, which are essential aspects of care for someone with R70's conditions. On two separate occasions, the call light was found on the floor, out of reach, and the resident had food on his face and clothes for an extended period after breakfast. Interviews with staff, including a CNA, MDS Coordinator, LPN, and the Director of Health Services, confirmed that the facility's staff did not follow the care plan interventions for residents with visual impairments. The care plan specified that the call light should be within reach and that residents should be assisted with eating and cleaned afterward. The staff acknowledged the need for regular checks to ensure these interventions were followed, but these actions were not consistently implemented, leading to the deficiency in care for R70.
Unauthorized Bedside Medication Storage
Penalty
Summary
The facility failed to ensure unauthorized medications were not stored at the bedside for three residents, leading to potential unauthorized access to medications. Resident 58, who was authorized to self-administer only albuterol and eye drops, was found with unauthorized medications, including nasal spray and Advair Diskus, in their room. The Director of Health Services and Unit Manager were unaware of these unauthorized medications, which posed a risk of other residents coming into contact with them. Resident 19, with no physician's orders or self-assessment for self-administration, had 23 bottles of medications on their bedside table. The resident admitted to taking their own vitamins and medications without any formal authorization or monitoring by the facility staff. The Director of Health Services confirmed that Resident 19 was not supposed to have medications at the bedside and emphasized the need for a self-assessment and physician's order for self-administration. Resident 67, who had a diagnosis of chest pain, was found with a bottle of nitroglycerin tablets at their bedside, which they took as needed for chest pain. There were no physician's orders for self-administration, and the resident admitted to taking the medication due to delays in nurse response. The Licensed Practical Nurse confirmed the absence of a self-administration order and acknowledged that the resident should not have had the medication at their bedside. The facility's staff expressed concerns about the potential for overdose and adverse reactions due to unsupervised medication use.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to accommodate the needs of a morbidly obese resident, R66, by not providing a bed that was suitable for her size. R66, who had a history of obesity class 3, vascular dementia, and cerebral vascular accidents with left side paralysis, was observed lying in a bed with a mattress that was too narrow, causing her fear of falling during care activities. Despite expressing her concerns to the staff, the issue persisted, and it was confirmed by the Therapy Director that the bed was inadequate for R66's body size, putting her at risk of falling. Another deficiency was identified with resident R70, who was visually impaired and had multiple diagnoses including unspecified head injury, aneurysm of the heart, and muscle weakness. The facility failed to ensure that R70 had a call light within reach, as it was observed on the floor and out of reach on multiple occasions. Additionally, R70 was found with food on his face and clothes after breakfast, indicating a lack of assistance with eating and cleaning, which was necessary due to his vision impairment. Interviews with staff confirmed that the care plan required the call light to be accessible and assistance with eating and cleaning to be provided. The Director of Health Services and other staff acknowledged the deficiencies, noting that interventions in the care plan were not being followed, particularly for residents with visual impairments. The lack of adherence to the care plan and failure to provide necessary accommodations for residents' needs led to these deficiencies being identified during the survey.
Failure to Provide Written Information on Medical Rights
Penalty
Summary
The facility failed to provide residents and their representatives with written information regarding their right to accept or refuse medical or surgical treatment, as well as to formulate an advance directive. This deficiency was identified through resident and staff interviews, record reviews, and examination of the facility's Admission Packet and Advance Directive policy. The policy, dated November 6, 2017, required that residents or their responsible parties be asked about the existence of any advance directives prior to or upon admission, and that an Advance Directive Checklist be completed. However, the Admission Packet lacked language pertaining to the provision of written information about these rights. Three residents were specifically noted in the findings. One resident, admitted with Alzheimer's Disease and other conditions, had an undetermined cognition status. Another resident, with chronic kidney disease and cerebral infarction, had a BIMS score indicating little to no cognitive impairment and had signed an Advance Directive form, but there was no documentation of a discussion about their right to accept or refuse treatment. A third resident, with multiple diagnoses including viral pneumonia and diabetes, also had a BIMS score indicating little to no cognitive impairment. Interviews with facility staff confirmed that there was no evidence of residents being provided with the necessary written information regarding their rights upon admission.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on one of its halls, specifically the 100 hall. Observations revealed that the toilet base and caulking in a shared bathroom between rooms 102, 104, and other rooms were stained dark brown. Additionally, in one of the rooms, the light fixtures above the residents' beds were observed to be rusty brown colored, and the wall trim was sticking out toward the residents' bed. These conditions were noted during multiple observations over several days. The Maintenance Director confirmed the observations, acknowledging the stained toilet bases and caulking, rust-covered light fixtures, and the wall trim issue. The deficient practice resulted in an unsafe and unsanitary environment, potentially placing residents at risk for avoidable injury or illness and diminishing their quality of life.
Deficiencies in Care Plan Implementation and Oxygen Therapy Management
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. Resident R58, who had chronic kidney disease and other conditions, was assessed to self-administer medications such as albuterol and eyedrops. However, there was no care plan in place to support this assessment and authorization, indicating a lack of proper documentation and planning for the resident's medication management. Resident R77, with chronic respiratory failure and moderate cognitive impairment, was prescribed oxygen therapy at 2 liters per minute via nasal cannula. Observations revealed that the resident was receiving oxygen at 3 liters per minute without a humidifier, contrary to the physician's order. Additionally, the care plan for R47, who required oxygen therapy and had a risk of nutrition and hydration issues, was not followed as the resident was not weighed weekly as required. This lack of adherence to care plans and physician orders was confirmed by staff interviews, highlighting a systemic issue in care plan implementation. Further deficiencies were noted with residents R29 and R338, both of whom were receiving oxygen therapy at incorrect flow rates compared to their physician orders. R29 was observed receiving oxygen at 3 liters per minute instead of the prescribed 2 liters, while R338 was receiving 2.5 liters per minute instead of the ordered 3 liters. These discrepancies were verified by nursing staff, who acknowledged the responsibility to ensure care plans and physician orders were followed. The lack of updated care plans for oxygen use and the failure to administer oxygen at the correct rates were significant deficiencies in the facility's care delivery.
Failure to Apply Splints as Ordered for Resident with Contractures
Penalty
Summary
The facility failed to apply splints as ordered for a resident, identified as R56, who was receiving splints to manage contractures. R56 was admitted with multiple contractures and muscle weakness, requiring specific orthotic devices to be applied daily to prevent further deterioration. The care plan and medical orders specified the application of various orthoses for four-to-five-hour wear tolerance daily, with skin inspections following removal. However, during multiple observations over several days, R56 was found without the prescribed splints, indicating a lapse in care. Interviews with facility staff, including CNAs, LPNs, and the Director of Health Services, confirmed that the splints were not applied as ordered. The CNAs were responsible for applying the splints and documenting their application, but they failed to do so. The Director of Health Services and therapy staff emphasized the importance of following the orders to prevent worsening contractures. Despite the education provided to CNAs on the application of splints, the deficiency persisted, as evidenced by the absence of splints on R56 during the survey period.
Facility Fails to Prevent Accident Hazards for Residents
Penalty
Summary
The facility failed to ensure that two residents were free from accident hazards, as observed during a survey. Resident 59 was exposed to harmful chemicals when a bottle of bleach was found above the bathroom sink in their room. This was confirmed by a Registered Nurse, who acknowledged that bleach should not be stored in a resident's bathroom. The Director of Health Services also confirmed that it was against the facility's policy for residents to have bleach or any hazardous chemicals in their rooms. Resident 82 was exposed to a free-standing oxygen tank in their room, which was not secured in a rack or cart as required by the facility's policy on oxygen administration. The resident confirmed that the tank had been in the corner of the room for several weeks. The Director of Health Services and several staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, confirmed that oxygen tanks should be secured in a cradle or carrier to prevent them from falling and potentially causing harm.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, identified as R39, who was admitted with diagnoses including urinary retention and neurogenic bladder. The resident's care plan included instructions to keep the drainage bag below the level of the bladder. However, observations revealed that the catheter tubing was coiled and hung on a dresser knob, positioning the catheter at the height of the bed instead of below the bladder. This improper positioning was confirmed during an interview with the resident, who stated that staff placed the bag there. Further observations with a Certified Med Tech (CMA) and the Wound Nurse showed the catheter drainage bag was hung on the resident's bedside drawer handle, again resulting in the bag being at waist height. The CMA reported that the placement was based on the resident's preferences and admitted to not receiving instructions on how to hang the catheter bag. The Director of Health Services and the Unit Manager confirmed the improper positioning of the catheter bag and acknowledged that it was too high, subsequently repositioning it below the bladder.
Delayed Nutrition Assessments for Two Residents
Penalty
Summary
The facility failed to provide evidence that nutrition assessments were completed by the Registered Dietitian (RD) for two residents, R47 and R77, as per the facility's policy. The policy mandates that each resident receive an initial nutritional screening and comprehensive nutritional assessment within 14 days of admission. However, for R47, who was admitted with conditions including dysphagia, hypertension, and acute kidney failure, the nutrition assessment was not completed until several months after admission. Similarly, R77, admitted with diagnoses such as atrial fibrillation and end-stage renal disease, did not have a nutrition assessment completed until months after admission. Interviews with the RD confirmed the delay in completing the nutrition assessments for both residents. The RD acknowledged the oversight and mentioned having a system in place to track assessments, which failed in these instances. The facility's Administrator and Director of Health Services were unaware of the delay in completing the assessments, despite the facility's policy requiring timely completion. This deficiency had the potential to place the residents at risk of nutrition problems and weight loss.
Oxygen Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to physician orders for oxygen administration for four residents, leading to potential respiratory complications and infections. Resident R338, who had a BIMS score indicating little to no cognitive impairment, was observed receiving oxygen therapy at an incorrect rate of 2.5 LPM instead of the prescribed 3 LPM. This discrepancy was confirmed by a registered nurse, who adjusted the rate accordingly. The Director of Health Services (DHS) expected nursing staff to check oxygen concentrators every shift to ensure compliance with physician orders. Resident R77, with moderate cognitive impairment, was observed receiving oxygen at 3 LPM instead of the ordered 2 LPM. Additionally, there was no humidifier bottle attached to the oxygen concentrator. The DHS and Unit Manager confirmed the incorrect setting through photographic evidence and acknowledged the deficiency. They emphasized the responsibility of licensed nursing staff to monitor residents' oxygen saturation levels. Resident R29, with little to no cognitive impairment, was observed receiving oxygen at 3 LPM instead of the prescribed 2 LPM. The tubing and humidifier bottle were not dated, contrary to the facility's expectations. The DHS stated that it was not the facility's policy to label or date tubing or humidifiers. Resident R34, diagnosed with COPD, had issues with oxygen masks not being stored in bags when not in use, posing an infection control risk. Interviews with staff confirmed the expectation for oxygen masks to be covered to prevent infections.
Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication management protocols, as evidenced by several observations and staff interviews. A medication cart was found unlocked on the 200 long hallway, which was confirmed by an LPN who stated that the cart had been unable to lock since the previous week. The LPN admitted that the cart was placed against the wall with the drawers facing the wall when not in use, but it was not in full sight from the nurses' station, posing a risk of unauthorized access to medications. The Director of Health Services (DHS) was unaware of the issue and emphasized that medication carts should always be locked when not in use to prevent residents from accessing potentially harmful medications. Additionally, expired medications and medications without open dates were found on various medication carts. A bottle of Bisacodyl 5 mg tablets with an expiration date of 9/2024 was discovered, and an RN confirmed the medication was expired, noting that expired medications lose effectiveness. Furthermore, containers of insulin, glucometer strips, and eyedrops were found without open dates, which is crucial for diabetic management. The DHS expressed that staff should remove expired medications and label open dates to ensure effective treatment and prevent adverse reactions. An LPN confirmed the absence of open dates on medication containers, acknowledging the importance of this practice.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Valdosta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Crestwood, Llc | 0 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Valdosta, Llc | 0.1 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Lakehaven, Llc | 0.5 mi | ★★★★★ | 0 | 0 |
| Sgmc Health Villa | 17 mi | ★★★★★ | 0 | 0 |
| Hospital Authority Of Brooks County, Georgia, The | 18.3 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pruitthealth - Holly Hill, Llc.
100% money-back within 48 hours.
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.