Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Holly Hill House during CMS and state inspections, most recent first.
Surveyors observed a dirty kitchen with thick black residue on the wall above the 3-compartment sink and along the dirty side of the dishwasher area, old food particles on clean dish storage trays, and black residue inside the top panel of the ice machine. The dietary manager confirmed the residue was soil, acknowledged the clean dish storage surfaces were not sanitary, and stated the ice machine was dirty.
Incorrect MDS Coding for Antibiotic Use: A resident’s Quarterly MDS did not accurately reflect antibiotic use in Section N0415. The MAR showed the resident received Macrobid 100 mg daily for the month, and an RN later confirmed the MDS was coded incorrectly.
Urinary Drainage Bag Positioned Above Bladder: A resident with a suprapubic catheter and diagnoses including BPH, obstructive/reflux uropathy, and urinary retention was observed sitting in a wheelchair with the catheter tubing draped over the armrest and the drainage bag placed in the backrest pouch behind the resident, above the bladder. An RN, an LPN, and the DON all confirmed the bag was positioned above the bladder instead of below it as required by the facility’s catheter care policy and the resident’s care plan.
Improper Measurement of Nutritional Supplements: Dietary staff were observed pouring MedPlus 2.0 into 5 oz cups for residents’ ordered supplements without using a measuring device. An S8DA stated she had not been taught how to measure the portions, and an RD confirmed that ten residents were supposed to receive 4 oz each but staff had not been educated on proper measurement, leaving no way to ensure the supplements matched the ordered diet.
Improper Disposal of Garbage and Refuse: The facility failed to keep dumpster areas clean and sanitary and to keep dumpster doors and lids closed. Surveyors observed trash scattered around the dumpster area, including used gloves, cups, cutlery, paper and plastic litter, a broken patio umbrella, wooden pallets, and a bag of trash containing soiled adult briefs. The ADM and AIT confirmed the trash was from the facility and should not have been on the ground, and that the dumpster doors and lids should have been closed.
The facility failed to maintain its infection control program when an ice scoop used for resident water pitchers was found stored in a bag dated four days earlier instead of being cleaned and sanitized daily per policy. An LPN confirmed the scoop had last been cleaned and sanitized four days prior, and the ADON/Infection Preventionist stated the scoop should have been sent to the kitchen daily for cleaning and sanitizing but was not.
Pest control failed in the kitchen dishwashing area when surveyors observed live small dark brown insects crawling on the wall near the backsplash on both the clean and dirty sides of the dishwasher dish table. The DM verified the insects were roaches, and the ADM and AIT stated monthly pest control services included the kitchen area but they were unaware of any pest concerns.
A resident with morbid obesity, left AKA, cerebrovascular disease, dementia, and documented dependence for toileting and substantial/maximal assistance for bed mobility had a care plan requiring two or more staff for repositioning and turning in bed. During peri-care, a CNA provided bed mobility alone, turned the resident to the side to change a brief, and the resident grabbed the bed rail and rolled out of bed onto the floor. The resident was found on the floor with a hyperextended right leg, immediate bruising, and skin tears, and was later diagnosed in the hospital with a comminuted periprosthetic proximal tibia fracture, a proximal fibula fracture, and a significant lower-leg hematoma. The CNA admitted not reviewing the Kardex before care and not following the two-person assist requirement.
A resident with dementia and sensory impairment was physically abused by another resident with severe psychiatric and cognitive disorders. Despite a CNA's attempt to intervene, the aggressive resident bypassed staff and struck the victim in the face, causing visible injury. Staff interviews confirmed the incident and acknowledged that the resident was not protected from abuse, in violation of facility policy.
A resident was found with a hematoma and bruising on the right side of the head, but the LPN who was notified of the injury did not immediately report it to administrative staff. As a result, the administrative team and state agency were not notified within the required 2-hour timeframe, in violation of the facility's abuse prevention and reporting policy.
A resident with multiple mental health diagnoses was transferred from the facility to a hospital via stretcher, but the required notification to the State Long-Term Care Ombudsman was not made. Review of the emergency transfer log and staff interviews confirmed the omission.
Two residents with significant behavioral health diagnoses did not receive or have documented 1:1 supervision as ordered by a nurse practitioner following incidents of suicidal ideation and resident-to-resident aggression. Despite clear orders for 1:1 monitoring, the EMR lacked evidence that this supervision was provided prior to their transfers to behavioral hospitals, a deficiency confirmed by facility leadership.
A grievance regarding a resident's odor and soiled brief was not resolved within the facility's policy timeframe of 5 working days, taking 21 days instead. The resident had an acquired absence of the left leg above the knee, dementia, and morbid obesity. Both the DON and Administrator acknowledged the delay.
The facility failed to report and investigate critical incidents involving nine residents in a timely manner. Incidents of abuse, neglect, or injury were not reported within the required time frames, and investigation results were not submitted to the State Survey Agency within five working days. The administrator admitted to not having access to the reporting system and was unaware of pending incidents, leading to deficiencies in incident handling.
A facility failed to accurately complete the MDS for a resident, who was admitted with atrial fibrillation, vascular dementia, and anxiety disorder. The resident's MAR showed they received an anticoagulant and an antidepressant, but no antibiotics. However, the MDS incorrectly documented antibiotic use and omitted the anticoagulant and antidepressant. The MDS coordinator confirmed these discrepancies during a review.
Two residents experienced unwitnessed falls with visible blood, and the facility failed to complete the required neurological checks as per policy. Despite being transferred to the hospital, upon return, the checks were not consistently documented, and there was a lack of documentation regarding the residents' mental status. The ADONs confirmed the incompleteness of the assessments.
A facility failed to ensure up-to-date hospice documentation for a resident with multiple diagnoses, including CHF and Alzheimer's. The hospice nurse's visit notes were outdated, contrary to the hospice services agreement and facility policy. The administrator, responsible for hospice contact, acknowledged the lapse, having not followed up after initially contacting the hospice agency.
A resident with an indwelling catheter experienced a significant decrease in urinary output, which was not reported by the LPN to the physician or charge nurse, as required by facility policy. The resident, who had a history of urinary retention and other conditions, showed a urinary output of only 100 cc over an 8-hour period, significantly lower than usual. This deficiency was confirmed by the DON and ADON during interviews.
A resident with Alzheimer's and mild cognitive impairment was physically abused by another resident with Bipolar Disorder and mild cognitive impairment. The incident occurred when the aggressor accused the victim of gossiping and punched her in the hip. An LPN witnessed the event and confirmed the act was deliberate. The facility's policy defines such actions as abuse, and the DON acknowledged the incident as a willful act of physical abuse.
A resident with severe cognitive impairment and multiple diagnoses did not receive proper monitoring for foley catheter urinary output and anticoagulant side effects as outlined in their care plan. Facility staff confirmed the lack of documentation and absence of a policy for anticoagulant monitoring.
The facility failed to provide sufficient dietary staff, resulting in delayed meal service for 84 residents. Meals were consistently served late, with breakfast and lunch often delayed by up to two hours. Residents and staff reported inconsistent meal times, and snacks were frequently not delivered. These issues highlight the facility's inability to meet scheduled meal and snack times, affecting residents' nutritional needs.
The facility failed to provide meals according to residents' dietary preferences and needs, as observed in five residents. Instances included incorrect milk types being served and missing beverages. A CNA admitted to not checking diet slips before serving, and the Dietary Manager confirmed that substitutions were made without notifying residents.
The facility failed to weigh residents as per physician's orders, impacting 20 residents who were supposed to be monitored weekly for four weeks. The ADON confirmed the oversight, with missing weight records for various weeks across all residents reviewed.
The facility failed to maintain acceptable nutritional parameters for two residents. One resident experienced significant weight loss due to inadequate monitoring and lack of dietary intervention, while another did not receive recommended nutritional supplements. The oversight in implementing dietitian recommendations and monitoring weight changes contributed to these deficiencies.
The facility failed to provide adequate incontinence briefs and linens, affecting resident care. Staff confirmed shortages of large, XL, 2XL, and 3XL briefs, and insufficient towels and washcloths for personal hygiene. The Administrator's budget constraints led to critical supply shortages, impacting 74 incontinent residents and the overall census of 89.
A resident with a history of femur fracture experienced a fall and complained of leg pain. Despite a physician's order for an x-ray, the facility delayed obtaining the x-ray due to a communication lapse with the contracted radiology service. The x-ray, completed four days later, led to a delayed diagnosis of a femur fracture.
The facility failed to store food in accordance with professional standards and did not maintain sanitary conditions in the kitchen. Observations revealed spoiled and expired food items in the refrigerator, freezer, and dry storage, as well as a dirty cart used for food distribution. The Dietary Supervisor confirmed these deficiencies.
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for residents with infections, colonization with MDRO, chronic wounds, and indwelling medical devices. This deficiency affected 8 out of 14 residents who met the criteria for EBP, as confirmed by interviews with key staff members.
The facility failed to implement and maintain infection control practices, specifically Enhanced Barrier Precautions (EBP), for residents with chronic wounds or indwelling medical devices. Staff were unaware of EBP requirements, and multiple residents were observed without necessary signage, PPE, or biohazard bins, leading to potential infection risks.
The facility failed to accurately code the MDS assessment for a resident, incorrectly indicating the use of an antidepressant despite no physician orders for such medication. This error was confirmed by the MDS nurse upon review.
The facility failed to refer a resident with a newly diagnosed Delusional Disorder to the appropriate state-designated authority for a Level II PASARR evaluation. The Assistant Director of Nursing confirmed that the facility was unaware of the requirement to resubmit for a Level II PASARR review.
A resident with multiple diagnoses, including a UTI, was prescribed Bactrim DS. The care plan required monitoring for adverse reactions every shift, but a review of records and staff interviews confirmed that this monitoring was not documented or performed.
The facility failed to protect residents from abuse, resulting in psychosocial harm to a resident who was sexually abused, physical harm to a resident struck with a cane, and another resident who was hit in the eye during an altercation.
The facility failed to provide quarterly statements of personal funds for a resident with Chronic Obstructive Pulmonary Disease and other conditions. The resident, who was cognitively intact, reported not receiving a statement in over two years. The Business Office Manager confirmed the lack of documentation for the quarterly statements in 2023.
The facility failed to develop comprehensive care plans and follow physician orders for three residents, leading to unaddressed sexual behaviors, incorrect medication administration, and missed treatments for respiratory care.
A resident with chronic respiratory conditions had their BiPAP and nebulizer masks improperly stored on the bedside table, with the nebulizer mask also being outdated. Staff confirmed the equipment should have been bagged and replaced weekly, but no policy on respiratory equipment storage was provided.
Kitchen Sanitation Lapses in Dishwashing, Storage, and Ice Machine Areas
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen. During an initial tour of the kitchen with the dietary manager, surveyors observed a thick buildup of black residue on the brick wall above the stainless steel backsplash in the area of the three-compartment sink, extending approximately six inches high along the full length of the sink. A similar buildup of black residue was also observed on the brick wall above the stainless steel backsplash along the full length of the dirty side dish table of the dishwasher. The dietary manager scratched the residue with a fingernail and stated, "It's just dirty," confirming it was soil and not a permanent stain. Surveyors also observed clean dish storage trays with a buildup of old food particles while dinner plates, bowls, and dessert plates were stored upside down on them. In addition, the interior top panel of the kitchen ice machine had a buildup of black residue. The dietary manager acknowledged that the clean dish storage surfaces should not have old food particles and required cleaning, and also confirmed the ice machine was dirty and stated the ice would need to be discarded and the machine cleaned immediately.
Incorrect MDS Coding for Antibiotic Use
Penalty
Summary
The facility failed to accurately code Resident #5’s Quarterly MDS for antibiotic use. Review of the MDS dated [DATE] showed that Section N0415, High-Risk Drug Classes: Use and indication, did not have the box checked for antibiotic use during the last 7 days. However, review of Resident #5’s February 2026 electronic MAR showed that the resident received Macrobid 100 mg daily from 2/1/2026 through 2/28/2026, which is an antibiotic. During an interview and record review on 4/15/2026 at 8:25 a.m., S12RN reviewed the Quarterly MDS and the February 2026 MAR and confirmed that Resident #5 received antibiotic medications and that the MDS was not coded correctly.
Urinary Drainage Bag Positioned Above Bladder
Penalty
Summary
The facility failed to ensure that Resident #13’s urinary drainage bag was positioned below the bladder in accordance with the facility’s catheter care policy. The policy titled, Catheter Care, Urinary, stated that the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. Resident #13 had diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, and retention of urine, and had a physician order for a suprapubic urinary catheter every shift. Resident #13’s care plan included an intervention to position the catheter bag and tubing below the level of the bladder. During observation, the resident was sitting in a wheelchair in the dining room with the catheter tubing draped over the armrest and the drainage bag placed inside the pouch of the wheelchair backrest behind the resident’s back, which was above the bladder. An RN confirmed she had placed the bag there and stated it should have been below the bladder. An LPN also confirmed the bag was in the backrest pouch and stated it should have been placed in a privacy bag and below the bladder. The DON likewise confirmed the drainage bag was in the back pouch of the wheelchair above the bladder and should not have been.
Improper Measurement of Nutritional Supplements
Penalty
Summary
The facility failed to ensure dietary staff accurately measured nutritional supplements in accordance with residents’ assessed nutritional needs. A review of the facility’s policy, Dietitian Responsibilities, stated that the dietitian participates in developing and implementing an individualized plan of care to meet each resident’s nutritional needs. During an observation on 04/13/2026 at 11:50 a.m., S8DA was seen preparing nutritional supplements for residents’ noon meal by pouring MedPlus 2.0 from a 32 oz container into ten 5 oz cups without using a measuring device. During a concurrent interview, S8DA stated she had been instructed by S7RD to use MedPlus 2.0 for a list of residents who were to receive supplements, but she had not received education or instruction on measuring the portions. She stated that no one had told her she had to measure them. In a phone interview at 12:00 p.m. with S6DMA present, S7RD stated that the ten residents had been assessed to receive 4 oz of supplement each and confirmed dietary staff had not been educated on proper measurement. S7RD acknowledged that without measuring the supplement, there was no way to ensure the residents received the proper nutrition as ordered per their diet.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure garbage and refuse were disposed of properly. The facility policy titled, Garbage Disposal, stated that all outside dumpsters would be maintained in clean and sanitary conditions, outdoor trash receptacles would be kept covered, and the surrounding area would be kept free of litter. However, prior inspection reports dated 01/14/2026 and 03/18/2026 documented that the dumpster area needed attention, including keeping the dumpster doors closed and cleaning the area around the dumpster. On 04/13/2026 at 12:29 p.m., a concurrent observation and interview with the ADM and AIT found the dumpster side door open and trash scattered on the ground around the north-side dumpster, including used vinyl gloves, empty milk cartons, used plastic drinking cups, disposable cutlery, paper and plastic litter, a broken patio umbrella, and multiple wooden pallets. The ADM confirmed the trash was from the facility and should not have been on the ground. Later that day, at 2:30 p.m., a large bag of trash containing soiled adult briefs and other items was observed on the ground in front of the west-side dumpster, with one side door open and both top lids open. At 3:30 p.m., the ADM and AIT again observed open dumpster lids and doors and confirmed that maintenance was responsible for the dumpster areas, that there should not have been trash on the ground, and that all dumpster lids and doors should have been closed.
Ice Scoop Not Cleaned and Sanitized Daily
Penalty
Summary
The facility failed to implement and maintain an effective infection control and prevention program by not ensuring ice scoops used to fill resident water pitchers were cleaned and sanitized daily. The facility policy titled, Ice Handling and Storage, stated that scoops would be cleaned and sanitized daily. During an observation of the ice chest and ice scoop used for resident water pitchers, the scoop was found stored in a clear plastic bag labeled with a date four days earlier. An LPN confirmed the date showed the scoop had last been cleaned and sanitized four days prior and stated she was unsure of the required cleaning and sanitizing frequency. The ADON, who also served as the Infection Preventionist and oversaw the infection control program, stated the ice chests and scoops were supposed to be sent to the kitchen daily at the end of the evening shift for cleaning and sanitizing, and that after cleaning the scoops were to be placed in a clear plastic bag labeled with the current date. The ADON confirmed the observed scoop should have been cleaned and sanitized per policy but was not.
Pest Control Program Failed to Keep Kitchen Dishwashing Area Free of Roaches
Penalty
Summary
The facility failed to maintain an effective pest control program by not ensuring the kitchen dishwashing area was free from pests. During a tour of the kitchen dishwashing area with the dietary manager and dietary aide, four live, small, dark brown insects were observed crawling on the wall near the backsplash on the clean side of the dishwasher dish table, and the dietary manager verified the insects were roaches and confirmed the pest problem. Later the same day, a second observation of the same area revealed one additional live, small dark brown insect crawling on the wall near the backsplash on the dirty side of the dishwasher dish table. In interview, the administrator and assistant administrator stated pest control services were provided monthly and included the kitchen area, and they were unaware of any pest concerns in the kitchen.
Failure to Follow Two-Person Assist Care Plan During Bed Mobility Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented an established, individualized care plan requiring two-person assistance for bed mobility for one resident. The resident had been admitted with severe morbid obesity, an above-knee amputation of the left leg, cerebrovascular disease, and unspecified dementia. A quarterly MDS assessment showed the resident had a BIMS score of 8, indicating mild cognitive impairment, required substantial to maximum assistance for bed mobility, and was dependent for toileting hygiene. The resident’s care plan, initiated more than four years earlier, specified that the resident required participation of two or more staff for repositioning and turning in bed due to an ADL self-care performance deficit and impaired mobility. On the day of the incident, the resident was in bed when a CNA (S4CNA) provided peri-care and bed mobility without a second staff member present, contrary to the resident’s care plan. During this care, the CNA turned the resident to the left side in bed to change the resident’s brief. The resident grabbed onto the mobility rail to assist with turning and continued to roll completely out of the bed, falling to the floor on the left side of the bed. The nurse (S3LPN) heard the resident yell out and, upon entering the room, observed the resident lying on her left side on the floor with only the single CNA present. Following the fall, staff observed that the resident’s right leg was hyperextended on the floor, with instant bruising noted to the right ankle and top of the foot, as well as skin tears to the left abdomen and right center chest area. The right leg/ankle was in an unnatural position, and visible bruising was present on the right lower leg. The resident was lifted from the floor using a mechanical lift and returned to bed, and EMS was called for transport for post-fall evaluation. Hospital records later documented that the resident sustained an acute mildly displaced and angulated comminuted periprosthetic fracture of the proximal tibia extending to the distal tip of the tibial prosthesis, an acute mildly displaced fracture of the proximal fibula, and a hematoma of the proximal medial lower leg. In interviews, the CNA acknowledged providing care without a second staff member, not reviewing the Kardex prior to care, and not being aware or not having recently reviewed the resident’s care plan requirements for two-person assistance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On the date of the incident, a resident with unspecified dementia, psychotic disturbance, anxiety disorder, and bilateral conductive hearing loss was sitting at a dining room table, feeling his surroundings due to blindness. As he touched a package of graham crackers on the table, another resident with bipolar disorder, severe vascular dementia with psychotic disturbance and agitation, major depressive disorder, and anxiety disorder became upset. The certified nursing assistant (CNA) attempted to intervene by removing the first resident from the table and positioning herself between the two residents. Despite this, the second resident went around the CNA, confronted the first resident, yelled, and slapped him on the left side of the face, resulting in a visible red mark and a reported pain level of 4. Staff interviews confirmed that the CNA and a licensed practical nurse (LPN) were present during the incident. The CNA described her attempt to prevent the altercation by physically intervening, but was unable to stop the aggressive resident from reaching and striking the other resident. The LPN and the assistant director of nursing (ADON) both acknowledged awareness of the incident and confirmed that the resident was not protected from abuse. The facility's own policy states that residents must not be subjected to abuse by anyone, including other residents, but this policy was not effectively implemented in this case.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an allegation of injury of unknown origin was reported immediately to the Administrator or their designated representative, and subsequently to the state agency within the required 2-hour timeframe. According to the facility's abuse prevention and prohibition policy, any employee or agent who becomes aware of abuse, neglect, injuries of unknown origin, or alleged misappropriation of resident property must immediately report the matter to the Administrator. In this case, a resident was found with a hematoma and bruising on the right side of the head. The injury was discovered by a CNA and reported to an LPN on the morning of the incident, but the LPN did not notify administrative staff until later in the day, after lunch. The LPN confirmed during an interview that the injury was not reported immediately as required. Further review and interviews revealed that the administrative staff, including the ADON, DON, and Administrator, were not made aware of the injury until the evening of the same day. The critical incident report was entered nearly two hours after the injury was discovered, and the state agency was not notified within the mandated 2-hour window. The facility's own staff confirmed that the reporting procedures outlined in their policy were not followed, resulting in a delay in both internal and external notification of the incident involving the resident with the head injury.
Failure to Notify Ombudsman of Facility-Initiated Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of a facility-initiated transfer for one resident. The resident, who had diagnoses including depression, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, was admitted on 07/17/2025 and transferred out of the facility to a hospital via stretcher on 07/27/2025. Review of the emergency transfer log for July 2025 showed that the transfer was not documented as having Ombudsman notification. During interviews and record reviews, facility staff confirmed that the required notification to the State Long-Term Care Ombudsman was not made for this transfer.
Failure to Implement and Document 1:1 Supervision for Residents with Behavioral Health Needs
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan that addressed the need for 1:1 supervision for two out of four sampled residents. One resident, with diagnoses including depression, dementia, psychotic disturbance, mood disturbance, and anxiety, expressed suicidal ideation and was placed on 1:1 supervision per a nurse practitioner's order. However, there was no evidence in the electronic medical record (EMR) of continued 1:1 supervision from the evening until the resident was transferred to a behavioral hospital the following morning. Another resident, with a history of bipolar disorder, vascular dementia with psychotic disturbance and agitation, major depressive disorder, and anxiety, became aggressive and struck another resident. Following this incident, a nurse practitioner ordered 1:1 supervision and a psychiatric consult. Despite this order, there was no documentation in the EMR that 1:1 supervision was implemented for this resident from the time of the incident until the resident was transferred to a behavioral hospital. Facility leadership confirmed the lack of documentation and implementation of the ordered 1:1 supervision for both residents.
Grievance Resolution Delay
Penalty
Summary
The facility failed to resolve a grievance within the stipulated 5 working days as per its grievance policy. A grievance was filed concerning a resident with an acquired absence of the left leg above the knee, dementia, and morbid obesity, regarding odor and a soiled brief. The grievance was filed on 01/07/2025 and was not resolved until 01/28/2025, taking 21 days instead of the required 5 days. Both the Director of Nursing and the Administrator acknowledged the delay in resolving the grievance, which was not in compliance with the facility's policy.
Failure to Timely Report and Investigate Critical Incidents
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse, neglect, or injury of known origin for nine residents. The incidents were not reported immediately, or within the required time frames of two hours for abuse allegations and 24 hours for non-abuse incidents that do not result in serious bodily injury. Additionally, the results of investigations were not reported to the State Survey Agency within five working days of the incidents. For instance, Resident #1's neglect incident with a head injury occurred on 01/14/2025, but the report was not entered until 02/11/2025. Similarly, Resident #2's fall with a fracture was discovered on 01/08/2025, but the investigation was not completed until 02/04/2025. The facility's administrator, S1ADM, confirmed responsibility for reporting critical incidents but admitted to not having access to the state critical reporting system until recently. S1ADM stated that critical incident information was sent via fax to the state reporting agency but was unaware that the information needed to be entered into the system once access was granted. The administrator also acknowledged being unaware of pending critical incidents, confirming that four incidents were still pending. This lack of timely reporting and investigation completion led to deficiencies in the facility's handling of critical incidents.
Inaccurate MDS Documentation for Resident
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for one resident out of a sample of nine, potentially affecting the entire census of 82 residents. The resident in question was admitted with diagnoses including atrial fibrillation, vascular dementia, and anxiety disorder. A review of the resident's December 2024 Medication Administration Record (MAR) showed that the resident received Eliquis, an anticoagulant, and Trazodone, an antidepressant, but no antibiotics. However, the quarterly MDS dated 12/17/2024 incorrectly indicated that the resident was on antibiotics and failed to note the use of the anticoagulant and antidepressant. During a records review and interview, the MDS coordinator confirmed the discrepancies in the MDS documentation.
Incomplete Neurological Checks Post-Fall
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, specifically in conducting neurological checks following unwitnessed falls. Resident #1 experienced an unwitnessed fall with visible blood and a facial laceration. Despite the facility's policy requiring neurological assessments every 15 minutes for the first hour, then at decreasing intervals for a total of 72 hours, the checks were incomplete. Resident #1 refused initial checks and was later transferred to the hospital, but upon return, the required checks were not consistently documented. There was also a lack of documentation regarding the resident's mental status for a significant period following the incident. Similarly, Resident #3, who also had an unwitnessed fall with visible blood, did not receive the required neurological checks as per the facility's policy. The resident was found on the floor with right side weakness and was transferred to the hospital. However, upon return, the neurological checks were incomplete, with specific intervals missing documentation. Both incidents were confirmed by the Assistant Directors of Nursing (ADONs) during interviews, acknowledging the failure to complete the required neurological assessments.
Failure to Maintain Up-to-Date Hospice Documentation
Penalty
Summary
The facility failed to ensure that the hospice agency provided services according to the agreement and facility policy, specifically by not collaborating effectively to maintain up-to-date hospice nurse visit notes for a resident. The deficiency was identified during a review of the resident's hospice binder, which revealed that the last hospice nurse visit notes were dated several months prior. This lapse in documentation was contrary to the hospice services agreement and the facility's policy, which required complete, prompt, and accurate documentation of all services provided. The resident involved had multiple diagnoses, including Congestive Heart Failure, Alzheimer's disease, Muscle Wasting and Atrophy, and Unsteadiness on Feet. The facility's administrator, who was the designated hospice contact, acknowledged the issue during an interview, stating that although he had contacted the hospice agency about the missing notes in October, he did not follow up as required. This inaction contributed to the deficiency, as the facility did not ensure that the hospice agency adhered to the agreed-upon documentation standards.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) notified the physician or charge nurse when a resident experienced a significant change in condition. Specifically, the LPN did not report a significant decrease in urinary output for a resident with an indwelling catheter. The facility's policy on catheter care requires that noticeable decreases in urine output be reported to a medical practitioner or charge nurse. However, the LPN, who worked the night shift, observed a urinary output of only 100 cc over an 8-hour period, which was significantly lower than the resident's usual output of 350 cc to 800 cc per shift. The resident involved had a history of urinary retention, benign prostatic hyperplasia, and Parkinsonism, and was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 7. Despite these conditions, the LPN did not notify the resident's physician or the on-call charge nurse about the decreased urinary output. This oversight was confirmed during interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), who acknowledged that the low urinary output represented a significant change in the resident's condition that should have been reported.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #2, who was mildly cognitively impaired with a BIMS score of 9, was diagnosed with Alzheimer's disease, Major Depressive Disorder, and Mood Affective Disorder. On the day of the incident, Resident #2 was walking from the dining room when Resident #7, also mildly cognitively impaired with a BIMS score of 9 and diagnosed with Bipolar Disorder, Hallucinations, and Dementia, accused her of being a gossiper and punched her in the right hip. This incident was documented by S6LPN, who witnessed the event and confirmed that Resident #7's actions were deliberate. The facility's policy on abuse and neglect defines abuse as willful actions, which was applicable in this case as Resident #7's actions were intentional. The Director of Nursing, S1DON, confirmed the incident and acknowledged that Resident #7's act was a willful and intentional act of physical abuse. The incident was part of a broader investigation into abuse involving four residents, and the failure to protect Resident #2 from abuse by Resident #7 was identified as a deficiency that had the potential to affect the entire facility census of 78 residents.
Failure to Monitor Foley Catheter Output and Anticoagulant Side Effects
Penalty
Summary
The facility failed to provide services as outlined in the comprehensive care plan for a resident, specifically in monitoring and documenting foley catheter urinary output and side effects of anticoagulant therapy. The resident, who was admitted with diagnoses including urine retention, benign prostatic hyperplasia, and heart failure, had a severely impaired cognitive status. The care plan required monitoring and documentation of urinary output every shift and observation for anticoagulant side effects, such as blood in urine or stools, headaches, and changes in mental status. Upon review, it was found that the facility did not document the resident's urinary output from late April to early May, nor did they monitor or document the side effects of the anticoagulant from late April to mid-May. Interviews with facility staff, including the LPN and ADON, confirmed the lack of documentation and the absence of a policy for anticoagulant monitoring. The ADON acknowledged that the resident's care plan included orders for monitoring these aspects, but the records showed no evidence of compliance with these orders.
Inadequate Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide sufficient dietary staff to ensure timely meal service for 84 residents. According to the facility's policy, meals and snacks should be served at specific times, with breakfast at 7:30 a.m., lunch at 12:00 p.m., and afternoon snacks at 2:00 p.m. However, interviews and observations revealed that meals were consistently served late. A CNA reported that meal times varied daily, and residents confirmed that breakfast was often delayed. On one occasion, residents in the dining room waited until almost 9:00 a.m. for breakfast due to the absence of a nurse required to observe the meal. Further interviews and observations indicated that lunch trays were also delivered late, with some residents receiving their meals up to two hours past the scheduled time. A family member expressed concern about the frequent delays and potential weight loss of a resident. Additionally, snacks were not consistently delivered, as confirmed by a dietary manager and an LPN, who reported that snacks were often not received on time or at all. These findings highlight the facility's failure to provide adequate dietary staffing to meet the scheduled meal and snack times, impacting the residents' nutritional needs.
Failure to Provide Meals According to Dietary Preferences
Penalty
Summary
The facility failed to ensure that residents received meals according to their dietary preferences and needs as indicated on their diet cards. This deficiency was observed in five residents out of twenty reviewed for nutrition. Specific instances included a resident who was supposed to receive a banana and yogurt daily but had not been receiving them, and another resident who was served whole milk instead of the skimmed milk indicated on their dietary slip. Additionally, several residents were not provided with the beverages listed on their diet slips, such as hot tea and decaf coffee, and were only given water. Interviews and observations revealed that the dietary staff did not consistently follow the diet slips, leading to incorrect meal components being served. A Certified Nursing Assistant admitted to not checking the diet slips before serving meals, resulting in residents receiving the wrong type of milk. The Dietary Manager confirmed that sometimes food items listed on the meal slips were unavailable, and substitutions were made without notifying the residents. This lack of communication and adherence to dietary instructions contributed to an unpleasant dining experience for the residents.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to ensure that residents were weighed according to physician's orders, which was a requirement for monitoring their nutritional status. The deficiency was identified through record reviews and interviews, revealing that none of the 20 residents reviewed had their weights recorded as ordered. The orders specified that residents should be weighed every Tuesday for four weeks, but there was no evidence of compliance with these orders for various weeks across all residents. For instance, Resident #1 was not weighed during weeks 3 and 4, while Resident #2 missed weights for weeks 2, 3, and 4. Similarly, Resident #3 did not have weights recorded for weeks 2, 3, and 4. This pattern of missing weight records was consistent across all residents reviewed, including Resident #R6, who had no weights documented until a specific date, and Resident #R7, who had no weights recorded until a later date. The Assistant Director of Nursing (ADON) confirmed during an interview that the residents' weights were not obtained as ordered. This lack of adherence to physician's orders for weight monitoring was a significant oversight in the care provided to the residents, as it potentially impacted their nutritional management and overall health monitoring.
Failure to Maintain Nutritional Parameters for Residents
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutrition, specifically for two residents. Resident #3 was admitted with diagnoses including muscle wasting, atrophy, adult failure to thrive, and dementia. Despite an order for weekly weight monitoring, there was no evidence that weights were obtained for weeks 2, 3, and 4. A significant weight loss of 9.39% was noted over a month, which had not been addressed. Observations revealed that the resident had difficulty eating due to the food's texture, and the care plan only included serving the diet as ordered without further interventions. Additionally, the resident had not been seen by the registered dietitian as required. For Resident #R18, the facility failed to implement the registered dietitian's recommendation for nutritional supplements twice a day to increase caloric intake. The Assistant Director of Nursing confirmed that the recommendation was not addressed, as the resident was not identified on the list with the recommendation, and the dietitian's assessment was not reviewed in the electronic medical record. This oversight resulted in the resident not receiving the necessary nutritional support as advised by the dietitian.
Deficiency in Supply Management for Resident Care
Penalty
Summary
The facility failed to protect residents from neglect by not ensuring the availability of necessary supplies for incontinence care and personal hygiene. Observations and interviews revealed that the facility ran out of appropriately sized incontinence briefs for 74 incontinent residents. Staff members, including CNAs and LPNs, confirmed the shortage of large, XL, 2XL, and 3XL briefs, which are the most frequently used sizes. The Assistant Director of Nursing and Director of Nursing acknowledged the shortage, and the Medical Records/Central Supply staff indicated that the Administrator removed critical items from supply orders to fit the facility's budget, leading to a lack of necessary supplies. Additionally, the facility did not have a sufficient number of clean linens, such as towels and washcloths, to meet the residents' personal hygiene needs. Observations of the clean linen supply closets showed a shortage of these items across different halls. Staff interviews confirmed that they often ran out of towels and washcloths, which are essential for providing personal hygiene and incontinence care. The Director of Nursing verified the inadequacy of the available linens and noted that the facility did not use disposable wipes, further exacerbating the issue. The facility did not provide policies for the provision of sufficient supplies, including incontinence briefs and linens. The Administrator and Housekeeping/Laundry Manager acknowledged the shortage of supplies and the challenges in maintaining adequate stock. The lack of a structured policy and the removal of critical items from supply orders contributed to the deficiency, affecting the quality of care provided to the residents.
Delay in X-ray Order Fulfillment
Penalty
Summary
The facility failed to follow the physician's orders for a resident, resulting in a delay in obtaining necessary x-rays. The resident, who had a history of a fracture in the neck of the right femur and was admitted to the facility, experienced a fall and subsequently complained of pain in the left leg. Despite the nurse practitioner's order for an x-ray on the day of the fall, the x-ray was not completed until four days later. This delay was due to the contracted radiology service not receiving the order until four days after it was initially made. The resident's medical records showed multiple x-ray orders, but the initial order for the left leg x-ray was not fulfilled in a timely manner. The contracted radiology service confirmed they did not receive the order on the day it was made, and the x-ray was only completed after a follow-up order was sent. The delay in obtaining the x-ray led to a further delay in diagnosing a left femur fracture, which was only identified after additional imaging was conducted several days later.
Failure to Maintain Sanitary Conditions and Proper Food Storage
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service and did not maintain sanitary conditions in the kitchen. During a tour of the kitchen, it was observed that the deep fryer cooking oil collection area had a thick layer of debris and a large piece of fried food material, which had not been cleaned after its last use. Additionally, the stand-up refrigerator contained spoiled and expired food items, including a plastic gallon bag of lettuce with discoloration and a brown watery substance, and two opened containers of beef base broth past their expiration date. The stand-up freezer also contained expired food items, such as an opened container of English muffins and a plastic gallon bag of fried okra with gray discoloration and frozen chunks of ice. The dry storage room had an expired plastic gallon bag of raisin bran. The Dietary Supervisor confirmed that these items were spoiled or expired and should have been discarded. Furthermore, the food service line was observed to have unsanitary conditions. Cold drinks with lids were placed on a cart for tray distribution, but the cart had multiple areas of red sticky residue and food debris on both sides. The Dietary Supervisor confirmed that the cart had not been cleaned after its previous use, as required. These deficiencies had the potential to affect the 72 residents who consumed food from the kitchen.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for residents with infections or colonization with multi-drug resistant organisms (MDRO) or for residents with chronic wounds and/or indwelling medical devices. This deficiency was observed in 8 out of 14 residents who met the criteria for EBP. Specifically, residents with indwelling urinary catheters, PEG tubes, and chronic wounds were not provided with the necessary precautions as outlined in the facility's policy. The policy, written on 08/21/2023, mandates gown and glove use during high-contact resident care activities for these residents to reduce MDRO transmission. Interviews with the Assistant Director of Nursing (S4ADON), the Administrator (S2ADM), the Regional Director of Operations (S8RDO), and the Interim Medical Director (S9IMD) revealed a lack of awareness and implementation of the EBP policy. S4ADON admitted to being unaware of the EBP requirements until the day before the interview. S2ADM and S8RDO confirmed that the policy had not been implemented despite being aware of its existence. S9IMD also stated he was not aware of the EBP policies and procedures or their lack of implementation for residents meeting the criteria.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain infection control practices to prevent and control the spread of infectious communicable diseases. Specifically, the facility did not ensure that staff adhered to Enhanced Barrier Precautions (EBP) for eight residents who had chronic wounds or indwelling medical devices. The Assistant Director of Nursing (ADON) admitted to being unaware of the EBP requirements until the day before the survey, and none of the residents fitting the criteria were on EBP as required by the facility's policy. This lack of adherence was confirmed through multiple observations and interviews with staff members who were also unaware of EBP protocols. Resident #24, who had a urinary catheter, was observed without any EBP signage, PPE availability, or biohazard bins in the room. Similarly, Resident #232, who had a neurogenic bladder and an indwelling catheter, had no care plan addressing EBP. Staff members, including LPNs, confirmed their lack of knowledge about EBP and the absence of necessary precautions for these residents. Other residents, such as Resident #35 and Resident #68, who had PEG tubes, were also found without EBP signage, PPE, or biohazard bins, and staff admitted to providing care without following EBP protocols. Additional residents, including Resident #17, Resident #30, Resident #48, and Resident #75, all had indwelling catheters but lacked care plans addressing EBP. Observations and interviews revealed that there was no signage, PPE, or biohazard bins in their rooms, and staff were unaware of the EBP requirements. This widespread lack of adherence to infection control practices had the potential to affect 14 out of 74 total residents with chronic wounds or indwelling medical devices, as the facility failed to implement the necessary precautions to prevent the spread of infections.
Incorrect MDS Coding for Antidepressant Use
Penalty
Summary
The facility failed to ensure the residents' assessment accurately reflected the status of one resident by not correctly coding the Minimum Data Set (MDS) assessment for antidepressant use. Specifically, the MDS assessment for a resident with diagnoses including Emphysema, Diabetes Mellitus II, and Legal Blindness was incorrectly coded to indicate the use of an antidepressant. A review of the resident's Electronic Health Record and February 2024 Physician Orders revealed no orders for antidepressants. This discrepancy was confirmed during an interview with the MDS nurse, who acknowledged that the resident should not have been coded as using an antidepressant in the MDS assessment.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for a Level II PASARR evaluation and determination. Resident #55 was admitted on an unspecified date and was diagnosed with Delusional Disorder on January 19, 2024. A review of the resident's record revealed a Level 1 PASARR dated November 28, 2023, but no Level II PASARR was noted. During an interview on April 24, 2024, the Assistant Director of Nursing confirmed that the resident had received a qualifying diagnosis and that the facility had not resubmitted for a Level II PASARR review, as they were unaware that this was required.
Failure to Monitor Adverse Reactions to Antibiotics
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident who was prescribed Bactrim DS for a urinary tract infection. The resident's care plan included monitoring for adverse reactions to the antibiotic every shift, but a review of the Medication Administration Record (MAR) and Nurses Progress Notes revealed no documentation of such monitoring. Interviews with the Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON) confirmed that there was no order to monitor for adverse reactions and no documentation of monitoring, despite the care plan's requirements. The resident, who had diagnoses including Cerebral Infarction, Retention of Urine, and Urinary Tract Infection, was admitted to the facility and prescribed Bactrim DS. The care plan specified that the resident should be monitored for adverse reactions such as diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions every shift. However, the facility failed to follow through with this monitoring, as confirmed by multiple staff members during interviews and a review of the resident's records.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect Resident #1 from sexual abuse by Resident #2. Resident #2, who has diagnoses including Vascular Dementia, Aphasia, Mood Disorder, Sexual Dysfunction, and Disorder of Adult Personality and Behavior, was observed inappropriately touching Resident #1's breast in the dining room. The incident caused psychosocial harm to Resident #1, who was startled and upset. The facility's response included notifying the doctor, increasing Resident #2's medication, and placing him on 1-on-1 observation, but the care plan failed to identify Resident #2's diagnosis of Sexual Dysfunction prior to the incident. Resident #2 was also a victim of physical abuse by Resident #5. Resident #5, who has diagnoses including Cerebral Infarction, Vascular Dementia, and Metabolic Encephalopathy, struck Resident #2 on the head with a cane, resulting in a laceration that required sutures. The incident occurred when Resident #2 bumped into Resident #5's bed, waking him up. The facility's records show that Resident #5 was sent to the hospital for psychological evaluation and was later discharged to home with family. Resident #3 suffered physical harm when Resident #4 hit him in the eye during an altercation in the dining room. Resident #4, who has diagnoses including Unspecified Dementia and Major Depressive Disorder, became aggressive during a bingo game and struck Resident #3, resulting in a contusion and subsequent complaints of headaches and pain. The incident report and witness statements indicate that Resident #3 was defending another resident when the altercation occurred. Resident #3's eye injury required in-house monitoring and further assessment for pain and headaches.
Failure to Provide Quarterly Statements of Personal Funds
Penalty
Summary
The facility failed to provide quarterly statements of personal funds for one resident. Resident #7, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Unspecified Diastolic Congestive Heart Failure, had a BIMS score of 15, indicating she was cognitively intact. During an interview, Resident #7 stated that she had not received a statement of her funds in over two years and expressed a desire to know her account balance. The Business Office Manager confirmed that there was no documentation of Resident #7 receiving any quarterly statements for 2023, despite claiming to have provided one in January 2024 for the last quarter of 2023.
Failure to Develop Comprehensive Care Plans and Follow Physician Orders
Penalty
Summary
The facility failed to develop a resident-centered comprehensive care plan for three residents, leading to multiple deficiencies. Resident #2, who was admitted with a diagnosis of Sexual Dysfunction, exhibited numerous inappropriate sexual behaviors that were documented in the nurse's notes. However, the care plan did not identify or address the Sexual Dysfunction diagnosis or the resident's sexual behaviors, as confirmed by the Minimum Data Set (MDS) nurse and the Assistant Director of Nursing (ADON). This oversight resulted in repeated incidents of inappropriate behavior without a tailored intervention plan in place. Resident #4, diagnosed with Unspecified Dementia, Major Depressive Disorder, Anxiety Disorder, and Bipolar Disorder, was not administered the correct dosage of Buspirone as per the physician's updated orders following a hospitalization. The resident's medication was supposed to be increased to three times daily, but the facility continued to administer it only twice daily. This discrepancy was confirmed by both the resident's nurse and the ADON, who acknowledged that the readmission paperwork had not been properly reviewed and updated in the electronic health record (EHR). Resident #7, who had Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure, was not care planned for her BiPAP machine and had multiple physician's orders that were not followed. These included the application of antifungal powder, barrier cream, and Triamcinolone cream, as well as the weekly changing of oxygen tubing and cleaning of the oxygen concentrator filter. The resident confirmed that these treatments were not being administered as prescribed, and the ADON verified the lapses in care through a review of the Treatment Administration Record (TAR).
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to properly store respiratory equipment for a resident with Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Unspecified Diastolic Congestive Heart Failure. The resident, who was cognitively intact with a BIMS score of 15, had a physician's order for BiPAP use at bedtime and nebulizer treatments as needed for shortness of breath. During an observation, it was noted that the resident's BiPAP mask and nebulizer mask were left on the bedside table without proper storage. The nebulizer mask was also outdated, with a date of 03/22/2024, and had not been replaced as required. Interviews with the resident, an LPN, and the Assistant Director of Nursing confirmed that the respiratory equipment was not stored properly. The LPN acknowledged that the BiPAP mask should have been bagged and the nebulizer mask should have been changed weekly. Despite requests, the facility was unable to provide a policy on respiratory equipment storage. The Assistant Director of Nursing confirmed that the equipment should have been stored in a bag and labeled, but this was not done.
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 31 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 Sulphur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| High Hope Care Center | 6.1 mi | ★★★★★ | 8 | 0 |
| Grand Cove Nursing & Rehabilitation Center | 6.2 mi | ★★★★★ | 5 | 0 |
| Lake Charles Care Center | 6.5 mi | ★★★★★ | 0 | 0 |
| Resthaven Nursing & Rehab Center, Llc | 6.6 mi | ★★★★★ | 4 | 0 |
| The Gardens And Guardian | 6.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.