Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holly Springs Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to have the required members present at quarterly QAPI meetings. Review of the QAPI program showed the Medical Director was part of committee leadership and membership, but sign-in sheets for multiple quarterly meetings did not show the Medical Director in attendance. The Administrator confirmed the Medical Director did not attend the meetings and said he usually just called and filled her in afterward.
Care plan interventions were not implemented as written for three residents. One resident with CVA had long facial hair despite a care plan for shaving on shower days, another resident with MS had long jagged fingernails and no ordered hand/elbow contracture interventions in place, and a third resident with hemiplegia and encephalopathy had long jagged fingernails, poor oral hygiene, and no ordered left-hand splint in place. The DON and MDS Coordinator confirmed the care plans had been developed but staff failed to follow them.
Failure to provide ADL grooming and oral care: surveyors observed one resident with long facial hair, another with long jagged fingernails, and a third with long jagged fingernails plus poor oral hygiene with blackened, deteriorated teeth and buildup along the gum line. An LPN, CNA, and DON confirmed the conditions, and records showed the residents had significant medical and cognitive impairments, including cerebral infarction, severe protein-calorie malnutrition, MS, hemiplegia, metabolic encephalopathy, and BIMS scores indicating moderate impairment.
Unresolved Resident Council Food Grievances: Residents repeatedly raised concerns about cold, poor-quality, repetitive, and incorrect food service items during council meetings, and the DM was present at several meetings. Interviews with the AD, ADM, and DM confirmed the complaints were ongoing, no written follow-up was documented, and the grievances had not been resolved. The affected residents were cognitively intact or largely cognitively intact and included residents with renal dialysis dependence, malnutrition, DM, MDD, schizophrenia, anemia, and COPD.
Dignity and Privacy Failures in Toileting and Catheter Care: Two residents were not treated with dignity during toileting and catheter care. One resident who needed a bowel movement was told by staff to lie in bed, use the bathroom on herself, and then be changed, even though the DON said a bedpan should have been offered. Another resident’s urinary catheter drainage bag was observed hanging without the ordered privacy cover, and an LPN confirmed the cover should have been in place for privacy.
Failure to Honor Advance Directive for End-of-Life Decisions: A resident with dementia, CKD, and a pacemaker had an advance directive stating a choice not to prolong life, but the chart listed CPR/full code. An LPN confirmed the full-code order, while the DON confirmed the resident’s documented end-of-life wishes should have remained consistent with the advance directive. The resident and RR both stated the resident did not want resuscitation.
Unclean Resident Bathroom Toilet: A resident bathroom toilet in a room on the 200 hall was observed with dark yellow stagnant urine in the bowl and black, mold-like discoloration along the inner rim and water line. An LPN confirmed the toilet and bathroom were unclean and unsanitary, and the TCAM stated housekeeping staff were responsible for daily bathroom cleaning and confirmed the toilet had not been properly cleaned.
Failure to Provide Written Transfer Notification: The facility did not ensure that two residents transferred to the hospital received written notice to the resident and/or representative stating the reason for transfer, the effective date, and the receiving location. One resident was sent for tube/drain replacement, and another was sent to the ER after hitting their head. The BOM stated the facility only sent the bed-hold notice and notified the ombudsman, and was unaware that the written transfer notice was required.
Failure to apply ordered splints and contracture-prevention devices led to two residents being observed without prescribed interventions in place. One resident with severe MS and contractures was missing bilateral elbow rolls and hand supports ordered daily, while another resident with left hemiplegia and encephalopathy was repeatedly observed without the ordered left hand splint. Staff confirmed the devices were not being used as ordered, and the DON stated physician orders should be followed as written.
Failure to Clarify and Monitor Dialysis Fluid Restriction: A resident receiving dialysis had a clinically questionable fluid restriction order transcribed into the MAR without clarification from the dialysis center or physician. The order was converted from ounces to cc/ml and implemented as 3200 cc/ml per day, while the resident’s fluid intake was not documented or tracked. The DON and dialysis center RN confirmed the order was inaccurate and should have been clarified.
Failure to Follow Infection Control Practices for a Resident on TBP: A resident on contact isolation for ESBL in a wound was served breakfast on a reusable tray instead of a disposable tray, and the tray was removed with other trays. The resident was also taken to a shared shower room before other residents finished showering, and the room was not disinfected after use. The IP and DON confirmed that residents on TBP should receive disposable trays and be showered last with the shower area cleaned after use.
A resident with a PEG tube, severe cognitive impairment, and NPO status repeatedly entered other residents’ rooms and obtained food or drinks, despite being on visual monitoring for wandering. Multiple incidents of eating or drinking led to coughing, suspected aspiration, choking, and ED transfers. Interviews with the DON, SW, CNA, LPN, and ADON confirmed the resident’s behavior continued and that monitoring was not increased, even though one-on-one supervision had been discussed.
A facility failed to ensure residents received needed medical and dental services when scheduled appointments were missed because the transport van lacked fuel funds on the company gas card. A resident with COPD missed a pulmonary follow-up, a resident with major depressive disorder missed a dental visit with no reschedule date, and a resident with heart disease missed a cardiology appointment with no reschedule date. The DON, BOM, and van driver confirmed multiple missed appointments occurred during a period when the van could not be fueled through the company card.
Surveyors found that the facility failed to label and store food properly, maintain kitchen cleanliness, and ensure food safety, with multiple food items left unlabeled or uncovered, dirty kitchen equipment, and improper dishwashing temperatures. Additionally, meal trays were left in resident rooms for prolonged periods, including for residents with cognitive impairment, and staff did not consistently follow hand hygiene protocols.
Surveyors found that several residents with ADL deficits or dementia did not have appropriate care plans developed or implemented, resulting in unmet hygiene and personal care needs such as long, dirty fingernails and infrequent bathing. Staff interviews confirmed that care plans were not always followed or documented, and that residents' preferences and needs were not consistently addressed.
Several residents dependent on staff for ADL care were observed with long, dirty fingernails, unshaven facial hair, and lacking regular showers or baths. Despite some residents expressing a desire for grooming and hygiene, staff did not consistently provide these services or document refusals, even when residents had cognitive impairment or significant medical conditions. Staff acknowledged the need for regular assessment and care, but the facility failed to maintain residents in a clean and well-groomed condition.
Surveyors observed multiple instances of flies and gnats in resident rooms and the kitchen, with flies landing on residents and uncovered food trays, and gnats found around food waste. Maintenance and administrative staff confirmed ongoing pest issues, damaged window screens, and a lack of a specific pest control policy, while residents with significant medical conditions were affected.
A resident with moderate cognitive impairment was left wearing visibly soiled clothing and exposed protective underwear after staff failed to address his appearance, despite being aware of the issue. Both an LPN and a CNA acknowledged the dignity concern, and the facility's policy requires prompt attention to such needs.
Surveyors found that several residents did not have their call lights within reach, limiting their ability to request assistance, and one resident was observed with a mattress that was too short, leaving his feet unsupported. Staff confirmed that call lights should always be accessible and that the mattress was not the correct size. The affected residents had a range of cognitive and medical conditions.
Several residents were found living with unclean and damaged equipment, such as wheelchairs with missing or tattered armrests, dirty footrests, broken furniture, and soiled privacy curtains. Staff interviews revealed a lack of clarity and follow-through regarding responsibility for cleaning and repairs, and facility policies for maintaining equipment were either not in place or not followed, resulting in residents not receiving a safe, clean, and homelike environment.
Staff did not follow Enhanced Barrier Precautions during high-contact care for several residents with wounds or indwelling devices. Despite clear signage and available PPE, an LPN, a wound care nurse, and a CNA provided care without wearing gowns as required by facility policy and resident orders. Staff interviews confirmed knowledge of the EBP requirements, but the necessary precautions were not taken.
A resident with a history of obesity and muscle weakness was injured due to a failure to follow her care plan, which required two-person assistance with a lift for transfers. A CNA attempted to transfer the resident without the lift, based on incorrect information, resulting in fractures to the resident's leg.
A resident requiring a two-person assist with a full body lift was improperly transferred by a CNA who acted on incorrect information, leading to fractures in the resident's right leg. Despite the care plan specifying the need for a lift, the CNA attempted a pivot transfer, resulting in the resident's injury and subsequent hospital visit.
A resident with dementia and contractures required two-person assistance for care, as outlined in her care plan. However, a CNA provided care alone, resulting in the resident falling out of bed. The facility's failure to follow the care plan led to this deficiency, as confirmed by interviews with staff and a review of the resident's medical history.
A resident with contractures and dementia fell from bed when a CNA attempted to change their brief alone, despite the care plan requiring two-person assistance. The CNA positioned the resident too close to the bed's edge, resulting in a fall. No injuries were reported, and staff interviews confirmed the need for two-person assistance.
The facility failed to prevent the misappropriation of narcotics from a medication cart. During a narcotic count, an LPN discovered that a pill in a resident's Hydrocodone-Acetaminophen prescription was replaced with Atorvastatin. An audit revealed a similar issue with another resident's narcotic card. Both residents had moderate cognitive impairments. The facility's policy on controlled substances was not followed, leading to the unauthorized replacement of narcotic medications.
QAPI Committee Lacked Required Medical Director Participation
Penalty
Summary
The facility failed to have the required staff present and in attendance for each quarterly QAPI meeting reviewed. Record review showed the facility’s QAPI program identified leadership of the committee as including the Medical Director and/or NP, the Administrator, and the DON, and listed the Medical Director as a committee member. However, review of the sign-in sheets for the quarterly meetings dated 09/30/25, 12/29/25, 03/31/26, and 05/01/26 did not show participation by the Medical Director. During interview on 5/14/26 at 9:30 AM, the Administrator stated the facility discussed concerns during QAPI meetings but could not provide evidence of additional ongoing performance improvement activities, sustained monitoring tools, or systemic corrective actions related to recurring concerns. The Administrator also confirmed the Medical Director did not attend any of the QAPI meetings and stated he usually just called and filled her in about the meetings.
Care Plan Interventions Not Implemented as Written
Penalty
Summary
The facility failed to implement care plan interventions as written for three sampled residents. The deficiency was cited after observations, interviews, record review, and facility policy review showed that comprehensive, person-centered care plans were developed but not carried out as documented for residents with ADL deficits and other care needs. The facility policy stated that a comprehensive care plan with measurable objectives and timetables is to be developed and implemented for each resident. For one resident with a CVA and a BIMS score of 9, the care plan directed staff to ask on shower days whether he wanted to be shaved and to shave him as needed. However, observations showed his facial hair was approximately one inch long on multiple occasions. An LPN confirmed he had long facial hair and stated his shower days were Monday, Wednesday, and Friday, with a CNA assigned to shave residents on certain days. The MDS Coordinator confirmed the care plan had been developed but staff failed to implement the interventions as written. For a second resident with severe protein-calorie malnutrition and primary progressive MS, the care plan directed CNA staff to complete fingernail care daily and PRN, trim or file nails PRN, and apply carrots and elbow rolls after lunch and remove them at HS. Observations showed fingernails approximately one inch long with jagged edges, contractures to both hands, and no carrots, rolled cloths, or gauze in either hand. The DON confirmed the long, jagged fingernails and the absence of the ordered hand and elbow interventions, and the MDS Coordinator confirmed the care plan was not implemented as written. For a third resident with post-traumatic seizures, left-sided hemiplegia, and metabolic encephalopathy, the care plan directed a resting hand splint to the left hand after breakfast and removal at dinner or as tolerated, with skin checks before and after use, and listed oral hygiene and personal hygiene as dependent. Observations showed long jagged fingernails, blackened and deteriorated upper teeth with visible buildup along the gum line, and the left-hand splint not in place on multiple occasions. The resident stated he did not know where the brace was but said it helped hold his hand open, and the DON and MDS Coordinator confirmed the ordered care and splint interventions were not being carried out as written.
Failure to Provide ADL Grooming and Oral Care
Penalty
Summary
The facility failed to provide facial hair grooming, fingernail care, and oral hygiene for three residents reviewed for ADL care. The facility policy stated residents would be provided care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Survey observations and interviews showed Resident #2 had facial hair approximately one inch long on two observations, and an LPN confirmed the resident had long facial hair. The LPN stated the resident’s shower days were Mondays, Wednesdays, and Fridays, and that a CNA came on Wednesdays, Thursdays, and Fridays to shave residents. The Administrator stated residents should be offered a shave on shower days. Resident #2’s record showed diagnoses including cerebral infarction and an MDS BIMS score of 9, indicating moderate cognitive impairment. Resident #27 was observed with fingernails approximately one inch long with jagged edges, and a CNA confirmed several fingernails were very long but was unsure whether she could trim them because the resident might be diabetic. The DON confirmed the fingernails were very long and stated long, jagged fingernails could cause injury and should be kept clean and trimmed. Resident #39 was observed with fingernails approximately one inch long with jagged edges and with blackened, deteriorated upper teeth and visible buildup along the gum line, with significant discoloration and poor oral hygiene. The DON confirmed Resident #39 needed oral care and that fingernails should be kept trimmed, stating nail care and oral care should be provided daily and as needed. Resident #27’s record showed severe protein-calorie malnutrition and primary progressive multiple sclerosis, and Resident #39’s record showed post-traumatic seizures, left-sided hemiplegia, and metabolic encephalopathy; both residents had cognitive impairment documented in the MDS.
Unresolved Resident Council Food Grievances
Penalty
Summary
The facility failed to resolve resident grievances related to food service concerns that were repeatedly raised during Resident Council meetings. Based on resident and staff interviews, record review, and facility policy review, residents voiced ongoing complaints about cold food, poor food quality, repetitive menu items, incorrect meal items, inadequate portions, and missing requested beverages or foods. The facility policy titled Filing Grievances/Complaints stated that grievances, complaints, or recommendations from resident or family groups concerning resident care would be considered and responded to in writing if requested, including a rationale for the response. Resident Council Minutes documented repeated food complaints over multiple meetings, with the Dietary Manager present at several of them. Residents reported that the food was inedible, awful, cold, too salty, repetitive, and not served as listed on meal tickets. Additional concerns included tea glasses not being full or containing ice, green beans being served multiple days in a row, lack of fresh fruit or sliced apples, insufficient meat portions for sandwiches, not receiving the advertised meal of the month, and soup or oatmeal being served in dessert cups. During a later Resident Council meeting, residents continued to voice the same unresolved food service issues without follow-up or resolution. Interviews confirmed the concerns remained unresolved. The Activity Director stated cold food and food issues had been an ongoing concern discussed during Resident Council meetings and was unaware of any actions taken by the Dietary Manager to resolve them. The Administrator acknowledged awareness of the ongoing complaints and confirmed there was no written follow-up documentation regarding the grievances. The Dietary Manager also confirmed awareness of the concerns and acknowledged there was no documented follow-up and that the concerns had apparently not been resolved. The affected residents were cognitively intact or largely cognitively intact, including residents with diagnoses such as muscle weakness and dependence on renal dialysis, protein-calorie malnutrition and anemia, type 2 diabetes mellitus and major depressive disorder, schizophrenia and anemia, and COPD and anemia.
Dignity and Privacy Failures in Toileting and Catheter Care
Penalty
Summary
The facility failed to ensure a dignified existence for two residents by not providing appropriate privacy and toileting assistance. Facility policy stated residents are to be treated with dignity, courtesy, and respect, and to receive care necessary to achieve the highest practicable physical, mental, and psychosocial well-being. Resident #22 was observed sitting in a wheelchair near the doorway of her room with a frowning facial expression and scrunched eyebrows. She stated she needed to have a bowel movement, but staff told her they could not put her on the toilet and that she would have to lie in bed, use the bathroom on herself, and then be changed. The CNA confirmed telling her this, and the DON stated the resident required a total lift that would not fit into the bathroom and that no bedside commode was available, but the resident should have been offered a bedpan. The DON acknowledged that telling the resident to use the bathroom on herself was a dignity concern. Resident #22 had diagnoses including acute kidney failure, chronic kidney disease, anxiety disorder, and depression, and her BIMS score was 11, indicating moderate cognitive impairment. Resident #82 was observed with a urinary catheter drainage bag hanging on the lower bed frame, about one-third full of amber urine, without a privacy cover in place. The resident had an order for a privacy bag or covering over the urine collection bag for dignity. An LPN stated the drainage bag should have had a cover in place to provide privacy. Resident #82 had diagnoses including chronic kidney disease stage 3, benign prostatic hyperplasia, and personal history of malignant neoplasm of the prostate, and his BIMS score was 12, indicating moderate cognitive impairment.
Failure to Honor Advance Directive for End-of-Life Decisions
Penalty
Summary
The facility failed to honor Resident #25’s advance directive for end-of-life decisions. Record review showed the resident had an Advance Health Care Directive signed and notarized with a documented choice not to prolong life, but the Order Summary Report listed the resident as full code with a CPR order. During interview, an LPN confirmed the physician order reflected full code status, and the DON confirmed the resident had an advance directive indicating a choice not to prolong life. Resident #25 was admitted with diagnoses including unspecified dementia, chronic kidney disease, and presence of a cardiac pacemaker. The MDS showed a BIMS score of 07, indicating severe cognitive impairment. The resident stated she had always wanted no resuscitation if anything happened to her and confirmed she had completed paperwork documenting those wishes. The resident representative stated he had been contacted by the facility about code status but did not understand that his response would change the resident’s previously established end-of-life wishes, which he said should have remained as she wanted.
Unclean Resident Bathroom Toilet
Penalty
Summary
The facility failed to maintain a clean and sanitary environment by allowing a resident bathroom toilet in room [ROOM NUMBER] on the 200 hall to remain soiled. Review of the facility’s 7-Step Daily Washroom Cleaning policy showed that Environmental Services employees were responsible for sanitizing washrooms and cleaning and sanitizing the commode with a mop or toilet brush. During observation of the bathroom toilet, dark yellow stagnant urine was seen inside the bowl, and black discoloration adhered along the inner rim and water line of the toilet, appearing as multiple small circular black spots with a mold-like appearance. An LPN observed the toilet and confirmed there was stagnant urine and a black substance along the water line, stating it looked like mold and that the bathroom environment was unclean and unsanitary. The TCAM also observed the toilet and confirmed it was unclean and appeared to have mold, and stated housekeeping staff were responsible for cleaning residents’ bathrooms, including toilets, every day, confirming the toilet had not been properly cleaned.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to ensure that the resident and/or resident representative were provided written notification of transfer to the hospital for two residents reviewed for hospitalization. Facility policy titled "Transfer or Discharge Notice" stated the resident and representative are to be notified in writing of the specific reason for the transfer or discharge, the effective date, and the location to which the resident is being transferred or discharged. Resident #3, who was admitted with a diagnosis including disease of the biliary tract, was transported to a hospital for tube/drain replacement, and Resident #95, who was admitted with a diagnosis including malignant neoplasm of an unspecified part of an unspecified bronchus, was sent to the ER for evaluation after hitting their head and was transported by EMT to a hospital. During interview, the BOM stated that when a resident is transferred to the hospital, the facility only sends the bed-hold notice and notifies the ombudsman, and was unaware that written notification explaining the reason, date of transfer, and location of transfer was required to be provided to the resident and/or resident representative.
Failure to Apply Ordered Splints and Contracture-Prevention Devices
Penalty
Summary
The facility failed to provide necessary care and services to maintain range of motion and prevent worsening contractures for two residents. Facility policy stated that when a resident is discharged from therapy and a Restorative Nursing Program has been written, the DON or designee is to ensure the program is written correctly and implemented timely. For one resident with diagnoses including severe protein-calorie malnutrition and primary progressive multiple sclerosis, physician orders required bilateral elbow rolls and carrots to both hands daily after lunch and removed at bedtime, but observations showed the resident had contractures to both hands and elbows without the ordered interventions in place. During the survey, the ordered items were not on the resident, and staff later found the elbow rolls and carrots stored in drawers rather than in use. For another resident with diagnoses including post-traumatic seizures, left-sided hemiplegia, and metabolic encephalopathy, physician orders required checking skin before and after applying a left hand splint and applying the resting hand splint after breakfast daily and removing it at dinner or as tolerated. Observations on multiple occasions showed the resident without the splint in place on the left hand. The resident stated the brace helped hold the hand open but did not know where it was, and an LPN stated she did not usually work that hall and confirmed the brace had not been on the resident. The DON confirmed braces and splints should be applied as ordered to assist in preventing contractures and that physician orders should be followed as written.
Failure to Clarify and Monitor Dialysis Fluid Restriction
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for one resident receiving dialysis. The facility had a policy requiring coordination with the dialysis center and physician to monitor the resident’s clinical status, dialysis access, laboratory values, dietary needs, and complications related to dialysis therapy. Resident #22 was admitted with Acute Kidney Failure, Chronic Kidney Disease, and Dependence on Renal Dialysis, and the MDS indicated dialysis services were required and the resident had a BIMS score of 11, showing moderate cognitive impairment. The facility received a dialysis center order for a daily fluid restriction of 3200 fluid ounces, which was clinically questionable for a dialysis resident, but the order was transcribed into the MAR as 3200 cc/ml per 24 hours, with 1600 cc/ml per shift for dietary and nursing, without clarification from the dialysis center or physician. The MAR also showed no documented monitoring or tracking of fluid intake since admission. The dialysis center RN stated the 3200 fluid ounces order was not accurate and that dialysis residents were typically instructed to follow about a 32-ounce daily fluid restriction. The DON confirmed the order was unrealistic, should have been clarified, and that the resident’s fluid intake had not been monitored or documented since admission.
Failure to Follow Infection Control Practices for a Resident on Transmission-Based Precautions
Penalty
Summary
The facility failed to implement infection prevention and control practices for a resident on transmission-based precautions related to ESBL in a wound. Resident #8 had a physician order for contact isolation precautions, and on 5/12/2026 at 9:21 AM was observed eating breakfast on a regular reusable tray instead of a disposable tray. The tray was then picked up by an unidentified staff member and carried out with other trays. The Infection Preventionist stated she had sent a message to dietary staff earlier that morning regarding disposable trays for residents in isolation and confirmed that food trays for residents on transmission-based precautions should be disposable. The facility also failed to follow infection control practices for use of a shared shower room. Housekeeper #1 stated the shower room used by Resident #8 was routinely cleaned at 6:00 AM and again at approximately 2:00 PM daily. The Infection Preventionist stated residents on transmission-based precautions should be showered last and the shower room should be cleaned after use, and confirmed that allowing another resident to use the shower room before it was cleaned was not proper infection control practice. On 5/12/2026 at 10:00 AM, Resident #8 was transported to the common shower area and showered before other residents had completed their showers, and the shower room was not disinfected after use. The DON confirmed infection control practices should be used to prevent the spread of infection. Resident #8 had diagnoses including atherosclerotic heart disease and a BIMS score of 9, indicating moderate cognitive impairment.
Failure to Increase Supervision for NPO Resident Seeking Food
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with a PEG tube, severe cognitive impairment, and an NPO status. The resident had a history of traumatic brain injury, was identified as high risk for wandering/elopement, and had visual monitoring every shift ordered. Despite this, the resident repeatedly entered other residents’ rooms and obtained food or drinks from trays, snacks, and supplements throughout the facility. Record review showed multiple episodes in which the resident consumed food or liquids while NPO, including applesauce, lemonade, liquid supplement, a lunch tray, chocolate candies, and a snack cake. Several of these incidents led to signs of aspiration or choking and resulted in transfers to the ED for evaluation. ED records documented visits for possible aspiration, choking, aspiration into airway, and rhonchi in both lung bases. Interviews with the DON, SW, CNA, LPN, and ADON confirmed the resident continued to seek food from other residents’ rooms and that the facility did not increase monitoring despite the repeated episodes and ED transfers. The DON stated the resident had been to the hospital multiple times related to getting food wherever he could, and the ADON confirmed one-on-one supervision had been discussed but was not implemented. The facility administration also stated there were no policies or procedures related to accidents, monitoring, or supervision.
Missed Medical and Dental Appointments Due to Transport Fuel Funding Issues
Penalty
Summary
The facility failed to ensure that residents received necessary services to meet their medical needs when it allowed scheduled medical and dental appointments to be missed for 3 of 22 residents with scheduled appointments. The facility also stated that it had no policy or procedures on appointments. Resident #2, who was admitted with chronic obstructive pulmonary disease and had a BIMS score of 15, reported missing a pulmonary follow-up because staff told him there was no money on the gas card to put gas in the transport van, and his appointment was rescheduled to January. Resident #3, who was admitted with major depressive disorder and had a BIMS score of 15, missed a dental appointment because the van was out of gas, and no reschedule date was provided. Resident #4, who was admitted with congestive diastolic heart disease and had a BIMS score of 13, missed a cardiology appointment because there was no money to fill the transport van, and no reschedule date was provided. The van transport driver confirmed that at least 3 residents missed scheduled appointments during the period because there were no funds on the company gas card, and she stated there would have been more missed appointments if the DON and BOM had not used their personal credit cards to buy gas for the transport van. The DON confirmed that Resident #2, Resident #3, and Resident #4 missed appointments because there was no gas in the van and no funds on the company card, and the BOM confirmed that several residents missed appointments because there were no funds on the company gas card for about two weeks. The Administrator acknowledged there had been an issue with the company gas card, while also stating he filled the van himself and denied approving appointment reschedules due to transport card issues.
Deficient Food Storage, Kitchen Sanitation, and Meal Tray Removal
Penalty
Summary
The facility failed to properly label and store food, maintain kitchen cleanliness, and ensure food safety standards were met during multiple kitchen inspections. Observations revealed that numerous food items in the reach-in cooler and on prep tables were not labeled with open or expiration dates, and some were left uncovered. There were also open containers of seasonings, an open cup of salt, and a bag of bacon bits without dates. A box of potatoes with gnats was found on a prep table, and flies were observed in the kitchen. The return vent near the stove was heavily dust-laden, and several steam table lids and fry baskets were covered in grease and food debris. The deep fryer was reported as non-functional for months, but no maintenance request was documented. Additionally, pitchers of tea and lemonade were left out without dates, and the stove top was dirty with old grease and food buildup. Dishwashing and sanitation practices were also deficient. The low-temperature dishwasher was operating below the required temperature for effective sanitation, and dish machine logs showed missing documentation for wash and rinse temperatures over several days. During meal service, a dietary cook was observed leaving her station, touching personal items, and returning to food service without changing gloves or washing hands. The dietary manager confirmed that these actions were against facility policy and could compromise hygiene and food safety. Meal trays were left in resident rooms for extended periods, with several residents found with breakfast trays still present hours after meal service. Some residents were cognitively impaired, while others were cognitively intact. The facility did not have a policy specifying time frames for tray removal, and both the infection preventionist and administrator acknowledged that trays should be removed promptly to prevent potential illness. No foodborne illnesses were documented in the facility's infection log at the time of the survey.
Failure to Develop and Implement Comprehensive Care Plans for ADL and Dementia Needs
Penalty
Summary
Surveyors identified deficiencies related to the development and implementation of comprehensive, person-centered care plans for multiple residents. Several residents with ADL self-care deficits, cognitive impairments, or dementia did not have care plans that addressed all their needs, or the existing care plans were not followed. For example, one resident with a diagnosis of dementia did not have a dementia care plan developed after the diagnosis was added, which was confirmed by both the MDS Coordinator and Social Services. Other residents with ADL deficits, such as those requiring assistance with bathing, personal hygiene, and nail care, were observed to have unmet hygiene needs, including long and dirty fingernails, unshaven facial hair, and infrequent bathing, despite care plans indicating the need for regular assistance. Direct observations and interviews revealed that some residents expressed dissatisfaction with their hygiene and grooming, stating they wanted their nails trimmed or to be clean-shaven, and that they had not received showers or baths as scheduled. In several cases, staff interviews confirmed that residents had not received care as outlined in their care plans, and documentation of care refusals was lacking or absent. For instance, one resident had not received a bath or nail care since admission, and there was no documentation of refusals, despite staff stating the resident refused care. Another resident, who was cognitively intact, had long, jagged fingernails and stated he wanted them cut, but there was no evidence of recent nail care. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the survey found that care plans were either not developed for certain conditions, such as dementia, or not implemented as written for residents dependent on staff for ADLs. Staff interviews confirmed that failure to follow care plans resulted in residents not receiving the care they deserved, and that care plans are essential for guiding staff in providing necessary care.
Failure to Provide Adequate ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care, including personal hygiene and grooming, for five residents who were dependent on staff assistance. Multiple observations and interviews revealed that residents had long, jagged, or dirty fingernails, unshaven facial hair, and had not received regular showers or baths. In several cases, residents expressed a desire for nail care, shaving, or bathing, and staff confirmed the need for these services. Documentation did not consistently reflect refusals of care, and in some cases, there was no record of refusals despite staff claims that residents declined care. Residents affected included individuals with varying degrees of cognitive impairment and medical conditions such as diabetes, hemiplegia, chronic obstructive pulmonary disease, dementia, and end stage renal disease. For example, one resident with hemiplegia and diabetes had long, jagged fingernails and stated he did not like them that way, while another resident with moderate cognitive impairment had significant facial hair and could not recall the last time he received a shower. Another resident with severe cognitive impairment was observed with facial hair and had only refused care once in the past month, despite staff statements that she often refused grooming. Staff interviews confirmed the observations and acknowledged the importance of maintaining residents' hygiene and grooming to prevent health decline and preserve dignity. The facility's policy required monthly assessment and documentation of nail care and personal hygiene, including attempts to address refusals in residents with cognitive impairment. However, the lack of consistent documentation and failure to provide necessary ADL care led to the deficiency, as residents were not maintained in a clean, well-groomed condition as required.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Multiple observations revealed the presence of flies and gnats in both resident rooms and the kitchen area. Several residents were found in their rooms with flies flying over their beds, landing on their covers, and attempting to land on uncovered, leftover food trays. In the kitchen, gnats were observed flying around a cardboard box containing potatoes, and flies were seen in the prep and cook areas. The Dietary Manager noted that the box was considered garbage due to an overflowing trash can. Maintenance staff confirmed that flies had been a persistent problem for months, despite bi-monthly visits from a pest control company, and acknowledged that damaged window screens could be allowing flies to enter resident rooms. The process of replacing these screens was ongoing at the time of the survey. The Administrator confirmed that flies remained a concern in the facility, even with recent pest control visits, and admitted that no additional pest control services had been sought. It was also acknowledged that leaving meal trays in resident rooms could attract insects. Review of facility documentation revealed there was no specific pest control policy in place, and the existing environmental policy only addressed maintaining cleanliness in food service areas. Residents involved had medical conditions such as dementia, post-traumatic seizures, and amputation, and were observed to be in bed during the incidents.
Failure to Maintain Resident Dignity Due to Soiled Clothing and Exposed Undergarments
Penalty
Summary
A resident with a diagnosis of unspecified dementia and moderate cognitive impairment was observed sitting in his room wearing a visibly soiled shirt with food stains and liquids, and his pants were pulled down past his hips, exposing his protective underwear. The resident was in this state while a staff member changed his linen but did not provide any care or address his appearance. Both a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA) acknowledged the resident's soiled clothing and exposed undergarments, confirming it was a dignity issue. The CNA admitted to noticing the soiled shirt after breakfast but did not return to address it due to being occupied with another resident. The facility's policy on dignity requires that each resident be cared for in a manner that promotes well-being and self-worth. The administrator stated that staff are expected to address residents' needs as soon as they are identified. Despite this, the resident's needs were not promptly met, resulting in a failure to maintain the resident's dignity as required by facility policy.
Failure to Ensure Call Light Accessibility and Adequate Mattress Size
Penalty
Summary
Surveyors observed that multiple residents did not have their call lights within reach, limiting their ability to request assistance. For example, one resident was found in bed with the call light hanging behind the bed and inaccessible on several occasions throughout the day. The resident confirmed she could not reach the call light, and the CNA responsible acknowledged forgetting to attach it to the resident's pillow, as required by facility practice. The DON confirmed that staff are expected to ensure call lights are always accessible to residents. Other residents were also observed with call lights out of reach, including one sitting in a recliner with the call light tangled on the floor, and another lying in bed with the call light on the floor and not visible. Staff interviews confirmed that call lights should be within reach for safety and that all staff are responsible for ensuring accessibility. Residents affected had varying cognitive statuses, with some being cognitively intact and others having moderate to severe cognitive impairment. Additionally, one resident was repeatedly observed lying in bed with his feet hanging off the end of a mattress that was too short, with no support for his feet. The DON confirmed that the mattress was not the correct size and acknowledged the need for a mattress extender. The residents involved had medical histories including alcoholic polyneuropathy, repeated falls, schizophrenia, unspecified dementia, and other reduction deformities of the brain.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
Multiple residents were observed to be living in conditions that did not meet standards for a safe, clean, and homelike environment. One resident was found sitting in a wheelchair with 95% of the vinyl missing from the right armrest, tattered left armrest, and a frame and wheel spokes covered in a thick, gray substance. The resident was unsure why the wheelchair was in this condition or when it would be cleaned. The facility's Administrator confirmed the wheelchair was dirty and in disrepair, and did not know which staff member was responsible for cleaning wheelchairs. The DON stated that wheelchairs were supposed to be cleaned during the night shift, and the Maintenance Director was unaware of the damage, stating that staff should have reported it for repair. Another resident's motorized wheelchair footrests were covered with dirt and crumbs, and the resident reported it had not been cleaned in approximately six months. The Housekeeping Manager confirmed the wheelchair was dirty and that CNAs were responsible for cleaning wheelchairs. Additional deficiencies were observed in resident rooms. One resident's room contained a dresser with a missing drawer, exposing the contents, and several flies were present. Another resident's privacy curtain had eight circular dark brown stains, and the Housekeeping Supervisor confirmed it needed to be changed. A different resident's room had a chair with a broken armrest hanging down, exposing a screw, which the Maintenance Director confirmed could cause injury and should have been reported for repair. The Maintenance Director also confirmed the broken dresser drawer and stated that nurses and aides were responsible for reporting such concerns for repair. The Housekeeping Supervisor stated that housekeepers were expected to check privacy curtains for cleanliness and condition during daily cleaning. Facility policy review revealed a statement of resident rights to safe, decent, and clean conditions, and a policy requiring immediate removal of stained curtains. However, the facility did not have a specific policy in place for maintaining equipment. Staff interviews indicated that daily rounds were supposed to be conducted to report repair concerns, but these processes were not effectively implemented, resulting in multiple residents experiencing unclean, unsafe, or non-homelike living conditions.
Failure to Adhere to Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to adhere to Enhanced Barrier Precautions (EBP) during high-contact care activities for multiple residents with indwelling medical devices or wounds. Observations revealed that an LPN administered medications through a PEG tube to a resident with an active EBP order without wearing a gown, despite signage on the door and the nurse's acknowledgment of the requirement. Similarly, a wound care nurse and a CNA provided wound care and assistance with a sit-to-stand lift for another resident with a chronic wound, also under EBP, without donning gowns as instructed by posted signage. In another instance, a wound care nurse performed PEG site care for a resident with moderate cognitive impairment and an EBP order, again without using the required gown and gloves, even though PPE was readily available nearby. Record reviews confirmed that all affected residents had current orders for EBP due to the presence of wounds or indwelling devices, and facility policy required the use of gowns and gloves during high-contact care activities for these residents. Staff interviews further confirmed awareness of the EBP requirements and the purpose of PPE use, yet the required precautions were not followed during the observed care activities.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident requiring two-person assistance with a lift during transfers, resulting in an injury. The resident, who had an Activities of Daily Living (ADL) self-care performance deficit related to weakness, was supposed to be transferred using a full body lift with an extra-large sling by two staff members. However, on the day of the incident, a Certified Nursing Assistant (CNA) attempted to transfer the resident without the lift, based on incorrect information from another CNA. This action was contrary to the resident's care plan, which specified the need for a total lift for all transfers. As a result of the improper transfer, the resident complained of pain and was sent to the hospital, where x-rays confirmed fractures to her right leg. The resident, who had a history of obesity and generalized muscle weakness, was diagnosed with minimally displaced fractures of the distal tibia and fibula. The incident highlights a failure in adhering to the care plan, as the CNA did not verify the resident's transfer requirements and relied on incorrect information, leading to the resident's injury.
Inadequate Transfer Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate assistance during a transfer for a dependent resident, leading to an injury. The incident involved a resident who required a two-person assist with a full body lift for transfers, as outlined in her care plan. On the day of the incident, CNA #2, who was assigned to the resident, requested help from CNA #1 to transfer the resident back to bed. Despite CNA #2 bringing a Hoyer lift into the room, CNA #1 proceeded to transfer the resident without the lift, based on incorrect information from another aide that the resident could pivot for transfers. During the transfer, the resident's right leg was injured, resulting in pain and a subsequent hospital visit where x-rays confirmed fractures to her right leg. The resident, who had a history of obesity and generalized muscle weakness, was unable to pivot as CNA #1 attempted to transfer her, causing her foot to drag on the ground. This improper handling led to the resident's leg being injured during the transfer process. The facility's investigation revealed that CNA #1 acted on incorrect information and did not follow the care plan that required a full body lift for the resident. Both CNAs involved were from a staffing agency, and CNA #1 has not returned to work at the facility following the incident. The resident's care plan clearly indicated the need for a two-person assist with a full body lift, which was not adhered to, resulting in the resident's injury.
Failure to Implement Two-Person Assistance Care Plan
Penalty
Summary
The facility failed to implement the care plan for a dependent resident, resulting in a deficiency. The care plan for the resident, who had a self-care deficit and required total assistance by two persons for incontinent care, was not followed. On a specific date, a CNA entered the resident's room alone to provide care, despite the care plan's requirement for two-person assistance. This action led to the resident falling out of bed, as confirmed by interviews with the RN Supervisor, ADON, and CNA involved. The resident had contractures and was unable to assist in her own care, necessitating the two-person assistance outlined in her care plan. The resident's medical history included unspecified dementia, a need for assistance with personal care, and contractures in multiple areas. The MDS Coordinator confirmed that the care plans were designed to address the individualized needs of residents and that the CNA did not adhere to the care plan. The incident highlights a failure to follow established protocols, which were in place to prevent accidents and ensure the safety of residents with significant care needs.
Failure to Provide Two-Person Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent a fall for a dependent resident requiring two-person assistance. The incident involved a resident with contractures and a diagnosis of unspecified dementia, who was assessed as needing assistance with personal care. On the day of the incident, a Certified Nursing Assistant (CNA) attempted to change the resident's brief alone, despite the care plan indicating the need for two-person assistance. During the process, the resident was positioned too close to the edge of the bed, resulting in a fall to the floor. Fortunately, no injuries were observed at the time of the incident. Interviews with facility staff, including the Registered Nurse (RN) Supervisor and the Assistant Director of Nursing (ADON), confirmed that the resident required two-person assistance due to contractures. The CNA involved admitted to not paying attention to the resident's position on the bed and acknowledged the requirement for another person to assist. The CNA attempted to prevent the fall by supporting the resident's head and called for help immediately after the incident. The facility's policy on fall prevention emphasizes the need for specific interventions based on fall risk assessments, which were not adhered to in this case.
Misappropriation of Narcotics in Medication Cart
Penalty
Summary
The facility failed to prevent the misappropriation of narcotics from one of its medication carts. During a routine narcotic count at shift change, two LPNs discovered that a pill in a narcotic card for a resident's Hydrocodone-Acetaminophen prescription appeared different from the others. Upon further inspection, it was found that the pill had been replaced with a different medication, Atorvastatin, and the slot was sealed with tape. A subsequent audit revealed a similar issue with another resident's narcotic card, where a Norco tablet had been replaced with an Atorvastatin pill. The investigation revealed that the misappropriation involved two residents, both of whom had moderate cognitive impairments. One resident had a history of a skull injury and convulsions, while the other had dementia and an anxiety disorder. The facility's policy on controlled substances, which mandates compliance with laws and regulations regarding handling and documentation, was not adhered to, leading to the unauthorized replacement of narcotic medications with non-narcotic pills.
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What surveyors actually found near you
We read the 24 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
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Nursing homes near Holly Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ashland Health And Rehabilitation | 8.3 mi | ★★★★★ | 2 | 0 |
| Diversicare Of Ripley | 21.4 mi | ★★★★★ | 9 | 0 |
| Rest Haven Health And Rehabilitation | 21.4 mi | ★★★★★ | 1 | 0 |
| Tippah County Nursing Home | 21.7 mi | ★★★★★ | 7 | 0 |
| Great Oaks Rehabilitation And Healthcare Center | 22 mi | ★★★★★ | 5 | 0 |
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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 August 2026) and official state health department websites.