Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Springs Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
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.
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.
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.
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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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.
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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 | ★★★★★ | 8 | 0 |
| Tippah County Nursing Home | 21.7 mi | ★★★★★ | 7 | 0 |
| Great Oaks Rehabilitation And Healthcare Center | 22 mi | ★★★★★ | 5 | 0 |
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