Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 A Holly Patterson Extended Care Facility during CMS and state inspections, most recent first.
A resident who required two-person transfer assistance was moved from a wheelchair to bed by one CNA alone, and the resident’s leg struck the metal bed frame during the transfer. The resident reported severe shin pain, later X-rays showed tibia and fibula fractures, and staff interviews and records confirmed the CNA did not follow the resident’s transfer orders or check the CNA accountability record before providing care.
A resident with COPD was self-administering inhalers in the room, but the EMR had no physician order or self-administration assessment documenting that the resident could safely do so. Staff knew the resident used the inhalers, yet the meds were found unsecured and unlabeled in the room, and the LPN, charge nurse, DON, and attending MD each described gaps in awareness or documentation regarding the resident’s self-administration status.
Failure to Protect Residents from Abuse: The facility did not ensure residents were free from abuse when one resident with intact cognition struck a severely confused roommate in the face during an argument over a privacy curtain, and another resident with dementia and severe cognitive impairment was involved in two altercations with a cognitively intact resident over money, including being hit in the face with a TV remote and sustaining injuries that required hospital evaluation. Staff interviews and incident reports confirmed the resident-to-resident abuse, and facility leadership acknowledged the events met the definition of abuse.
A resident with dementia and later documented schizophrenia/schizoaffective disorder had MDS assessments showing impaired cognition and serious mental illness, but the record lacked evidence of a completed Level I or Level II PASARR. Staff interviews confirmed there was no PASARR on file for the resident’s stay, and the SW supervisor stated a Level II referral should occur when a resident has a new psychiatric diagnosis or change in psychiatric condition.
Failure to Follow Ordered Splint and Gauze Roll Interventions: A resident with CVA-related hemiparesis was observed multiple times without an ordered right-hand splint, and staff reported they could not locate it or did not apply it after AM care. Another resident with severe cognitive impairment and functional quadriplegia was repeatedly observed without an ordered gauze roll to the right anterior elbow; a CNA stated they misunderstood the order and placed it in the resident’s hand instead of the elbow, while the care plan did not include the intervention.
Advance Directive Care Plan Did Not Match DNR Orders: A resident with severe cognitive impairment, total dependence for care, and DNR/MOLST orders had a care plan that documented full CPR instead of DNR. Staff interviews confirmed the care plan did not match the physician order and MOLST, and the advance directive section was not revised to reflect the resident’s current code status.
Unsecured and unlabeled medications were found during survey observations. A medication cart was left unlocked in a hallway without staff present, an opened Ozempic pen in a med room refrigerator was not dated, and a resident with COPD had unlabeled inhalers on a nightstand and bed despite no order to self-administer. Staff interviews confirmed the cart should have been locked, injectable meds should be dated when opened, and the resident’s inhalers were not stored in a locked area.
An infection control deficiency occurred during heel wound care when an LPN left the old dressing on the clean field and the cleansed wound came into contact with the dirty dressing after the resident lowered the leg. The wound was then considered contaminated and would need to be re-cleansed; staff interviews confirmed assistance should have been obtained during the procedure.
A CNA was observed on surveillance video restraining and striking a resident with severe cognitive impairment in the head, while two other CNAs in the hallway did not intervene or report the incident. The event was reported by a visitor days later, and staff interviews confirmed that the abuse was not immediately reported as required by facility policy.
A resident with severe cognitive impairment was physically abused by a CNA, who was seen on video restraining and striking the resident. Two other CNAs present did not intervene or report the incident, and the event was only reported by a visitor days later. The staff failed to follow abuse prevention and reporting policies, resulting in a delay that allowed the involved CNAs continued access to residents.
A resident with dementia and other medical conditions was pushed to the floor by a CNA after a verbal disagreement over wheelchair placement, resulting in a head injury and hospitalization. The incident was witnessed by an RN, and the CNA was removed from duty. The facility's policy against abuse was not upheld in this case.
A facility failed to ensure a safe environment, resulting in harm to two residents. One resident with Cerebral Vascular Accident and Osteoarthritis fell from a mechanical lift due to missing safety latches, leading to a right humerus fracture. The facility's policy required equipment inspection and immediate sequestering of faulty equipment, which was not followed. Another resident with Peripheral Autonomic Neuropathy, End Stage Renal Disease, and Seizures was found with an unattended medication capsule on their overbed table. The resident had severely impaired cognition and was not assessed for self-administration of medications, contrary to the facility's policy requiring direct observation and verification of swallowing.
The facility failed to ensure that drug records were in order and accounted for all controlled drugs on three nursing units. Specifically, the Controlled Substance Administration Record forms were not reconciled to reflect the available medications in the blister packs for three residents, leading to discrepancies in medication counts.
The facility failed to ensure residents were treated with dignity during meal assistance. Two residents with conditions such as stroke and dementia were observed being fed by staff who stood over them instead of sitting next to them, contrary to the facility's policy for dignified care.
The facility failed to ensure that a resident with severe cognitive and physical impairments had an accessible call bell, as required by policy. Despite multiple observations and staff acknowledgments, the call bell was repeatedly found on the floor and out of reach, leading to a deficiency identified during the survey.
A facility failed to ensure a resident's comprehensive care plans were reviewed and revised in accordance with the MDS assessment schedule. The resident, who was cognitively intact and required assistance with daily activities, had care plans that were not updated as required, indicating a lapse in the facility's process for timely and accurate care plan updates.
A facility failed to ensure that an enteral feeding bottle for a resident was properly labeled with the resident's name, time feeding was started, and feeding directions as prescribed by the physician. Despite protocols requiring such labeling, observations on two separate days found the bottle without the necessary label, and staff interviews confirmed lapses in adherence to these procedures.
The facility failed to maintain an infection prevention and control program, as a CNA did not follow the required PPE protocols for residents on Special Droplet/Contact Precautions, despite clear signage indicating the necessary PPE.
Unsafe one-person transfer led to resident leg fracture
Penalty
Summary
The facility failed to ensure that a resident who required two-person assistance for transfers received the level of supervision and assistance ordered in the plan of care. Resident #314 had diagnoses including muscle weakness, lack of coordination, and osteoarthritis, and was documented as cognitively intact. The resident’s assessment and care plan indicated dependence on staff for transfers, and a physician’s order required out-of-bed transfers to a wheelchair with the assistance of two people. The resident also had a left lower extremity contracture and had been placed on skilled rehabilitation therapy because of a decline in functional transfers and balance. On 01/10/2025, Certified Nursing Assistant #8 transferred the resident from the wheelchair to the bed without a second staff member. During that transfer, the resident’s left leg struck the metal bed frame and the resident reported severe pain in the left shin. The incident report documented that the resident complained of pain after the transfer, and the physician was notified after the resident was assessed and pain medication was administered. A written statement from the CNA indicated the resident said they hit the right leg on the bed, while other documentation and interviews identified the left leg as the injured area. The investigation records stated that the resident required two-person assistance for transfers and that the CNA lifted the resident alone. The CNA also admitted not checking the CNA Accountability Record before providing care. An X-ray completed after the incident showed an acute fracture of the fibula, and hospital records confirmed minimally displaced fractures of the tibia and fibula. Interviews with staff and the resident consistently described that only one aide performed the transfer and that the resident’s leg contacted the bed frame during the move.
Failure to Assess and Order Self-Administration of Inhalers
Penalty
Summary
The facility did not ensure that the interdisciplinary team determined whether self-administration of medications was clinically appropriate for a resident who was self-administering inhaler medications. The resident had diagnoses including COPD, bronchitis, and colon cancer, and a quarterly MDS documented a BIMS score of 15, indicating intact cognition. The resident had physician orders for Advair HFA and Spiriva, but the electronic medical record did not contain a physician's order allowing self-administration and did not contain a self-administration assessment. The care plan addressed respiratory distress and included administering treatments and medications as ordered by the physician, monitoring effectiveness, observing adverse drug reactions, and notifying the physician of abnormal findings. During observation, an unlabeled Spiriva Handihaler box and an unlabeled Advair HFA inhaler were found in the resident's room, and the resident stated they administered their own inhalers and that nursing staff were aware. An LPN stated the resident was alert and oriented and capable of self-medicating the inhalers, but was unsure whether an assessment had been completed and did not know the inhalers were not stored in a locked cabinet. A charge nurse stated they were not aware the resident had the inhalers in the room and was administering them, and said the attending physician should have been notified to assess the resident's capacity to self-administer medications. The DON stated nursing staff should have ensured the resident was assessed, had a physician's order, and that medications were stored according to facility policy. The attending physician later stated the resident was alert and oriented and capable of administering the inhalers, but was not aware an evaluation was needed.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse. Survey findings identified two resident-to-resident abuse incidents involving four residents. One incident involved a resident with intact cognition and schizophrenia who struck a severely cognitively impaired roommate in the face during an argument over a privacy curtain, resulting in a swollen lip. The resident who was struck had diagnoses including diabetes mellitus and bipolar disorder and was documented as severely confused on the MDS. The facility’s own investigation concluded there was reasonable cause to believe abuse occurred, and facility leadership later stated the incident was abuse because the resident who struck the other resident was alert and knew what they were doing. A second incident involved a resident with dementia and severe cognitive impairment and another resident with intact cognition. The residents first argued in the hallway over money, with one resident tapping the other on the shoulders and arms while staff separated them and placed both on half-hour visual rounds. Later the same day, the cognitively impaired resident was found on the floor in their room with bleeding and injuries to the head, face, and left pinky fingers, and reported being hit in the face with a television remote control by the other resident. The injured resident was transferred to the hospital for CT scans of the head, spine, and face, and an X-ray of the left 5th digit. The investigation summary for both incidents concluded there was cause to believe resident-to-resident abuse had occurred. The record also shows that staff interviews and incident documentation confirmed the events. In the first incident, staff reported the residents were fighting over the privacy curtain and that one resident hit the other in the face after being struck with a shoe. In the second incident, staff and the residents described an argument over money that escalated into physical aggression, followed by a later assault in the room. The facility’s policy defined abuse to include willful infliction of injury and physical abuse such as hitting, and the facility’s Administrator, DON, and Risk Manager all acknowledged the events constituted abuse.
Failure to Complete PASARR Referral for New Serious Mental Illness
Penalty
Summary
The facility failed to coordinate and refer a resident for Level II PASARR review when the resident was newly diagnosed with schizoaffective disorder during the stay. The record showed the resident had a long history at the facility with diagnoses including dementia, depression, and schizophrenia, and was prescribed Risperdal. A psychiatric evaluation later documented a history of schizoaffective disorder and unspecified dementia, and subsequent hospital documentation also listed schizoaffective disorder among the resident’s past diagnoses. The resident’s MDS assessments documented impaired cognition, including BIMS scores indicating severely impaired and moderately impaired cognition at different times. One assessment identified schizophrenia as an active diagnosis and indicated the resident was not currently considered by the State level II PASARR process to have serious mental illness, intellectual disability, or other related conditions, with the Level II screen condition section left incomplete. A later significant change MDS documented schizophrenia and depression as active diagnoses, again with severely impaired cognition, and this time indicated the resident was currently considered by the State level II PASARR process to have serious mental illness, intellectual disability, or other related conditions; the Level II screen condition section was completed and indicated serious mental illness. The medical record lacked documented evidence that either a Level I or Level II PASARR had been completed for the resident. During interviews, the Director of Admission stated there was no completed Level I or Level II PASARR on file for the resident during the entire stay, and the Social Work Supervisor stated that a Level II referral should be done when a resident has a change in psychiatric condition or a new psychiatric diagnosis. The Administrator stated that residents with a new diagnosis of serious mental illness after admission should be screened to determine whether they require additional mental health services.
Failure to Follow Ordered Splint and Gauze Roll Interventions
Penalty
Summary
Resident #6 had diagnoses including hypertension and diabetes mellitus and a significant change MDS documented a BIMS score of 9, indicating moderately impaired cognitive skills for daily decision making. The resident required substantial to maximal assistance for upper body dressing and was dependent on staff for lower body dressing. A physician’s order dated 03/17/2025, last renewed 08/27/2025, directed staff to apply a right hand splint in the morning and remove it at sleep time for right-sided hemiparesis due to CVA. The resident’s CNA Assignment/Accountability Record listed a right-hand splint under devices, but the comprehensive care plan did not include the splint. During survey observations on 09/23/2025 and 09/24/2025, Resident #6 was seen sitting upright in bed and later seated in a wheelchair without the right-hand splint in place. During interviews, a CNA stated they did not apply the splint because they could not find it and had notified an RN, while the RN later found the splint in the top drawer of the dresser. Another CNA stated the splint should have been applied after morning care. The DON stated the splint should have been applied according to the physician’s order and as soon as morning care was completed. Resident #70 was admitted with diffuse traumatic brain injury, functional quadriplegia, and dysphagia, and an annual MDS documented a BIMS score of 0, indicating severe cognitive impairment. The resident was dependent on caregivers for dressing, bathing, toileting, eating, and all personal care. An OT screen documented impairments on both sides of the upper extremities and the use of a gauze roll on the right anterior elbow, and a physician’s order dated 08/11/2025 directed a gauze roll to the right anterior elbow for skin care. The comprehensive care plan did not document this intervention, although the CNA Assignment/Accountability Record listed the gauze roll and CNAs documented it as applied daily on all shifts. Survey observations on 09/23/2025, 09/24/2025, and 09/25/2025 found Resident #70 in bed without the gauze roll applied to the right anterior elbow. During interview, a CNA stated they did not know the gauze roll was supposed to be applied to the elbow and usually placed it in the resident’s hand, not the elbow, and said they mistakenly signed that they applied it. An RN stated CNAs were responsible for following the accountability record and nurses were responsible for ensuring physician’s orders were followed. The OT director stated the gauze roll was recommended for skin integrity and should have been included in the skin integrity care plan.
Advance Directive Care Plan Did Not Match DNR Orders
Penalty
Summary
The facility did not ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for one resident with advance directive orders. Resident #70 was admitted with diffuse traumatic brain injury, functional quadriplegia, and dysphagia, and had severe cognitive impairment with a Brief Interview for Mental Status score of 0. The resident was dependent on caregivers for dressing, bathing, toileting, eating, and all personal care. The Minimum Data Set documented the resident’s advance directive as Do Not Resuscitate. The resident’s comprehensive care plan for advance directives documented Medical Orders for Life Sustaining Treatment and Full Cardiopulmonary Resuscitation, while the resident’s MOLST and physician’s order both documented Do Not Resuscitate/allow natural death. During interviews, the RN stated the physician order and MOLST indicated DNR and that the care plan and physician’s order should match. The Social Worker Supervisor stated the care plan documented the resident as full code and should have been revised to accurately identify the resident’s advance directive wishes, and the DON stated the care plan should reflect the current advance directive orders and should have been revised to reflect the DNR status.
Unsecured and Unlabeled Medications
Penalty
Summary
Drugs and biologicals were not consistently stored in locked compartments and were not always labeled according to accepted professional principles. During the recertification survey, a medication cart on Unit 22 was observed unlocked in the hallway without any staff member present. The RN later acknowledged the cart had been left unlocked while medications were being administered in a nearby room and stated it should have been locked when unattended because residents could access medications from it. The Unit 22 medication room refrigerator contained an opened Ozempic pen for a resident with diabetes, hypertension, and chronic ischemic heart disease, and the pen was not dated. The resident’s physician had ordered Ozempic weekly, and the MAR showed it had been administered as ordered. The RN stated injectable medications should be dated when opened and discarded after the applicable discard period, and the DON stated all insulin and insulin pens should be dated when opened and discarded after 28 days. Resident #94, who had COPD, bronchitis, and colon cancer and had intact cognition on MDS assessment, was observed with an unlabeled Spiriva Handihaler on the nightstand and an unlabeled Advair inhaler on the bed. The resident stated they administered their own inhalers, but the chart did not contain an order for self-administration. An LPN stated the resident was capable of self-medicating inhalers, while the charge nurse was not aware the inhalers were kept unlocked in the room. The DON stated the resident should have had a locked drawer for medications and should have been assessed for self-administration by the physician and nursing staff.
Infection Control Lapse During Heel Wound Care
Penalty
Summary
The facility did not ensure it maintained an infection prevention and control program to prevent the development and transmission of communicable diseases and infections for a resident with a left heel pressure ulcer. Resident #314 was admitted with diagnoses including muscle weakness, lack of coordination, and osteoarthritis, and had moderate cognitive impairment with an unstageable left heel pressure ulcer that was later updated to an open wound requiring Carrasyn Wound Gel after cleansing with normal saline and a dry protective dressing. During wound care observation, an LPN performed treatment on the resident’s left heel and placed a clean field under the heel, but left the old dressing on the clean field instead of discarding it. After cleansing the wound, the resident lowered the leg and the cleansed heel came into contact with and rested on the folded dirty dressing. The LPN stated the wound had been contaminated and would need to be re-cleansed. Staff interviews confirmed the nurse should have obtained assistance during the procedure and that once the wound touched a dirty surface, it had to be re-cleansed before treatment could continue.
Failure to Prevent and Report Physical Abuse of a Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) was observed on facility surveillance video restraining both hands of a resident with severe cognitive impairment and striking the resident in the head twice. The incident took place in a hallway, with the resident seated in a wheelchair. The resident had a history of dementia, hyperlipidemia, and hypertension, and was documented as severely impaired for decision-making and communication. The facility's policy requires all staff to report and immediately intervene in cases of abuse, neglect, or mistreatment. The incident was initially reported by an anonymous visitor who witnessed the event and notified a unit liaison two days after it occurred. The unit liaison did not immediately report the allegation to a supervisor, instead waiting until the following morning. Review of the surveillance footage confirmed the abuse, and it was also observed that two other CNAs were present in the hallway, facing the direction of the incident, but did not intervene or report the event. Both denied witnessing the abuse during the investigation. Interviews with staff revealed that the resident was not known to be combative and that yelling was heard during the incident, but staff did not investigate or report the situation. The director of nursing confirmed that the incident should have been reported immediately upon the visitor's disclosure. The facility's investigation concluded that abuse did occur, and the medical director confirmed that the resident had no visible injuries but emphasized that no resident should be struck by staff.
Failure to Prevent, Protect, and Report Resident Abuse
Penalty
Summary
On 05/04/2025, a resident with severe cognitive impairment, as indicated by a BIMS score of 99 and diagnoses including dementia, was subjected to physical abuse by a Certified Nursing Assistant (CNA). The CNA was observed on facility video surveillance restraining both hands of the resident and striking them in the head while the resident was seated in a wheelchair in the hallway. Two other CNAs were present in the hallway at the time, with one standing at the nurse's station and the other taking vital signs for another resident. Both were observed facing the direction of the incident but did not intervene, correct, or report the abuse as required by facility policy. The incident was not reported by any staff members who were present or nearby. Instead, it came to the facility's attention when a visitor reported the event to a unit liaison two days later. The unit liaison failed to immediately notify their supervisor, delaying the report until the following morning. This delay allowed the involved CNAs continued access to the abused resident and other residents in the facility for several days after the incident. Interviews with staff revealed that the CNAs who were present either denied witnessing the abuse or claimed not to recall the incident, despite video evidence to the contrary. The LPN on duty heard screaming but did not witness or report any abuse. The Director of Nursing and the Facility Administrator both acknowledged that the incident should have been reported immediately and that staff failed to follow the facility's abuse prevention and reporting policies. The facility's investigation confirmed that abuse had occurred and that staff failed to protect and report as required.
Resident Abuse by CNA Leading to Hospitalization
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, specifically a Certified Nurse Assistant (CNA). The incident involved a resident with a medical history of Non-Alzheimer's Dementia, Diabetes Mellitus, and coronary artery disease, who was observed being pushed to the floor by the CNA. This occurred after a verbal disagreement between the resident and the CNA over the placement of the resident's wheelchair. The resident, who had impaired cognition and used a manual wheelchair, was upset when the CNA moved the wheelchair to access the sink, leading to a confrontation. The incident was witnessed by a Registered Nurse (RN), who reported seeing the CNA push the resident, causing them to fall and hit their head and left leg. The resident was subsequently admitted to the hospital with a diagnosis of non-traumatic intracranial hemorrhage. The facility's investigation documented that the resident became angry and approached the CNA, who then pushed the resident away, resulting in the fall. The RN and Nursing Supervisor confirmed the CNA's actions, and the resident was noted to have limited range of motion in the left leg and was gesturing towards the CNA as the one who pushed them. Interviews with the facility's Director of Nursing and Administrator revealed that the CNA was immediately removed from the schedule following the incident. The family of the resident was informed, and they chose not to involve the police. The facility's policy emphasizes that residents should be free from abuse, and the staff is educated on this policy upon hire and annually. However, the incident highlights a failure in adhering to this policy, resulting in harm to the resident.
Equipment Safety and Medication Administration Lapses Identified
Penalty
Summary
During the Recertification and Abbreviated Survey, it was identified that the facility failed to ensure a resident's environment was free from accident hazards, resulting in harm to two residents. Resident #42, with diagnoses including Cerebral Vascular Accident and Osteoarthritis, fell from a mechanical lift due to missing safety latches, resulting in a right humerus fracture. The facility's policy required inspection of equipment before use, replacement of malfunctioning parts, and immediate sequestering of faulty equipment. Despite policies in place, the missing safety latches on the mechanical lift were not addressed promptly, leading to the resident's fall and subsequent injury. In another instance, Resident #159, diagnosed with Peripheral Autonomic Neuropathy, End Stage Renal Disease, and Seizures, was found with a medication capsule on their overbed table without staff supervision. The resident had severely impaired cognition and was not assessed for self-administration of medications. The facility's policy mandated direct observation of medication administration and verification of swallowing. However, the medication was left unattended with the resident, indicating a failure to adhere to proper medication administration protocols, potentially putting the resident at risk of harm or medication errors.
Failure to Reconcile Controlled Substance Records
Penalty
Summary
The facility did not ensure that drug records were in order and accounted for all controlled drugs on three of its nursing units. Specifically, during medication storage observations, the Controlled Substance Administration Record forms were not reconciled to reflect the available controlled medications in the medication blister packs for three residents. For Resident #35, the record indicated 55 tablets of Clonazepam remaining, but the blister pack only had 24 tablets. The nurse admitted to not documenting the administration of the medication due to being busy. For Resident #221, the record showed 34 tablets of Lacosamide remaining, but the blister pack only had three tablets. The nurse stated that they had administered the medication but did not document it immediately because they were busy and not feeling well. Similarly, for Resident #7, the record indicated eight tablets of Xcopri remaining, but the blister pack had only seven tablets. The nurse explained that they had been busy with calls from residents and did not document the administration immediately. Interviews with the Registered Nurse Inservice Coordinator and the Director of Nursing Services confirmed that all medications, especially controlled substances, must be signed for immediately after administration. The failure to document and reconcile the Controlled Substance Administration Record forms as required led to discrepancies in the medication counts, which were identified during the survey.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This deficiency was identified during a lunch meal observation where two staff members were observed standing over two residents while assisting them with eating. Specifically, Resident #134 and Resident #192, who both required setup or clean-up assistance for meals, were fed by staff members who stood over them instead of sitting next to them, as required by the facility's policy for dignified care during meal times. Resident #134, who had a history of Cerebral Vascular Accident (stroke), Dementia, and Depression, was observed being fed yogurt by a Certified Nursing Assistant (CNA) who stood over them. The CNA acknowledged that they should have sat next to the resident while assisting with the meal. Interviews with the Registered Nurse (RN) and the Director of Nursing Services (DON) confirmed that staff are expected to sit and interact with residents during meal assistance to maintain their dignity and quality of life. However, the facility's Meal Pass policy did not explicitly state this requirement. Similarly, Resident #192, who had diagnoses including Cerebral Vascular Accident (stroke), Dementia, and Left Hemiparesis, was observed being fed sherbet by another CNA who also stood over them. The CNA admitted that they should have been seated next to the resident while assisting with the meal. Interviews with the RN and DON reiterated the expectation for staff to sit next to residents during meal assistance. Both residents expressed varying degrees of discomfort with being fed, and the facility's policy was found lacking in explicit instructions for maintaining resident dignity during meal times.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility did not ensure that each resident received services with reasonable accommodation of their needs, specifically failing to provide Resident #233 with an accessible call bell. Resident #233, who has severe cognitive impairment and range of motion impairment in both upper extremities, was observed multiple times with the call bell on the floor and out of reach. Despite the facility's policy requiring call bells to be accessible, the call bell was not within reach during observations on 3/26/2024 and 3/28/2024. Certified Nursing Assistant #5 and Registered Nurse #1 acknowledged that the call bell should be accessible, but it was not consistently placed within the resident's reach. Further interviews revealed that Resident #233 was evaluated by an Occupational Therapist and found unable to use the call bell, necessitating frequent monitoring. The Director of Nursing Services stated that residents unable to use the call bell should be assessed for alternative alert systems and monitored closely. However, Resident #233 was not assessed upon admission for their ability to use the call bell system, leading to the deficiency identified during the survey.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility did not ensure a person-centered comprehensive care plan was reviewed and revised to address each resident's needs. This deficiency was identified for one resident who was cognitively intact and required setup assistance for eating and bed mobility, and supervision for toileting and transfer. The comprehensive care plans for this resident, which included areas such as dementia, dental, vision, communication, and pain, were not reviewed and/or revised in accordance with the Minimum Data Set (MDS) assessment schedule. Specifically, there was no documented evidence that the care plans were updated when the quarterly MDS assessment was completed on 1/19/2024. Interviews with facility staff revealed that Registered Nurses and Nursing Supervisors are responsible for initiating, updating, and reviewing care plans. However, there was a lack of awareness and communication among the staff regarding the need to update the care plans in accordance with the MDS schedule. The Director of Nursing Services confirmed that the care plans should have been updated with the 1/19/2024 MDS assessment but were not. This oversight indicates a failure in the facility's process to ensure timely and accurate updates to residents' care plans as required by policy and regulation.
Failure to Label Enteral Feeding Bottles
Penalty
Summary
The facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment, care, and services to prevent complications of enteral feeding. This was identified for one resident who had an enteral feeding bottle hanging from the feeding tube stand without a label indicating the resident's name, the time feeding was started, and the feeding directions as prescribed by the physician. The facility's policy and procedure for enteral tube feeding required that the feeding bottle be labeled with the resident's name, the administering nurse's initials, date, and time of administration. However, during observations on two separate days, the resident's enteral feeding bottle was found without the required label. Interviews with the nursing staff and the Director of Nutrition and Food Services revealed that the process of labeling enteral feeding bottles starts in the kitchen, and the nurses are responsible for ensuring that the labels are in place before administering the feeding. The Licensed Practical Nurse on duty admitted to not noticing the missing label and stated that they were concentrating on medication administration. The Director of Nursing Services confirmed that all nurses are expected to follow the protocol for tube feeding, which includes labeling the feeding bottle as per the physician's orders. Despite these protocols, the deficiency was observed, indicating a lapse in adherence to the facility's established procedures.
Inadequate Infection Control Practices
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This deficiency was identified for four residents who were under Special Droplet/Contact Precautions. Specifically, a Certified Nursing Assistant (CNA) was observed taking vital signs for one of the residents while only wearing gloves and a surgical mask, contrary to the required Personal Protective Equipment (PPE) which included a gown and a face shield or goggles as indicated on the precaution sign outside the room. Resident #151, who had diagnoses including Acute Respiratory Failure with Hypoxia, Traumatic Brain Injury, and Sepsis, was on Contact Isolation due to a history of Multi-Drug Resistant Organism (MDRO) infections. Despite the precaution sign indicating the need for full PPE, the CNA did not adhere to these requirements. Similar observations were made for Residents #64, #374, and #282, all of whom had various diagnoses and were also on Contact Isolation due to MDRO infections. The CNA admitted to not checking the precaution sign and not wearing the required PPE. Interviews with the Infection Preventionist and the Director of Nursing Services confirmed that the signage posted outside the residents' room was meant to alert staff about the proper PPE use before entering the room. The CNA's failure to follow the correct PPE protocols as indicated on the signage was acknowledged as a breach of the facility's infection control protocols, which are in place to ensure the safety of both residents and staff.
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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 Uniondale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hempstead Park Nursing Home | 1.3 mi | ★★★★★ | 0 | 0 |
| Townhouse Center For Rehabilitation & Nursing | 1.6 mi | ★★★★★ | 1 | 0 |
| Mayfair Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Fulton Commons Care Center Inc | 1.8 mi | ★★★★★ | 0 | 0 |
| Belair Care Center Inc | 2.3 mi | ★★★★★ | 0 | 0 |
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