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 Holiday Retirement Home Inc during CMS and state inspections, most recent first.
Failure to timely provide hospice pain and symptom management: A resident with acute respiratory failure and heart failure was admitted to hospice with respiratory distress, pain, moaning, and agitation. Hospice recommended morphine and lorazepam for comfort, but staff did not promptly review or implement the orders, did not notify the provider about missed doses, and did not use available morphine in the Pyxis. After a fall and worsening distress, hospice ordered STAT comfort meds and increased dosing, but the record did not show they were given as recommended before the resident expired.
Failure to Report Resident Death After Fall With Head Injury: A resident with acute respiratory failure with hypoxia and heart failure sustained an unwitnessed fall and was found face down with bleeding from the nose and forehead. Hospice later documented a hematoma and forehead laceration, and the resident died several hours later. The facility did not provide evidence that the death was reported to the appropriate authorities, including the State Survey Agency, and the DON could not verify that the required report had been made.
Failure to revise a resident's care plan after repeated falls. A resident with Alzheimer's disease and a history of falls had multiple falls, was hospitalized after one fall with a wrist fx, and was later diagnosed with a hip fx. The care plan identified increased injury risk, but the record did not show updated interventions after the falls, and the DON could not provide evidence of an interdisciplinary revision.
Incorrect transcription and implementation of hospice medication orders. A resident with acute respiratory failure with hypoxia and HF was admitted to hospice and had physician-approved PRN orders for Levsin, Lorazepam Intensol, and Morphine Concentrate. The Levsin order was not transcribed or implemented, and the Lorazepam and Morphine orders were incorrectly entered as scheduled q1h meds instead of PRN; the MAR showed they were administered as scheduled meds, and an RN and the MD acknowledged the transcription errors.
A resident with a history of falls, cognitive impairment, and heart failure sustained unwitnessed falls with head injury, but the care plan was not revised, neuro checks were not documented after the head injury, and staff did not complete required post-fall monitoring per policy. The resident also had a DNR order, but staff could not promptly provide the Advance Directive to EMS, and CPR was initiated despite the DNR status.
A resident receiving hospice care had no evidence in the chart of required hospice documents, including the hospice POC, election form, physician certification/recertification, contact info for hospice staff, 24-hour on-call instructions, hospice med info, or MD orders. The record also lacked hospice recommendation forms for nursing visits. The DON said hospice documents should be scanned into the EMR, but could not produce the missing records.
A nurse’s transcription error led to a Farxiga order, intended for one resident, being entered into another resident’s chart, causing that resident—who had diagnoses including edema and hypokalemia—to receive Farxiga 5 mg daily for an extended period before the mistake was discovered. The issue came to light following a community complaint and was confirmed through record review, a Medication Error Form, staff statements, and an interview with the DON, all documenting that the incorrect medication was administered for many days.
A resident with chronic inflammatory demyelinating polyneuropathy and lymphedema developed large bruises on the right upper buttock and later on the left proximal thigh, described as deep purple and measuring approximately 18 cm by 22 cm. Facility policy on abuse and injuries of unknown origin requires initiation of an investigation, obtaining witness statements, notifying administrative personnel, and documenting a comprehensive internal investigation in the clinical record. Record review showed no evidence that any investigation was conducted to determine the origin of either bruise, and the DON confirmed that while new bruising should be investigated and documented, he could not provide evidence that this was done in these instances.
Two residents did not receive care consistent with physician orders and professional standards. One resident with significant neuromuscular and edema-related conditions had an order requiring two staff members at all times for care, yet was showered by a hospice NA alone after being transferred with assistance, during which active bleeding occurred and a traumatic wound to the great toe was later documented. Another resident with a history of MI and stroke, on dual antiplatelet therapy with aspirin and Plavix, had a physician order for a cardiology consult prior to possible discontinuation of Plavix, but no evidence was found that the consult was scheduled, and the Scheduler reported being unaware of the need for the appointment.
Surveyors found that several residents did not receive care in accordance with physician orders and professional standards, including improper air mattress settings, incorrect oxygen administration, and failure to notify a physician of significant weight gain. Staff were unaware of correct procedures, and documentation did not reflect required notifications.
Nursing staff failed to accurately document and follow physician orders for several residents, including not verifying air mattress settings according to weight, not ensuring correct oxygen flow rates, and documenting encouragement of incentive spirometer use when the device was not present. Staff acknowledged documenting completion of these tasks without performing them, resulting in inaccurate medical records.
The facility did not conduct required antibiotic 'time outs' or reviews for three residents who were prescribed antibiotics for conditions such as a toe infection, a surgical incision, and pneumonia. Medical records lacked documentation of clinical reviews within the recommended timeframe, and the Infection Preventionist confirmed that no staff member was assigned to complete these reviews during her absence.
A resident with multiple chronic conditions was not assessed or monitored for respiratory status, edema, and congestion as ordered, despite exhibiting symptoms such as lower extremity swelling and a persistent cough. Staff failed to document required assessments, did not notify the physician of the change in condition in a timely manner, and only performed necessary evaluations after surveyor intervention. Facility policy requiring prompt notification and assessment was not followed.
A resident with a stage two pressure ulcer and orders for Enhanced Barrier Precautions did not receive care in accordance with infection control protocols. During wound care, an RN failed to don a gown before starting the procedure, placed soiled materials on the bedside table without disinfecting it, and exited the room wearing the gown. Additionally, two NAs performed a transfer using a Hoyer lift without wearing the required PPE, despite clear signage and orders. All involved staff acknowledged not following the EBP protocol.
The facility did not ensure that two residents' medical records included documentation of being offered, receiving, or refusing the updated pneumococcal vaccine (PCV20 or PCV21), despite prior vaccinations with PCV13 and PPSV23. Staff interviews confirmed the absence of this documentation, and the facility's vaccination policy was found to be outdated and not aligned with current CDC recommendations.
Surveyors observed that the main kitchen's walk-in freezer had significant ice buildup on the sprinkler head and fan, and a kitchenette microwave was severely cracked with peeling paint. The Food Service Director confirmed both issues during the inspection.
A resident with peripheral vascular disease was found to have severe foot wounds infested with maggots, indicating a failure in providing adequate foot care. Despite being dependent on staff for lower body dressing, the resident's wounds were not identified during routine assessments. An LPN noted significant wounds with maggots, but other staff failed to conduct thorough skin checks. The DON admitted the lack of preventive care protocols for residents prone to foot problems.
A facility failed to ensure nursing staff had the necessary competencies for conducting thorough skin assessments, leading to a resident being hospitalized with untreated foot wounds and maggots. The facility's policy required weekly skin assessments, but a nurse did not check between the resident's toes, missing the wounds. Six nursing staff members lacked competency-based training, and the facility did not follow its assessment plan, putting all residents at risk.
A facility failed to maintain accurate medical records for a resident, as a skin assessment did not identify foot wounds later found at a hospital. The RN admitted to not checking between the toes, and the DON confirmed this was expected. The facility could not prove the assessment was done accurately.
A facility failed to follow professional standards by not having a physician's order or documentation for a resident's Freestyle Libre sensor, a continuous glucose monitoring system. The resident, with diabetes and COPD, indicated the sensor should be changed every 14 days, but records lacked evidence of orders or change history. The DON confirmed the absence of necessary documentation and orders.
A resident with diabetes received incorrect insulin dosages on multiple occasions due to a failure to follow physician's orders. Despite blood sugar levels indicating the need for 35 units of Humalog Mix 75-25 insulin, only 25 units were administered. This error was acknowledged by the DON during a surveyor interview.
Failure to Timely Provide Hospice Pain and Symptom Management
Penalty
Summary
The facility failed to ensure timely and appropriate pain and symptom management for a hospice resident receiving end-of-life care. The resident had diagnoses including acute respiratory failure with hypoxia and heart failure, and the care plan identified a risk for impaired comfort with directions to administer pain medication as ordered, monitor effectiveness, and observe for non-verbal signs of pain such as grimacing and agitation. Physician orders included pain assessment every shift and acetaminophen for mild pain. After hospice admission, the resident was documented as having respiratory distress, a respiratory rate of 30 breaths per minute, pursed-lip breathing, and pain rated 6/10. Hospice recommended morphine concentrate and lorazepam intensol on scheduled and as-needed bases for pain, shortness of breath, restlessness, and anxiety. A nursing note documented the resident was moaning and groaning, but the record did not show that the hospice recommendations were reviewed with the provider at that time, and there was no evidence the resident received medication to address the documented pain, distress, or anxiety. The hospice note later stated the recommendations still had not been reviewed, approved, or implemented by the facility. The MAR showed scheduled morphine and lorazepam doses were marked unavailable, and the record did not show the provider was notified that doses were missed. Although morphine was available in the Pyxis MedStation and staff acknowledged access to it, one LPN did not notify the NP of the hospice visit or recommendations, and an RN stated she did not obtain assistance to access the medication. After the resident fell and sustained a forehead laceration and hematoma, hospice documented restlessness, moaning, calling out, elevated heart rate, rapid shallow labored respirations, and poor response to prior medications, then recommended STAT comfort medications and increased scheduled dosing. The resident received a 5 mg morphine dose about an hour later, but the record did not show a follow-up assessment or that the STAT morphine and lorazepam doses were administered as recommended after provider approval. The resident expired shortly thereafter.
Failure to Report Resident Death After Fall With Head Injury
Penalty
Summary
The facility failed to ensure that an allegation involving an unwitnessed fall with head injury and subsequent death was reported to the appropriate authorities, including the State Survey Agency, as required by state law. A community-reported complaint alleged that Resident ID #1 sustained a fall with a head injury and expired approximately six hours later. Record review showed the resident had been readmitted to the facility in October 2025 with diagnoses including acute respiratory failure with hypoxia and heart failure. A progress note dated [DATE] at 7:02 PM documented that the resident was found lying face down on the floor after an unwitnessed fall, with active bleeding from the nose and forehead. A hospice visit note dated [DATE] at 7:50 PM documented evaluation after the fall and noted a hematoma and a laceration to the forehead. The resident expired on [DATE] at 1:15 AM. Record review did not reveal evidence that the facility reported the death to the appropriate authorities, including the State Survey Agency, and during interview the DON acknowledged the head injury from the fall and was unable to provide evidence that the death had been reported in accordance with state law.
Failure to Revise Care Plan After Repeated Falls
Penalty
Summary
The facility failed to ensure that the care plan for Resident ID #2 was revised by the interdisciplinary team after multiple falls. Resident ID #2 was admitted in July 2025 with diagnoses including Alzheimer's disease and a history of falls. Record review showed falls on 3/29/2026 and 3/30/2026, with the resident transferred to the hospital after the 3/30/2026 fall and later diagnosed with a left wrist fracture; additional record review showed a left hip fracture diagnosed on 4/4/2026. The resident's care plan had a problem area initiated on 3/25/2026 for increased risk for injury related to impaired balance, history of falls, and cognitive impairment, but the record did not show that interventions were revised or updated after the 3/29/2026 and 3/30/2026 falls. During interview, the DON was unable to provide evidence that the care plan had been revised or updated with additional interventions following the falls.
Incorrect transcription and implementation of hospice medication orders
Penalty
Summary
The facility failed to ensure that physician-approved hospice medication orders were accurately transcribed and implemented for Resident ID #1, who had been readmitted with diagnoses including acute respiratory failure with hypoxia and heart failure and was admitted to hospice services on 5/1/2026. A hospice note on 5/1/2026 recommended Levsin 0.125 mg sublingual every 4 hours as needed for secretions, and the provider approved the order on 5/2/2026 at 12:14 PM. The record did not show that the approved Levsin order was transcribed into the medical record or implemented by facility staff. A hospice note on 5/3/2026 recommended Lorazepam Intensol 2 mg/ml, 1 mg as needed for agitation and restlessness, and Morphine Concentrate 20 mg/ml, 10 mg every 1 hour as needed for pain or shortness of breath. The provider approved these recommendations on 5/3/2026 at 9:47 PM, but the orders were incorrectly transcribed as scheduled every 1 hour medications. The May 2026 MAR showed the medications were administered on 5/4/2026 at 12:00 PM as scheduled medications rather than as needed, and an RN acknowledged the transcription error. The physician also acknowledged that the Levsin order should have been transcribed and that the Morphine and Lorazepam orders were approved as needed orders, not scheduled medications.
Failure to follow fall monitoring and DNR orders
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards of practice for a resident who sustained a fall with head injury. The resident had diagnoses including acute respiratory failure with hypoxia, heart failure, and fall history, and had experienced falls on two separate occasions. After one unwitnessed fall, the resident was found lying in the bathtub with the head against the tub, and after another unwitnessed fall the resident was found face down on the floor with bleeding from the nose and forehead. The care plan identified the resident as being at increased risk for injury due to impaired balance, cognitive impairment, and history of falls, but the record did not show that interventions were revised or updated after the fall to address the resident’s ongoing and escalating fall risk. The record also did not show that neurological checks were completed after the unwitnessed fall with head injury, despite facility policy requiring neuro checks after such events. In addition, the resident had a signed Advance Directive and a physician order for DNR, but when the resident was found without a pulse, respirations, or blood pressure, staff could not promptly locate the Medical Examiner’s contact information or produce the Advance Directive for EMS. As a result, 911 was called, EMS documented that the DNR status could not be verified on arrival, and CPR was initiated by responders despite the resident’s DNR order.
Missing Hospice Documentation and Communication
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for 1 of 2 residents reviewed who were receiving hospice services, Resident ID #1. The resident had been readmitted to the facility in October 2025 with diagnoses including acute respiratory failure with hypoxia and heart failure, and was admitted to hospice services in May 2026. A community-reported complaint alleged that the resident was experiencing terminal agitation and that the facility failed to timely implement hospice recommendations to provide comfort, relief, and dignity at the end of life. Record review found no evidence in the resident’s electronic or paper medical record of required hospice documentation being maintained and readily accessible, including the most recent hospice plan of care, hospice election form, physician certification and recertification of terminal illness, hospice personnel contact information, instructions for accessing the hospice 24-hour on-call system, hospice medication information, and hospice physician and attending physician orders. The record also lacked hospice recommendation forms for all hospice nursing visits. During interview, the DNS stated the facility did not have individual hospice binders for each resident and said hospice documents should be scanned into the EMR, but he was unable to provide evidence that the required hospice documents, including all hospice recommendation forms, were present in the resident’s medical record.
Prolonged Administration of Incorrect Medication Due to Transcription Error
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a nurse incorrectly transcribed a Farxiga order into the wrong resident’s medical record, resulting in the resident receiving another resident’s medication for an extended period. A community complaint reported that a nurse had transcribed Farxiga, a medication used to treat type 2 diabetes, kidney disease, and congestive heart failure, into the records of two residents, and the error was not identified for 18 days. Clinical record review showed that Resident ID #3, who had been readmitted with diagnoses including edema and hypokalemia, was administered Farxiga 5 mg daily that was intended for a different resident, and this error persisted for 19 days. A Medication Error Form and a written statement from the Assistant Director of Nursing documented that Staff A mistakenly entered the Farxiga order into the wrong chart, and during an interview the Director of Nursing Services acknowledged that the resident received Farxiga in error for 19 days. These findings were based on review of the community complaint, the resident’s clinical record, the Medication Error Form, staff written statements, and an interview with the Director of Nursing Services, all confirming the prolonged administration of an incorrect medication to Resident ID #3.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of unknown origin for a resident who had significant bruising on two occasions. The facility’s abuse prohibition policy defines injuries of unknown origin and requires that an initial investigation be started, witness statements obtained, appropriate administrative personnel notified, and a comprehensive internal investigation carried out, with documentation in the clinical record. The resident, readmitted in July 2025, had diagnoses including chronic inflammatory demyelinating polyneuropathy and lymphedema. Progress notes showed that on 8/26/2025 a large bruise was noted on the right upper buttock, and on 9/8/2025 staff found a large, deep purple bruise on the left proximal thigh measuring approximately 18 cm by 22 cm during care at 12 AM. Further record review did not show any evidence that an investigation was conducted to determine the origin of either bruise. In an interview, the Director of Nursing Services stated that new bruising should trigger an investigation to determine etiology and be documented in the clinical record, but he was unable to provide evidence that such investigations were completed for the bruising documented on 8/26/2025 and 9/8/2025.
Failure to Follow Physician Orders for Two-Person Care and Cardiology Consult
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of practice for two residents. One resident, readmitted in July 2025 with chronic inflammatory demyelinating polyneuropathy and lymphedema, had a physician’s order dated 7/10/2025 requiring two staff members at all times for resident care. On 8/27/2025 during the 7:00 AM to 3:00 PM shift, the resident was taken to the shower room by a facility NA and a hospice NA. The facility NA assisted with transferring the resident into the shower chair via a Hoyer lift along with the hospice NA, but the hospice NA then showered the resident alone. During the shower, the hospice NA observed active bleeding from an unidentified source, and when nursing staff arrived, a pool of blood was noted in the bathroom. A skin assessment revealed an open area with a split to the skin on the top of the right great toe, and progress notes documented a traumatic wound to the distal tip of the right great toe with copious blood drainage and active bleeding. The NA assigned to the resident stated she was not aware that the resident required two staff members for care at all times, and record review did not show evidence that two staff members were present for care during the shower as ordered. The second deficiency concerns a failure to carry out a physician’s order for a cardiology consult for another resident. This resident was readmitted in September 2025 with diagnoses including myocardial infarction and cerebral infarction and had existing physician’s orders for aspirin 81 mg daily and Plavix 75 mg daily. A progress note dated 10/30/2025 documented that the resident was on dual antiplatelet therapy with aspirin and Plavix, and the pharmacy recommended discontinuation of Plavix. This recommendation was reported to the physician, who issued a new order to obtain a cardiology consult prior to discontinuing the medication. A physician’s order dated 10/31/2025 directed staff to obtain a cardiology consult for possible discontinuation of Plavix. Record review failed to show evidence that a cardiology consult had been scheduled, and the Scheduler reported being unaware that the resident needed a cardiology appointment and had not reached out to schedule it.
Failure to Follow Physician Orders and Professional Standards of Care
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed that the facility failed to ensure residents received care in accordance with professional standards and physician orders. Multiple residents with air mattresses had their mattress settings incorrectly adjusted, not matching either the physician's order or the resident's current weight. For example, one resident weighing 119.6 lbs had their air mattress set to 300 lbs, while another resident weighing 141 lbs had their mattress set to 350 lbs. Staff interviewed were unaware of the correct settings, and the Director of Nursing Services confirmed that the settings should have matched the residents' weights or the specific physician orders. Additionally, a resident with a physician's order for continuous oxygen at 2 liters per minute was observed receiving oxygen at 4 liters per minute on several occasions. Staff acknowledged that the oxygen was not being administered as ordered, and the DNS stated that the physician's order should have been followed regarding the oxygen flow rate. Another deficiency was identified for a resident with an order for daily weights three times per week, with instructions to notify the physician if there was a weight gain greater than 3 lbs in a day or 5 lbs in a week. The resident experienced a weight gain of 5.4 lbs in one week, but there was no evidence that the physician was notified as required. Staff interviews confirmed that the weight gain was not reported to the physician, and the nurse practitioner and DNS both indicated that notification should have occurred per the order.
Failure to Accurately Maintain Medical Records and Follow Physician Orders
Penalty
Summary
The facility failed to accurately maintain medical records and safeguard resident-identifiable information in accordance with accepted professional standards for several residents. For three residents with air mattresses, physician orders required that the mattress settings be checked every shift and set according to the resident's weight. However, surveyor observations revealed that the air mattresses were not set to the correct weights, and nursing staff documented in the Treatment Administration Record (TAR) that the checks were completed without verifying or adjusting the settings. Staff interviews confirmed that the documentation was completed without actually performing the required checks. For a resident receiving oxygen therapy, a physician's order specified oxygen at 2 liters per minute via nasal cannula continuously. Despite this, the resident was observed receiving oxygen at 4 liters per minute on multiple occasions. The Medication Administration Record (MAR) indicated that the resident was documented as receiving the ordered amount, but staff acknowledged that they signed off on the order without verifying the actual oxygen flow rate. Additionally, for a resident with an order to encourage the use of an incentive spirometer every shift, surveyors found that the device was not present in the resident's room during multiple observations. Despite this, the TAR reflected that staff had documented the order as completed. Staff interviews confirmed that documentation was made without ensuring the resident had access to or used the incentive spirometer.
Failure to Monitor and Review Antibiotic Use
Penalty
Summary
The facility failed to establish and implement an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, for three residents who were prescribed antibiotics for various conditions—including an infection of the great toe, a surgical incision, and pneumonia—there was no evidence in the medical records that an antibiotic 'time out' or review was conducted within 48 to 72 hours after the initiation of antibiotic therapy, as recommended by the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes. Record reviews for these residents showed that antibiotics such as doxycycline and cephalexin were administered, but documentation of a clinical review to assess the appropriateness of the antibiotic, its dose, route, or duration was absent. During an interview, the Infection Preventionist confirmed that no antibiotic timeouts were completed for these residents and further disclosed that, during her leave of absence, there was no designated staff member responsible for completing these reviews.
Failure to Monitor and Notify Physician of Resident's Change in Condition
Penalty
Summary
A resident with a history of Alzheimer's disease, acute kidney failure, hypertensive heart disease, and chronic kidney disease was readmitted to the facility and had physician's orders in place for diuretic use, monitoring for edema, congestion, and weight changes every shift, as well as specific orders to assess and document respiratory status every shift for three days. Despite these orders, there was no evidence that the resident's respiratory status was assessed and documented as required on multiple shifts. Additionally, staff failed to monitor and document the presence of edema and congestion as ordered. Surveyor observations revealed that the resident exhibited swelling in the lower legs and a congested, non-productive cough over several days. Staff interviews confirmed that the resident was observed coughing, but assessments were not performed or documented, and the physician was not notified of the change in condition in a timely manner. One LPN admitted to documenting that an assessment was completed when it was not, and only assessed the resident for edema after the surveyor brought the issue to her attention. The resident was found to have severe pitting edema at that time. The facility's policy required notification of the physician and responsible party when a change in condition occurred, including the need to alter medical treatment. However, the physician was not notified of the resident's change in condition until several days after the initial assessment, and only after the surveyor intervened. Staff and leadership interviews confirmed that the expected standard of care was not met, as the resident was not assessed or monitored according to physician orders and professional standards of practice.
Failure to Follow Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required by policy and physician orders, specifically regarding the use of Enhanced Barrier Precautions (EBP) for a resident with a stage two pressure ulcer. The resident, who was readmitted with muscle weakness and difficulty walking, had physician orders for EBP and wound care, including the use of gowns and gloves during high-contact care activities such as transfers and dressing changes. Despite clear signage and documented orders, staff did not consistently follow these protocols. During a wound dressing change, a registered nurse began the procedure without donning a gown, only putting it on after realizing the omission. The nurse also placed soiled dressing materials directly on the bedside table and failed to disinfect the area afterward. Additionally, the nurse exited the resident's room into the hallway while still wearing the gown, only returning to remove it after noticing the error. Further observations revealed that two nursing assistants entered the resident's room and performed a transfer using a Hoyer lift without wearing the required gown or gloves, despite the EBP signage and orders. Both nursing assistants acknowledged after the fact that they did not follow the EBP protocol. The staff educator confirmed that the expectation was for staff to adhere to infection control protocols and wear appropriate PPE as indicated by orders and signage. These actions and inactions directly led to the identified deficiency in the facility's infection prevention and control program.
Failure to Document and Update Pneumococcal Vaccination Practices
Penalty
Summary
The facility failed to ensure that residents' medical records included documentation indicating whether the pneumococcal vaccine (PCV20 or PCV21) was offered, received, or refused, or if there were medical contraindications. Specifically, for two residents who were readmitted to the facility, their immunization records showed they had previously received PCV13 and PPSV23 vaccines, but there was no evidence in their records regarding the offering or administration of the updated pneumococcal vaccines as recommended by current CDC guidelines. During staff interviews, the Infection Preventionist was unable to provide documentation that these residents had been offered or had declined the PCV20 or PCV21 vaccine. Additionally, the facility's policy on resident vaccination for flu and pneumonia was found to be outdated. The policy referenced guidelines from 2019 and did not include the most recent recommendations for pneumococcal immunizations. The Director of Nursing Services acknowledged during an interview that the current policy did not reflect the latest guidance, contributing to the lack of proper documentation and adherence to updated vaccination protocols.
Environmental Deficiencies in Kitchen and Kitchenette Areas
Penalty
Summary
Surveyor observations identified that the facility failed to maintain a safe, functional, and comfortable environment in both the main kitchen and one of three kitchenettes. In the main kitchen, the walk-in freezer was found to have an accumulation of ice buildup on the sprinkler head and the left fan near the ceiling, as confirmed by the Food Service Director (FSD) during the inspection. Additionally, in the Jamestown Unit Kitchenette, a microwave mounted above the counter was observed to be severely cracked with peeling paint on its exterior, which was also acknowledged by the FSD. These conditions were directly observed by surveyors and confirmed by staff interviews.
Failure to Provide Adequate Foot Care for Resident with Peripheral Vascular Disease
Penalty
Summary
The facility failed to provide appropriate foot care and treatment for a resident with peripheral vascular disease, leading to severe complications. The resident was readmitted to the facility with diagnoses including cellulitis and peripheral vascular disease. A complaint was reported to the Rhode Island Department of Health, alleging that the resident was treated at a hospital for multiple foot wounds infested with maggots. Hospital records confirmed the presence of wounds with black tissue and maggots, and the resident was admitted with cellulitis and started on intravenous antibiotics. The facility's staff failed to conduct thorough skin assessments, as evidenced by a registered nurse who did not inspect between the resident's toes. A nursing assistant also did not notice any wounds during a shower. However, an LPN observed a significant wound with moving maggots and redness on the resident's leg, indicating a lack of consistent and comprehensive foot care. The Director of Nursing Services acknowledged the expectation for full skin assessments, including between toes, and admitted the absence of standing orders for preventive foot care for residents with diabetes and circulatory disorders.
Inadequate Skin Assessment Competency Among Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to conduct thorough skin assessments, which compromised resident safety and well-being. A review of the facility's policy on skin care indicated that weekly skin assessments were required for every resident. However, a community-reported complaint revealed that a resident was hospitalized with multiple wounds on their feet, including maggots, which were not identified during a skin assessment conducted by a registered nurse the day before hospitalization. The nurse admitted to not checking between the resident's toes, where the wounds were located. Further investigation showed that six licensed nursing staff members lacked evidence of competency-based training on skin assessments. Interviews with the Director of Nursing Services and the Assistant Director of Nursing confirmed that the facility did not provide such training, nor did they follow their facility assessment regarding competency-based training. This oversight placed all 150 residents requiring weekly skin assessments at risk for serious injury, harm, impairment, or death.
Incomplete Skin Assessment Leads to Deficiency
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding skin assessments. A community-reported complaint alleged that a resident was treated at a hospital for multiple wounds on their feet that contained maggots. Hospital records from the admission on 8/4/2024 indicated the presence of wounds with black tissue and maggots between the toes, as well as cellulitis in the right lower extremity, necessitating intravenous antibiotics. However, a skin assessment conducted by a registered nurse on 8/3/2024, the day before the hospitalization, only noted dry skin on the resident's lower extremities and did not identify any foot wounds. During an interview, the registered nurse admitted to not examining the skin between the resident's toes during the assessment. The Director of Nursing Services confirmed that the nursing staff is expected to assess the skin between a resident's toes during skin assessments. The facility was unable to provide evidence that the skin assessment for the resident was completed accurately, leading to the deficiency in maintaining proper medical records.
Failure to Follow Physician's Orders for Glucose Monitoring
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for a resident using a Freestyle Libre sensor, a continuous glucose monitoring system. The resident, who was admitted with diagnoses including diabetes and chronic obstructive pulmonary disease, reported that the sensor needs to be changed every 14 days. However, the record review did not show any evidence of a physician's order for the sensor or documentation indicating when it should be changed or when it was last changed. During an interview, the Director of Nursing Services was unable to provide documentation of the sensor's presence, the schedule for changing it, or the last change date, and acknowledged that there should be a physician's order for the sensor and its replacement schedule.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The resident, who was admitted in April 2024 with diagnoses including diabetes and chronic obstructive pulmonary disease, had a physician's order for Humalog Mix 75-25 insulin with specific instructions based on blood sugar levels. The order specified administering 25 units if blood sugar was less than 150 and 35 units if it was above 150. However, on multiple occasions in April and May 2024, the resident's blood sugar was recorded as greater than 150, yet only 25 units of insulin were administered instead of the prescribed 35 units. This error was acknowledged by the Director of Nursing Services during a surveyor interview, who confirmed that the resident received the incorrect insulin dosage on the specified dates.
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What surveyors actually found near you
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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 Manville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adviniacare Oakland Grove Llc | 2.2 mi | ★★★★★ | 12 | 0 |
| Cedar Haven Operations Holding Llc Valley View Hea | 2.5 mi | ★★★★★ | 0 | 0 |
| Woonsocket Health Center | 3 mi | ★★★★★ | 0 | 0 |
| The Friendly Home | 3.8 mi | ★★★★★ | 13 | 0 |
| St Antoine Residence | 3.9 mi | ★★★★★ | 4 | 0 |
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