Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Oak Hollow Of Georgetown Rehabilitation Center Llc during CMS and state inspections, most recent first.
A CNA did not wear a gown while bathing a resident with a feeding tube, despite facility policy and CDC/CMS guidelines requiring both gloves and a gown for high-contact care activities involving indwelling medical devices. The resident, who was fully dependent on staff due to cerebral palsy and contractures, had a care plan directing staff to use enhanced barrier precautions. Facility leadership confirmed the expectation for proper PPE use during such care, and acknowledged the lapse in protocol.
A resident with a DNR order was inappropriately given CPR by a CNA in a facility, despite policies stating that only nurses should initiate CPR and that DNR orders must be respected. The CNA, unaware of the resident's DNR status, began CPR after the resident became unresponsive, while LPNs present did not intervene. The facility's Administrator and DON were not informed of the resident's code status until after the incident, indicating a failure in communication and policy adherence.
A facility failed to follow a resident's DNR order, resulting in CPR being administered despite the resident's wishes. The Administrator and DON were unaware of the resident's code status until informed by the family. The incident was not investigated or addressed in QAPI meetings, and only partial staff training was conducted.
A resident with a documented DNR order was administered CPR by nursing staff, despite having a terminal condition and explicit instructions against resuscitation. The incident was not reported to the QAPI committee, which is responsible for monitoring care quality and safety. This oversight led to the declaration of Immediate Jeopardy, highlighting a systemic issue in the facility's processes for handling residents' end-of-life wishes.
The facility's admission packet contained an Arbitration Agreement that failed to meet regulatory requirements. It did not clarify that signing was not a condition for admission and incorrectly allowed only three business days for rescission instead of thirty. The Administrator confirmed these deficiencies.
The facility failed to ensure proper use of PPE for two residents requiring Enhanced Barrier Precautions, as staff did not wear necessary PPE during care. Additionally, glucometers were not cleaned according to manufacturer instructions, risking cross-contamination. Observations showed staff using glucometers without cleaning them before or after use, and placing them on surfaces without barriers. Interviews revealed a lack of awareness and implementation of EBP, and some staff did not attend training on proper diabetic supply storage and cleaning.
The facility failed to provide written notification to residents, their representatives, and the Ombudsman for hospital transfers of two severely cognitively impaired residents. The DON confirmed that notifications were made via telephone, and the facility lacked a policy for hospital transfers.
A resident with a history of falls and cognitive impairment experienced repeated falls due to inadequate interventions and lack of a root cause analysis. Despite being at risk, the facility's interventions were limited to re-education and non-skid socks, which were ineffective. Observations showed inconsistencies in the use of hipsters and floor mats, and staff interviews revealed a lack of clarity on supervision and no evidence of a toileting study, despite falls occurring during restroom attempts.
A facility failed to document and assess the use of side rails for a resident with quadriplegia, as required by their policy. The resident was observed with side rails up without evidence of a current assessment or alternatives tried. Interviews revealed inconsistencies in assessment frequency, and a family member stated that alternatives were not discussed despite giving consent.
Failure to Follow Enhanced Barrier Precautions During Resident Bathing
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow the facility's Enhanced Barrier Precautions (EBP) policy while providing direct care to a resident with a feeding tube. During an observed bathing and dressing activity, the CNA wore a surgical mask and gloves but did not don a gown, despite the resident being on EBP due to the presence of a percutaneous endoscopic gastrostomy (PEG) feeding tube. The facility's policy, consistent with CDC and CMS guidelines, requires staff to wear both gloves and a gown during high-contact care activities, such as bathing, for residents with indwelling medical devices, regardless of their multi-drug resistant organism status. The resident involved had a medical history of cerebral palsy, contractures in all limbs, and was dependent on staff for all activities of daily living, including bathing. The care plan specifically directed staff to follow enhanced barrier precautions related to the resident's PEG tube. Both the Director of Nursing and the Administrator confirmed that the expectation was for staff to don appropriate PPE, including a gown, during such care activities, and acknowledged that the CNA did not comply with these protocols during the observed incident.
Failure to Adhere to DNR Order Leads to Inappropriate CPR
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident who had a Do Not Resuscitate (DNR) order. Despite the resident's DNR status, nursing staff performed Cardiopulmonary Resuscitation (CPR) on the resident, who had been admitted with diagnoses including Parkinson's disease and chronic atrial fibrillation. The incident occurred when the resident was found unresponsive, and CPR was initiated by a Certified Nursing Assistant (CNA) who was unaware of the resident's DNR status. The facility's policy clearly stated that CPR should not be performed on residents with a DNR order, yet this policy was not followed. The CNA, who was providing care to the resident, called for help when the resident became unresponsive. Licensed Practical Nurses (LPNs) arrived but did not immediately take action, leading the CNA to begin CPR. The CNA was not informed of the resident's DNR status until after the incident, highlighting a breakdown in communication and adherence to the facility's policies. Interviews with the facility's Administrator and Director of Nursing (DON) revealed that they were not aware of the resident's code status until after the incident. The facility's policy required that only nurses initiate CPR, but this was not adhered to in this case. The lack of awareness and communication regarding the resident's DNR status contributed to the inappropriate administration of CPR, which was contrary to the resident's documented wishes and the facility's established procedures.
Removal Plan
- The resident's Electronic Medical Records have been audited by the RN Nursing Home Administrator and Director of Nursing-RN to ensure all residents or resident's representative, that have elected a code status, the orders were updated to reflect the signed medical intervention. The necessary documentation has also been copied and placed in a 3-ring binder labeled Code Status Binder for ease of access for nurses to identify residents that are FULL CODE or DO NOT RESUSCITATE and placed at each nurse's station.
- The Administrator and Director of Nursing were educated by the CEO who is also a Social Worker, LNHA and Nurse on ensuring the resident is provided advanced directives upon admission, revised PRN and at a minimum of quarterly for any updates and changes they may elect.
- The Administrator and DON will educate the licensed nurses and certified nursing assistants to ensure the wishes of the residents in relation to their DNR or Full Code Status are followed. The education will be completed for all licensed nurses and Certified Nursing Assistants.
- The licensed nurses and certified nursing assistants were educated on the facility's CPR/DNR policies.
- They will be further instructed that a breach in a policy may result in a negative outcome, must have an investigation to include reporting to any state agency if warranted and reviewed with the monthly QAPI committee. The new licensed nurses and certified nursing assistants will be educated on the medical intervention status and location of the code status binder at each nurse's station during new hire orientation.
- The nurse Unit Managers will ensure the Code Status Binders and EMR are updated to reflect the residents, or RR wishes for advanced directives, PRN, upon admission and at a minimum of quarterly.
- The Director of Nursing or designee will audit the Code Status Binders until 100% compliance is achieved.
- Any code called will be reviewed by the Director of Nursing or Administrator to determine the action provided by staff. Any identified areas of concern will result in further education or disciplinary action.
- The Director of Nursing will review their findings with the Administrator for recommendations or follow up as indicated.
- The Administrator and/or Director of Nursing will report the finding of the audit to the Quality Assessment Performance Improvement Committee for further recommendation as indicated.
Failure to Follow Resident's DNR Order
Penalty
Summary
The facility Administrator failed to implement her job description to ensure the correct clinical operations related to a resident's code status were followed. This resulted in a situation where cardiopulmonary resuscitation (CPR) was administered to a resident, identified as R77, who had a Do Not Resuscitate (DNR) order. The incident occurred when R77 became unresponsive, and CPR was performed by a Certified Nurse Aide (CNA) with the awareness of two Licensed Practical Nurses (LPNs). Neither the Director of Nursing (DON) nor the Administrator were aware of R77's code status until informed by the resident's family member. The facility's administration did not identify or investigate the adverse event in which R77's DNR order was not followed. This oversight was not addressed in the Quality Assurance and Performance Improvement (QAPI) monthly meetings, and the incident was not investigated to correct the quality deficiency and prevent recurrence. Furthermore, the administration only provided training to a portion of the nursing staff, with 14 out of 47 members receiving education on the matter. During interviews, the Administrator confirmed her lack of awareness regarding the resident's code status until after the incident. The DON was informed of the event on the evening it occurred but did not take immediate action to address the oversight. The failure to investigate and address the incident was acknowledged as an oversight by both the DON and the Administrator in Training (AIT).
Removal Plan
- The residents' Electronic Medical Records have been audited by the RN Nursing Home Administrator and Director of Nursing-RN to ensure all residents or residents' representatives that have elected Do Not Resuscitate have been updated.
- The necessary documentation has been copied and placed in a 3-ring binder labeled Code Status Binder for ease of access for nurses to identify residents that are FULL CODE or DO NOT RESUSCITATE and placed at each nurse's station.
- The Administrator and Director of Nursing were educated on ensuring the resident is provided advanced directives upon admission, revised PRN, and for any updates and changes they may elect.
- The Administrator and Director of Nursing will educate the licensed nurses to ensure the wishes of the residents in relation to their DNR or Full Code Status are followed.
- The nurse Unit Managers will ensure the Code Status Binders and EMR are updated to reflect the residents' or RR wishes for advanced directives, PRN upon admission.
- The Director of Nursing or designee will audit the Code Status Binders until 100% compliance is achieved.
- The Director of Nursing or designee will review their findings with the Administrator for recommendations or follow-up as indicated.
- Any code called will be reviewed by the Director of Nursing or Administrator to determine the action provided by staff. Any identified areas of concern will result in further education or disciplinary action.
- The Administrator and/or Director of Nursing will report the findings of the audit to the Quality Assessment Performance Improvement Committee for further recommendation as indicated.
Failure to Adhere to DNR Order and Report Incident to QAPI
Penalty
Summary
The facility failed to address a critical incident involving a resident with a Do Not Resuscitate (DNR) order. On the specified date, nursing staff administered cardiopulmonary resuscitation (CPR) to a resident who had a DNR order documented in their electronic medical record (EMR). This incident occurred despite the resident having a terminal condition and explicit instructions against resuscitative efforts, as indicated by the signed DNR form in the EMR. The incident was not reported to the Quality Assurance and Performance Improvement (QAPI) committee, which is responsible for monitoring and evaluating the quality and safety of resident care. The QAPI committee was unaware of this high-risk issue and was not monitoring the facility's practices related to the accurate communication of residents' code status. The facility's policy requires that such incidents be promptly investigated and documented, but this was not done in this case. The failure to communicate and adhere to the resident's code status led to the declaration of Immediate Jeopardy (IJ) by surveyors, indicating a serious threat to the health and safety of residents. The facility's administration, including the Administrator and Director of Nursing (DON), acknowledged that the incident should have been investigated and reviewed by the QAPI committee, but it was overlooked. This oversight highlights a systemic issue in the facility's processes for handling and communicating residents' end-of-life wishes.
Removal Plan
- The residents' Electronic Medical Records have been audited by the RN Nursing Home Administrator and Director of Nursing-RN to ensure all residents or residents' representatives that have elected Do Not Resuscitate have been updated.
- The necessary documentation has been copied and placed in a 3-ring binder labeled Code Status Binder for ease of access for nurses to identify residents that are FULL CODE or DO NOT RESUSCITATE and placed at each nurse's station.
- The Administrator and DON will educate the licensed nurses and certified nursing assistants to ensure the wishes of the residents in relation to their DNR or Full Code Status are followed.
- The licensed nurses and certified nursing assistants were educated on the facility's CPR/DNR policies.
- The nurse Unit Managers will ensure the Code Status Binders and EMR are updated to reflect the residents' or RR wishes for advanced directives, PRN upon admission.
- The Director of Nursing or designee will audit the Code Status Binders until 100% compliance is achieved.
- The Director of Nursing or designee will review their findings with the Administrator for recommendations or follow-up as indicated.
- Any code status called will be reviewed by the Director of Nursing or Administrator to determine the action provided by staff. Any identified areas of concern will result in further education or disciplinary action.
- The Administrator and/or Director of Nursing will report the findings of the audit to the Monthly Quality Assessment Performance Improvement Committee for further recommendation as indicated.
Deficient Arbitration Agreement in Admission Packet
Penalty
Summary
The facility failed to ensure that the Addendum One-Arbitration Agreement in the admission packet met all fundamental requirements. Specifically, the agreement did not state that signing it was not a condition for admission to the facility. Additionally, the agreement incorrectly stated that residents or their representatives had only three business days to rescind the agreement, rather than the required thirty days. This oversight was confirmed during an interview with the Administrator, who acknowledged that the agreement did not comply with the necessary regulations.
Infection Control Deficiencies in PPE Use and Glucometer Cleaning
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) while providing direct care for two residents who required Enhanced Barrier Precautions (EBP). Observations revealed that there were no EBP signs posted or PPE available outside the rooms of residents with catheters and those receiving tube feedings. Specifically, a Licensed Practical Nurse (LPN) provided catheter care to a resident without wearing the necessary PPE, and there was no indication of EBP orders in the resident's electronic medical record. Similarly, another resident with a stage three pressure ulcer did not have EBP signs or PPE outside their room, and a Certified Nurse Aide (CNA) was observed providing care without PPE. The facility also failed to ensure that glucometers were cleaned according to manufacturer instructions, which could lead to cross-contamination between residents. Observations showed that an LPN used a glucometer on a resident without cleaning it before or after use, placing it directly on surfaces without a barrier. Another LPN repeated this process, failing to clean the glucometer after use and placing it back on the medication cart without a barrier. Interviews with staff indicated a lack of adherence to the facility's policy on cleaning glucometers, despite the presence of bleach wipes on medication carts. Interviews with the Director of Nursing (DON) and other staff members revealed a lack of awareness and implementation of EBP within the facility. The DON and Administrator acknowledged that they were waiting for a policy from corporate regarding EBP and that no residents were identified as requiring EBP at the time of the survey. Additionally, there was no evidence that certain staff members attended in-service training on the proper storage and cleaning of diabetic supplies, contributing to the deficiencies observed in infection control practices.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the resident, resident representative, and the Ombudsman when initiating a transfer or discharge for two residents reviewed for hospitalization. Resident 24, who was severely cognitively impaired with a BIMS score of 3 out of 15, was transferred to the hospital due to nausea and vomiting. The facility did not provide written notification of this transfer. Similarly, Resident 31, also severely cognitively impaired and unable to complete the BIMS interview, was transferred to the hospital due to difficulty breathing, yet no written notification was provided. During interviews, the Director of Nursing (DON) confirmed that the facility's practice was to notify residents or their representatives of hospital transfers via telephone and provide the Bed Hold notice physically or via certified mail. However, the facility lacked a policy related to hospital transfers, and the Ombudsman only received an email with transfer notifications for the period from January to August. This lack of written notification constitutes a deficiency in the facility's compliance with regulatory requirements for resident transfers and discharges.
Failure to Prevent Repeated Falls in a Resident
Penalty
Summary
The facility failed to conduct a root cause analysis and implement appropriate interventions for a resident, R26, who experienced repeated falls. R26 was admitted with a fracture of the neck of her right femur and had a history of abnormal gait, lack of coordination, unsteadiness on feet, difficulty walking, and repeated falls. Despite being identified as at risk for falls in multiple evaluations, the facility did not adequately address the causes of R26's falls or implement effective interventions to prevent further incidents. The facility's policy required staff to identify interventions based on the resident's specific risks and causes to prevent falls. However, after R26's falls on several occasions, the interventions were limited to re-education on the use of the call bell and non-skid socks, which proved ineffective. The facility's documentation lacked evidence of a comprehensive investigation or new interventions after each fall, and the care plan was not updated with effective strategies to mitigate the risk of further falls. Observations revealed that R26 was not consistently wearing hipsters, and the floor mat was not always in place, contrary to the orders in the electronic medical record. Interviews with staff indicated a lack of clarity on how supervision was increased for R26, and there was no evidence of a toileting study being conducted, despite the resident's falls being associated with attempts to use the restroom. The facility's approach to addressing R26's falls was inadequate, as they treated each fall as an isolated incident without a comprehensive strategy to prevent recurrence.
Failure to Document and Assess Side Rail Usage
Penalty
Summary
The facility failed to ensure proper documentation and assessment for the use of side rails for a resident with quadriplegia and muscle weakness. The facility's policy requires an assessment to determine the resident's symptoms, risk of entrapment, and reason for using side rails, as well as obtaining consent after discussing potential benefits and risks. However, the resident, identified as R27, was observed with the left side quarter side rail in the up position on multiple occasions without evidence of a current assessment or documentation of alternatives tried prior to the use of side rails. The last documented assessment for R27's side rail usage was dated several months prior, and there was no evidence of quarterly assessments as required by the facility's policy. Interviews with the Director of Nursing and the Administrator revealed inconsistencies in the frequency of side rail assessments, with the Administrator confirming that R27 had not had a side rail assessment since the previous year. Additionally, a family member of R27 indicated that while consent was given for the side rails, the facility did not discuss any alternatives, contrary to the facility's policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Georgetown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prince George Healthcare Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Lakes At Litchfield | 14.8 mi | ★★★★★ | 1 | 0 |
| Nhc Healthcare - Garden City | 25.1 mi | ★★★★★ | 0 | 0 |
| Angel Oak Nursing And Rehabilitation Center, Llc | 30.6 mi | ★★★★★ | 1 | 0 |
| Pruitthealth- Conway At Conway Medical Center | 35.6 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.