Average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holly Hall during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including weakness, cellulitis, an open wound, and wrist injury, was not given scheduled showers or bed baths, and her bathing records showed multiple missed full-body bathing opportunities. She reported going many days without a shower, family said staff did not offer bathing and responded with a nasty attitude, and no shower sheets were recorded for the month. In a group interview, several residents reported inconsistent or absent showers, including one who said he had only been offered one shower a week and another who said he had gone 10 days without bathing.
A resident with multiple serious diagnoses, including weakness and muscle wasting, and several other residents did not consistently receive scheduled showers or bed baths. The resident stated she went many days without bathing and wanted care on her assigned shower days, while family reported she had to ask for help wiping her face. In a group interview, residents described missed or inconsistent shower schedules, one resident reported going 10 days after hospital discharge without a shower, and shower records showed missing or inconsistent documentation, including one resident with no shower sheets for the month.
A resident with a suprapubic catheter and urinary incontinence developed a red, raw split in the penis with pain noted during care, while the catheter securement device was found unsecured and the skin change was not documented on the weekly skin assessments. During Foley and incontinent care, CNA staff did not consistently perform hand hygiene or change gloves appropriately, and the Foley bag was placed on the resident’s bed during care.
Inaccurate resident weights and missed follow-up on weight loss. The facility failed to maintain acceptable nutritional status for multiple residents and did not follow up on significant weight changes. Records and staff interviews showed that several residents had large weight discrepancies, one CNA entered a prior weight without weighing the resident, and the DON/ADON identified that the sitting scale was off and the mechanical scale was rounding weights. Residents with complex medical conditions, including CHF, Parkinson’s disease, cancer, wounds, and hospice status, had care plans for hydration, intake, and weight monitoring, but the documented weights and follow-up were inconsistent.
Medication administration errors exceeded the allowed rate, with omitted doses, incorrect tablet counts, and improper administration methods observed for several residents. Errors included a nurse aide failing to give ordered meds, another aide giving the wrong quantity of Eliquis and not following chewable instructions, and an LVN not fully delivering crushed meds via PEG tube. The DON stated staff should read the MAR and blister packs before giving meds and follow physician orders.
Significant medication errors occurred for two residents. One resident received carvedilol before breakfast even though the order required it with meals, and the MA stated she had not read the blister packet. Another resident with a PEG tube received crushed lisinopril that was not fully removed from the medication cup during administration, and the LVN used a syringe to stir and push the medication through the G tube, with medication left behind in the cup.
Missing Diagnostic and Lab Results in Resident Records: The facility failed to file lab and diagnostic reports in the clinical records for two residents. One resident with cancer-related diagnoses had a CBC/CMP result missing from the EMR, and another resident with DM, CHF, CAD, and other chronic conditions had multiple lab results not uploaded to the EMR despite active orders and care plan directions to monitor labs and diagnostic work.
Improper Administration of G-Tube Medications: A resident with a PEG tube, severe cognitive impairment, and multiple chronic conditions had orders for meds to be given via PEG with flushes before, between, and after administration. An LVN crushed the meds, mixed them in water, and administered them by plunging with a syringe through the G tube instead of by gravity, leaving medication in the cups; the LVN said she had not received facility training, and the DON stated G tube meds were expected to be given by gravity unless otherwise ordered.
Medication Cart Storage and Labeling Deficiency: Nurse Cart A had multiple open medications that were not labeled with names or open dates, including eye drops and ophthalmic solution. An LVN stated opened medications should be dated, while the DON stated nurses were not supposed to date ointments, despite the facility policy requiring medication labeling to follow accepted pharmaceutical principles and include an expiration date when applicable.
A resident with CKD, Parkinson's disease, ASHD, HTN, and severe cognitive impairment had ordered CBC, CMP, TSH, BMP, and CBC labs collected later than ordered. The BMP and CBC results showed critically high sodium and BUN levels. The DON stated the weekend timing contributed to the delay and that lab results should have transferred automatically from the portal to the resident's chart.
Expired food was found in the dry storage room when the surveyor and DM observed 5 boxes of angel hair spaghetti with a best if used by date that had passed. The DM discarded the boxes and stated they should have been thrown out, while the Administrator said food should be discarded to avoid residents getting expired food that could get them sick. The facility policy reviewed did not specifically address expired food.
Hand Hygiene Not Performed Between Glove Changes During Incontinent Care: A CNA providing incontinent and Foley catheter care for a resident with an indwelling catheter changed gloves multiple times without washing hands or using hand sanitizer between glove changes. The resident was totally dependent for toileting and had diagnoses including acute osteomyelitis, cognitive communication deficit, obstructive and reflux uropathy, and a history of stroke. The CNA acknowledged the missed hand hygiene, and the DON stated staff should perform hand hygiene with each glove change and before donning clean gloves.
Dumpster Door Left Open: The facility failed to keep the dumpster door closed for its only dumpster reviewed. A DM observed the metal dumpster door partially open with cardboard containers inside, and the Administrator later stated the dumpster should be closed to prevent residents from going in there and to keep the environment clean. The facility policy stated dumpster lids must remain closed at all times to prevent pests and odors.
A resident with ALS did not receive scheduled showers or bed baths, leading to poor hygiene and hospital admission with wounds and cerumen impaction. Despite being dependent on staff for all ADLs, there was no documentation of care provided, and family members expressed concerns about the handling of the resident's BIPAP mask. Facility staff acknowledged the lack of documentation and care, which was deemed unacceptable by the DON and Administrator.
A resident with a DNR order was given CPR due to a documentation error in their electronic medical record. The DNR form was placed in a separate Hospice binder instead of being uploaded to the electronic record, leading to CPR being administered during an emergency. The facility's policy requires advance directives to be prominently displayed in the medical record, which was not followed.
A facility failed to maintain a clean and safe environment for three residents. A resident's shower had dried fecal matter and a urine odor, another resident's room was cluttered with clothes and shoes, and a third resident's room had a strong urine odor. These deficiencies were observed despite the residents' care plans requiring staff assistance for daily living activities. Interviews with staff confirmed the issues, indicating a lack of adherence to facility standards.
The facility failed to provide necessary hygiene care for two residents who were unable to perform activities of daily living. One resident, with multiple medical conditions, was found with a wet adult brief and a urine smell, indicating a lack of timely care. Another resident, with severe cognitive impairment, did not receive scheduled showers, as evidenced by limited documentation and a strong urine odor in the room. Staff interviews revealed inconsistencies in performing these tasks, which were acknowledged by the DON.
Failure to Provide Scheduled Showers and Document Bathing
Penalty
Summary
The facility failed to treat residents with respect and dignity by not providing showers to Resident #37 and 3 of 3 confidential group residents. Resident #37 was an older female with diagnoses including rotator cuff tear or rupture, non-Hodgkin lymphoma, muscle wasting and atrophy, generalized muscle weakness, cellulitis of the left lower limb, an open wound of the left lower leg, a displaced fracture of the distal pole of the navicular/scaphoid bone of the right wrist, and pain in the joints of the right hand. Her care plan did not reflect any ADL care needs, and the MDS record was requested but not received. Record review showed that for September 2025, Resident #37's bathing record indicated that full-body bathing activity did not occur on multiple scheduled dates. During observation and interview, the resident stated it had been 9 days since her last shower or bed bath even though she had scheduled shower days on Tuesday, Thursday, and Saturday, and her hair was observed to be oily. Family A stated the resident had not been offered a shower or bed bath and reported that when the resident asked staff when she could receive a shower, staff responded with a nasty attitude. The resident later stated she received a shower on 10/04/2025 and felt good. No shower sheets were recorded for September. During a confidential group meeting, 3 of 6 residents stated showers were not being offered or provided on 3 days a week. One resident stated she had not received a shower in 10 days after asking 3 staff members on 3 occasions, and she became tearful while saying it was inhumane to deny a shower. Another resident stated he often refused showers to keep his dialysis port dry, while a third resident stated shower days were inconsistent and that he was told he would only be offered one shower a week. Facility leadership stated one resident refused showers because of the dialysis port and that wrap coverage was available, while the DON also stated nurses were responsible for signing off on shower sheets and CNAs were to update the POC and shower sheets on every shower day. Review of logged shower sheets showed one resident had only one sheet for the month, another had three sheets with two dated the same day by different staff, and the third had no logged shower sheets for the month. A policy on showers was requested but not received.
Missed Scheduled Showers and Inconsistent Bath Documentation
Penalty
Summary
The facility failed to ensure residents who were unable to complete activities of daily living received needed bathing assistance to maintain personal hygiene. For Resident #37, the record showed diagnoses including rotator cuff tear, hypertension, hyperlipidemia, osteoporosis, acute respiratory failure with hypoxia, sepsis, hypotension, elevated white blood cell count, non-Hodgkin lymphoma, muscle wasting and atrophy, and muscle weakness. The resident’s care plan did not reflect ADL care needs, and the MDS record was not provided. Record review showed that Resident #37’s POC response history documented that bathing did not occur on multiple scheduled shower days in September 2025. On observation and interview, the resident stated she had not had a shower or bed bath in 9 days, said her shower days were Tuesday, Thursday, and Saturday, and stated she wanted showers and/or bed baths when scheduled and her bedding changed. Family also stated the resident had not had a shower or bed bath and had to ask for clothes to wipe her face. On later interview, the resident stated she finally received a shower and felt very happy. During a confidential group meeting, 3 of 6 residents stated they were not receiving scheduled showers or bed baths 3 times a week and were lucky to receive one shower a week. One resident stated she had gone 10 days after hospital discharge without a shower until staff finally provided one, another stated he avoided showers because of a dialysis port and would begin to smell foul, and another stated shower days changed and were not consistent. The DON stated CNAs were expected to document shower status in the POC and on shower sheets, and that if a resident refused, the charge nurse was responsible for circling back and encouraging the resident to accept the shower. Record review of shower sheets for the confidential residents showed one resident had no logged shower sheets for September 2025, one had three shower sheets with two dated the same day by different staff, and one had one shower sheet documenting a declined shower. The facility did not provide the shower policy when requested.
Failure to Provide Appropriate Catheter and Incontinence Care
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling suprapubic catheter and urinary incontinence when the resident’s groin and penile skin condition changed and the resident reported pain. The resident had diagnoses including acute osteomyelitis, cognitive communication deficit, obstructive and reflux uropathy, and a history of stroke. Records showed he was totally dependent for toileting and had a care plan and orders for catheter care, securement of the catheter to the leg, and skin monitoring. On observation, the catheter securement device was folded up and not secured, and the resident’s penis was red, raw, and split down the center, measuring 1.8 cm by 0.5 cm. The resident grimaced and said “ouch” when the catheter was moved. The resident’s records showed a prior note of blood in the catheter and briefs, but the weekly skin assessments did not document the penile split. The physician order for the penile wound care and triple antibiotic ointment was entered after the split was observed. Staff interviews reflected that the slit had been seen by nursing staff, but it was not documented as a trauma or skin issue at the time because it was believed to be healed. The ADON stated she saw the slit on a prior date but did not document it, and the DON stated she was not aware of the slit until later. The MD stated the slit was due to prolonged use of the indwelling catheter and did not know how long it had been present. The facility also failed to ensure infection control and catheter care practices were followed during incontinent and Foley care. During observation, CNA B did not change gloves and perform hand hygiene appropriately while providing care, and CNA B placed the Foley bag on the bed while repositioning the resident. The observation also showed CNA G and CNA H placing the Foley bag on the resident’s bed during Foley and incontinent care. Staff interviews confirmed that some aides knew the catheter should be secured, the bag kept below the bladder, and skin changes or bleeding reported to the nurse, but the observed care did not follow those practices.
Inaccurate resident weights and missed follow-up on significant weight loss
Penalty
Summary
The facility failed to ensure residents maintained acceptable nutritional status and failed to follow up on significant weight changes identified on 09/10/2025 for multiple residents, including a discharged resident and residents #7, #9, #10, #23, #29, and #42. The report states that 8 of 8 residents reviewed for weight loss had not maintained acceptable parameters of nutritional status, and that 3 of 3 scales used for weighing residents were not calibrated accurately. The facility also did not follow up appropriately when significant weight losses were discovered. Resident #10 had diagnoses including Parkinson’s disease, type 2 diabetes, CHF, and COPD. His care plan addressed dehydration risk related to diuretics and nutritional problems, with interventions for monitoring intake, hydration, and weight. His labs showed a low albumin level, and his weights varied widely across multiple dates, including a 6.8% loss within 4 days based on one set of weights. The dietary consultant later noted low albumin and recommended liquid protein and weekly weights. The attending MD stated the resident’s weights fluctuated and related this to fluid overload. Resident #37 had diagnoses including non-Hodgkin lymphoma, sepsis, hypotension, muscle wasting, weakness, cellulitis, and an open wound. Her care plan identified nutritional problems related to abnormal labs and included monitoring weight, intake, and signs of malnutrition and dysphagia. Her hospital discharge weight was 132.4 lbs, but facility weights later showed 153.0 lbs and then 156.4 lbs, and during observation she was weighed at 161.0 lbs. Staff interviews revealed concerns that the mechanical lift scale may have calibration issues and that the resident had not been weighed as expected. The resident and family stated they had not been informed that the lift was being used as a scale. Resident #9 had diagnoses including osteomyelitis, coronary artery disease, vertigo, diabetes, and hospice status. His care plan addressed nutritional problems, hydration, wound healing, and weight monitoring. The record showed major weight discrepancies, including a documented weight of 261 lbs, later 205 lbs, then 204 lbs, and finally a dietary record showing 180.6 lbs with a 30.8% loss from the earlier weight. The DON and ADON stated the sitting chair scale was off by 9 lbs, the mechanical scale appeared to round weights, and one CNA admitted entering a prior weight as the resident’s current weight without weighing him. The report also states the facility had not been monitoring residents for excessive weight loss or gain and that inaccurate weights could affect medication administration and care.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent. Surveyors identified 8 medication errors out of 36 opportunities, resulting in a 22 percent error rate, involving 3 staff members and 4 residents reviewed for medication administration. The errors included omitted medications, incorrect administration, and failure to follow ordered routes and directions. For one resident with multiple chronic conditions including weakness, failure to thrive, hypertension, chronic kidney disease, cognitive impairment, malnutrition, and osteoporosis, MA A did not administer Vitamin D and Carvedilol as ordered. During observation, MA A prepared Carvedilol labeled to be given with meals even though the resident was not eating breakfast and had not yet been fed. MA A stated she did not read the blister packet instructions. For another resident with diagnoses including gout, hypothyroidism, a pacemaker, polyneuropathy, gait impairment, and cognitive communication deficit, MA A did not administer Ferrous Sulfate even though the MAR showed it as given. MA A later stated it was an oversight. For a third resident with asthma, atrial fibrillation, hypertension, hyperlipidemia, pneumonia, sepsis, and other significant conditions, MA B did not administer cetirizine Hydrochloride, Simethicone, and Eliquis as ordered. MA B also punched out 2 Eliquis tablets instead of 1 and administered Simethicone without following the chewable instruction. MA B stated she knew Eliquis could cause bleeding if given wrongly and said she had not received training at the facility. For a fourth resident with Alzheimer’s disease, severe protein-calorie malnutrition, hypertension, COPD, a gastrostomy tube, diabetes, and GERD, LVN R crushed Lisinopril and Sennosides for PEG-tube administration but did not ensure all medication was delivered from the cup. LVN R used a syringe to administer the medication and water through the G-tube, and the surveyor stopped her when medication remained in the cup. LVN R stated she was supposed to rinse the cups and said she had not received training at the facility. The DON stated staff should read the MAR and blister packets before administration and that medications should be given as ordered.
Significant Medication Errors During Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors for 2 of 5 residents reviewed for pharmacy services. One resident, a 93-year-old female with diagnoses including essential hypertension, chronic kidney disease stage 3, weakness, malnutrition, cognitive communication deficit, and severe cognitive impairment with a BIMS score of 5, had an order for Carvedilol 25 mg by mouth twice daily with meals and to hold for SBP under 110 or HR under 60. During observation, MA A prepared and administered the Carvedilol at 8:00 AM before the resident had breakfast, and the resident had not yet been fed. During interview, MA A stated the resident had not yet eaten and that staff would be coming soon to feed her. When shown the blister packet indicating the medication was to be given with meals, MA A stated she did not read that and apologized. The record review showed the medication order required administration with meals, and the observed administration occurred before the meal was provided. A second resident, a 73-year-old male with Alzheimer’s disease, severe protein-calorie malnutrition, hypertension, COPD, diabetes, and a PEG tube, had an order for Lisinopril 20 mg via PEG tube daily for HTN. During observation, LVN R crushed the tablet, poured it into a medication cup, diluted it with water, and did not ensure all of the medication was removed from the cup during administration. She used a syringe to stir, aspirated the medication, and administered it via G tube, then aspirated additional water and administered that as well. The surveyor observed medication remaining in the cup before it was discarded. In interview, LVN R stated she was supposed to rinse the medication cups and was going to rinse them and push the water and medication via G tube. The DON stated staff should read the MAR and blister packet before medication administration and that G tube medications should be given as ordered by gravity unless the doctor ordered them to be pushed.
Missing Diagnostic and Lab Results in Resident Records
Penalty
Summary
The facility failed to file signed and dated reports of x-rays and other diagnostic services in the clinical records for 2 of 8 residents reviewed. Resident #3, an older male with diagnoses including cerebral infarction, dysphagia, acute myeloblastic leukemia not having achieved remission, multiple myeloma, and immunodeficiency, had an active order for CBC and CMP related to multiple myeloma dated 09/14/2025, but the lab result was not uploaded to his electronic medical record when reviewed on 10/08/2025. His care plan included chemotherapy treatment and education on the importance of routine laboratory monitoring. Resident #4, an older male with diagnoses including muscle weakness, diabetes mellitus, hyperlipidemia, hypertension, atherosclerotic heart disease, atrial fibrillation, and heart failure, had multiple active lab orders related to diabetes, a sacral ulcer, and CHF. Record review on 10/07/2025 showed that lab results ordered on 02/08/2025, 03/16/2025, 03/18/2025, and 04/11/2025 were not uploaded to his electronic medical record. His care plan included monitoring lab and diagnostic work as ordered, monitoring cholesterol levels, and fasting serum blood sugar as ordered by the doctor.
Improper Administration of G-Tube Medications
Penalty
Summary
Resident #18, a [AGE]-year-old male admitted to the facility with diagnoses including Alzheimer's disease with late onset, severe protein-calorie malnutrition, hypertension, hyperlipidemia, COPD, a gastrostomy tube, diabetes mellitus with hypoglycemia, and GERD, had a physician order for NPO status with medications to be given via PEG tube and flushed before, between, and after administration. His quarterly MDS showed severe cognitive impairment and extensive assistance needs for ADLs. The physician's orders included Lisinopril 20 mg via PEG tube daily and Sennosides 8.6 mg via PEG tube twice daily, and the MAR reflected those medications as ordered via PEG tube. During observation on 10/1/25, LVN R crushed the Lisinopril and Sennosides, diluted them in water, and used a 60 cc syringe tip to stir the mixture before aspirating it and plunging it through the G tube. She then aspirated 30 cc of water and plunged it via the G tube, and was about to discard the medication cups when the surveyor stopped her and showed her medication remained in the cups. In interview, LVN R stated she was supposed to rinse the medication cups and said she was working through a nursing agency and had not received training at the facility. The DON stated nursing staff were expected to give G tube medications by gravity unless the physician ordered them to be pushed or plunged.
Medication Cart Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely for one of three medication carts reviewed, Nurse Cart A. During observation of the cart on 10/02/2025 at 12:40 PM, multiple medications were found open, with no names and no open dates written on them. The medications observed included Dozolamide Hydrochloride 2% -0.5%, Artificial tears lubricant eye drops, and Latanoprost ophthalmic solution. During interviews, LVN R stated on 10/01/25 at 1:27 PM that medications were supposed to have an open date when opened because she did not want to keep them forever. In a later interview on 10/1/25 at 1:48 PM, LVN R said she always checked the medication cart when she worked and would place an open date on medications to ensure therapeutic effectiveness, and that she would notify the ADON about medications that were not dated. On 10/4/25 at 2:30 PM, the DON stated the nurses were not supposed to date the ointments, even though the DON was told that most of the ointments and gels on the nurse's medication carts had open dates on them. The facility policy on Medication Labeling and Storage, revised in 2001, stated that medication labeling must be consistent with applicable federal and state requirements and currently accepted pharmaceutical principles, and that the medication label includes an expiration date when applicable.
Delayed Laboratory Testing and Result Transfer
Penalty
Summary
The facility failed to obtain laboratory services in a timely manner for Resident #5, who had diagnoses including chronic kidney disease, Parkinson's disease, atherosclerotic heart disease, and hypertension, and whose PPS MDS reflected severe cognitive impairment. Record review showed lab orders entered on 07/31/2025 for CBC, CMP, and TSH with a diagnosis of stroke, and another set of orders entered on 08/09/2025 for BMP and CBC with a diagnosis of anorexia. The resident's lab collection dates did not match the order dates: the 07/31/2025 orders were collected on 08/04/2025, and the 08/09/2025 orders were collected on 08/12/2025. Review of the BMP and CBC collected on 08/12/2025 showed critically high sodium of 160 mmol/L and BUN of 93 mg/dL. During interview, the DON stated the 08/09/2025 lab orders were placed on a weekend and, because they were routine and not critical, it took time for the labs to be completed. The DON also stated the results should have automatically transferred from the lab portal to the resident's medical chart and that she had contacted the portal company to investigate why the results did not transfer over.
Expired Food Found in Dry Storage
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in its only kitchen reviewed for food safety requirements and kitchen sanitation. During observation, the surveyor and the DM found 5 boxes of angel hair spaghetti in the dry storage room with a best if used by date of 01/29/2025. The DM removed the boxes and discarded them in the main kitchen trash. During interview, the DM stated the boxes should have been thrown out, explained that best if used by referred to food quality or peak, and said he had posted reminders for staff to throw out expired food because everyone was responsible for checking for expired food. The Administrator later stated that food should be discarded to ensure residents were not getting expired food that could get them sick and that the dietary manager was responsible for discarding expired food items. Record review of the facility's Environmental Services policy with an effective date of 09/30/2025 did not include specific mention of expired food.
Hand Hygiene Not Performed Between Glove Changes During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for one resident and one staff member reviewed for infection control. During observation of incontinent and Foley catheter care for a resident with diagnoses including acute osteomyelitis, cognitive communication deficit, obstructive and reflux uropathy, and a history of stroke, CNA A washed her hands and donned clean gloves, but then changed gloves three times without washing her hands or using hand sanitizer between glove changes. The resident’s records showed he was totally dependent on staff for toileting, required substantial assistance with transfers, and later had a care plan and orders for indwelling catheter care, catheter securement, and skin assessment. During interview, CNA A stated she forgot to wash her hands or use hand sanitizer and acknowledged that failing to do so after handling dirty gloves could result in reinfecting the resident. The DON stated that staff should wash their hands or use hand sanitizer with each glove change during incontinent care and that cross contamination could occur if hands were not cleaned before donning clean gloves. The DON also stated the expectation was for hand hygiene to be performed prior to donning clean gloves, and the facility policy on Handwashing/Hand Hygiene stated to perform hand hygiene before applying non-sterile gloves.
Dumpster Door Left Open
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for its only dumpster reviewed for garbage disposal because the dumpster door was left a quarter of the way open. During observation and interview with the DM, the metal dumpster door was seen open with some cardboard containers inside the dumpster, and the DM stated it was not supposed to be open and fully closed it, causing the trash to compress. The DM also stated the door should be closed to maintain a clean area. During interview with the Administrator and DON, the Administrator stated the dumpster should be closed to prevent residents from going in there and to keep the environment clean, and said pests could go into the dumpster and bring pests into the facility. The facility policy on Environmental Services, including Dumpster management, stated that lids must remain closed at all times to prevent pests and odors.
Failure to Provide Adequate ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident diagnosed with Amyotrophic Lateral Sclerosis, who was dependent on staff for all ADLs, including personal hygiene. The resident did not receive scheduled showers or bed baths for a significant period, as documented between late August and late September. Despite being scheduled for showers three times a week, there was no documentation to support that these were provided, and the resident was found to have poor hygiene upon hospital admission. The resident was admitted to the hospital with a dislodged G-tube and was diagnosed with aspiration pneumonia. Upon examination, the resident was noted to have wounds on the nose, ears, and hands, as well as cerumen impaction, indicating poor hygiene. Interviews with family members revealed concerns about the resident's care, particularly regarding the handling of the resident's BIPAP mask and the roughness of staff during care, which contributed to the resident's refusal of some bed baths. Interviews with facility staff indicated a lack of consistent documentation and communication regarding the resident's care refusals and hygiene needs. The facility's Director of Nursing and Administrator acknowledged the deficiencies in care and documentation, noting that the lack of proper hygiene and documentation was unacceptable. The facility's policy on giving bed baths was not followed, as evidenced by the absence of documentation and the resident's condition upon hospital admission.
Failure to Honor DNR Order Due to Documentation Error
Penalty
Summary
The facility failed to ensure that personnel provided basic life support, including CPR, in accordance with physician orders and the resident's advance directives. A resident with metastatic cholangiocarcinoma, who was receiving hospice services and required total assistance for ADLs, was admitted with a physician-signed DNR order. However, this DNR order was not documented in the resident's electronic medical record. During an emergency situation, the resident was found unresponsive, and CPR was initiated by RN B, as the DNR status was not visible in the electronic record. Paramedics continued CPR upon arrival until the DNR form was found in the Hospice binder, at which point CPR was stopped. The incident revealed a breakdown in the facility's procedure for handling advance directives. The DNR form, brought in by the resident's family, was placed in a separate Hospice binder instead of being uploaded to the electronic medical record. The Director of Nursing (DON) acknowledged that the failure to document the DNR status in the electronic record could lead to residents not having their end-of-life preferences honored. The facility's policy on advance directives requires that such information be prominently displayed in the medical record, which was not adhered to in this case.
Facility Fails to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for three residents, as observed during a survey. Resident #1's shower was found to have dried fecal matter on the floor and wall, and a urine odor was present. This resident, who has a history of heart failure, Alzheimer's disease, type 2 diabetes, and essential hypertension, requires assistance with activities of daily living, including bathing and toileting. The care plan indicated that the resident is dependent on staff for these tasks, yet the shower area was not maintained in a sanitary condition. Resident #2's room was observed to be cluttered with a bag of clothes and shoes on the floor. This resident, who has a diagnosis of malignant neoplasm of connective tissue and gait abnormalities, expressed that she was unable to manage housework and had requested assistance to organize her belongings. Despite this, the clutter remained, indicating a lack of attention to her needs for a clean and organized living space. Resident #3's room was noted to have a strong urine odor during multiple observations. This resident, with a history of acute cerebrovascular insufficiency, cognitive communication deficit, sepsis, and acute respiratory failure, has a care plan that includes regular checks for incontinence. However, the persistent odor suggests that these checks and necessary interventions were not adequately performed. Interviews with staff, including the DON and the facility administrator, confirmed the issues and highlighted a reliance on agency staff who may not have been fulfilling their responsibilities effectively.
Failure to Provide Adequate Hygiene Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living, specifically in maintaining good nutrition, grooming, and personal and oral hygiene. Resident #1, a [AGE] year-old with diagnoses including heart failure, Alzheimer's disease, type 2 diabetes, and essential hypertension, was observed to have a urine smell and a wet adult brief that was not changed in a timely manner. Despite being dependent on staff for toileting hygiene and frequently incontinent, the resident's brief was not checked or changed as needed, as confirmed by observations and interviews with the resident's responsible party. Resident #3, an [AGE] year-old with severe cognitive impairment and other medical conditions, was also not provided with scheduled showers, as evidenced by the limited documentation of showers in the electronic medical record. The resident's room had a strong urine odor, indicating a lack of proper hygiene care. Interviews with staff, including a contract nurse and a CNA, revealed that CNAs were responsible for changing briefs and providing showers, but these tasks were not consistently performed. The DON acknowledged the issue and noted that it was both the nurses' and CNAs' responsibility to ensure residents received appropriate care.
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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.
Illustrative
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Illustrative
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Terrace Healthcare Center Of Houston | 0.7 mi | ★★★★★ | 8 | 1 |
| The Methodist Hospital Snf | 1.8 mi | ★★★★★ | 0 | 0 |
| Bayou Manor | 2.6 mi | ★★★★★ | 4 | 0 |
| Avir At Orem | 4.3 mi | ★★★★★ | 1 | 0 |
| Paradigm At Westbury | 4.6 mi | ★★★★★ | 18 | 1 |
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