Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Hollymead during CMS and state inspections, most recent first.
A resident with Huntington’s disease, multiple prior falls, and recent hospice enrollment experienced an unwitnessed nighttime fall resulting in facial bruising, a facial skin tear, an abrasion to the back of the head, and arm bruising. Staff later observed the injuries, initiated neuro checks, and obtained a facial bone x-ray, but the attending MD reported he was not notified of this fall or the resident’s recent pneumonia, and the NP stated she was only sent the x-ray result without being told a fall had occurred or that there was a head abrasion. Family and a private caregiver reported that the back-of-head injury was first identified by the caregiver, not facility staff. Despite facility policies requiring prompt MD notification for significant changes in condition and falls with major injury, surveyors found that the facility did not immediately and fully inform the physician and NP of the fall, the pneumonia diagnosis, or the full extent of the resident’s injuries, potentially limiting the providers’ ability to direct care.
A CNA preparing a snack for a resident with Huntington's disease and multiple comorbidities placed an unpackaged cookie on a plate and then picked up wrapped chocolate candies from the floor and put them on the same plate, thereby contaminating the cookie. The CNA later acknowledged this created a contamination risk and that the resident could get sick. Another CNA reported she would not give food picked up from the floor to residents and referenced prior infection control in-servicing. The DON confirmed awareness of the incident and acknowledged it was an infection control problem, while facility policy stated that all staff must follow infection prevention and control procedures based on accepted standards.
Multiple residents did not have comprehensive, person-centered care plans addressing their specific medical, nursing, and psychosocial needs, including conditions such as ADHD, diabetes with insulin dependence, ADL dependence, and fall risk. Staff interviews and record reviews confirmed that care plans were missing, incomplete, or not updated in a timely manner, resulting in the potential for unmet care needs.
Several residents dependent on staff for ADL care were found with excessively long, dirty, and untrimmed fingernails, despite facility policies and care plans requiring regular nail care. Staff interviews revealed inconsistent understanding of responsibilities, and some staff admitted to not noticing or addressing the issue. Care plans often lacked specific interventions for personal hygiene, resulting in unmet needs for grooming and hygiene among residents.
A resident with a history of stroke and hemiplegia, who had a contracture in her left hand, did not receive consistent application of prescribed splints or range of motion interventions. Staff were unaware of the care plan requirements, and necessary tasks were not included on CNA task lists. Documentation of splint use and restorative care was lacking, resulting in a failure to provide appropriate treatment and services to prevent further decline in the resident's range of motion.
Nursing staff failed to ensure the secure storage and proper handling of controlled medications, as multiple blister packs containing tramadol tablets were found with broken seals and pills still inside, including one instance where a broken blister was taped over. Staff did not consistently check blister pack integrity during narcotic counts, and the facility's policy requiring the discarding of medications from broken blisters was not followed.
Surveyors found that a packet of frozen pork and vegetable eggrolls was stored in the kitchen freezer without proper covering, labeling, or dating, contrary to facility policy and FDA Food Code. Staff interviews confirmed that all kitchen staff were responsible for ensuring food items were covered and labeled, and acknowledged the risks of cross-contamination and foodborne illness from such lapses.
Two residents did not have required physician orders for immediate care needs, including oxygen therapy and colostomy care, despite receiving these treatments. Staff interviews and record reviews confirmed that orders were missing from the medical record, and facility policy requires such orders for all treatments.
Two residents did not have their current conditions and diagnoses accurately reflected in their MDS assessments, including a missing colostomy status and an omitted ADHD diagnosis, despite supporting documentation and staff awareness. Staff interviews revealed the omissions were not identified during assessment completion, and a transition to a new electronic health record system may have contributed to the errors.
A CNA failed to use a gait belt while transferring a resident with severe cognitive impairment and mobility issues, instead lifting the resident by her clothes and under her arms, causing the resident pain. This action was not in accordance with the resident's care plan or facility policy, both of which required the use of a gait belt for transfers.
A resident with a suprapubic catheter and bowel incontinence did not receive proper perineal and catheter care, as a CNA failed to clean under skin folds, separate the labia, or clean around the catheter site, and an RN did not maintain sterile technique during catheter reinsertion, allowing urine to drain onto the resident's side. These actions did not follow facility policies and increased the risk of infection.
Staff failed to follow infection control protocols for two residents, including not wearing required PPE during catheter care for a resident with an indwelling device and not performing proper glove changes and hand hygiene during incontinence care for another resident. These lapses were observed during direct care and confirmed through staff interviews and policy review.
A resident with multiple health conditions was administered the wrong G-tube formula, Fibersource HN 1.2, instead of the prescribed Isosource 1.5, due to a nurse's failure to verify the physician's order. This error could lead to inadequate nutrition as the resident is NPO and fully dependent on the G-tube for nutrition.
A resident with a G-tube under Enhanced Barrier Precautions (EBP) did not receive proper infection control measures when an LVN failed to don a gown while administering G-tube feeding. Despite EBP signage and facility policy requiring gowns and gloves for high-contact care, the LVN only wore gloves. The DON confirmed the policy and the necessity of PPE to prevent infections.
A resident with a history of metabolic encephalopathy, vascular dementia, and multiple fractures experienced severe pain during repositioning, which was not adequately managed by the facility. Despite having a care plan for pain management, there were gaps in documentation and assessment, leading to unrelieved pain. Staff interviews revealed inconsistent communication and documentation, resulting in the resident's pain being unaddressed until a hospital evaluation identified a right subcapital hip fracture.
A facility failed to maintain a resident's dignity by allowing a caregiver to stand over the resident while assisting with a meal. The resident, who had multiple medical conditions and required extensive assistance, was observed being fed by a caregiver standing at her bedside. The DON and Administrator were unaware of this practice, and the facility lacked a specific policy on feeding residents, despite having a policy on treating residents with respect and dignity.
A resident requiring extensive assistance with personal hygiene was found with unclean and untrimmed fingernails, despite facility policies stating that nail care is part of the bathing process. Interviews revealed that CNAs were responsible for nail care unless the resident was diabetic, highlighting a lapse in adherence to care protocols.
A resident with COPD was found with unlabeled and undated nasal cannula tubing, contrary to physician orders and care plan requirements. An LVN admitted to changing the tubing without labeling it due to time constraints and did not document the change in the MAR. The DON and Nursing Manager acknowledged the risk of infection control issues due to the lack of proper labeling, although no formal policy was in place.
A resident with moderately impaired cognition and wrist concerns was not provided a divided plate as ordered, affecting her ability to eat independently. Despite the physician's order and the resident's expressed need, the facility failed to ensure the adaptive device was available, leading to the resident consuming only a portion of her meal. Staff interviews revealed a lack of communication and adherence to the facility's policy on providing necessary adaptive equipment.
A facility failed to maintain an infection control program when two CNAs did not perform proper hand hygiene while providing care to a resident with severe cognitive impairment and hemiplegia. The CNAs did not change gloves or perform hand hygiene between tasks, despite being aware of the protocols. The DON confirmed the expectation for hand hygiene to prevent infection spread.
A resident in an LTC facility missed two doses of Hydromorphone due to the facility's failure to have the medication available. Despite the resident's multiple diagnoses and need for pain management, the medication was not administered as scheduled. Staff interviews revealed communication issues and a lack of a medication refill policy, contributing to the oversight.
The facility failed to maintain the personal hygiene of a resident who required maximal assistance with ADLs. The resident was observed with long, dirty fingernails, and staff interviews revealed a lack of awareness and communication regarding nail care responsibilities.
Failure to Immediately Notify Physician of Fall, Pneumonia, and Extent of Injuries
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with the resident’s physician regarding an accident with injury and significant changes in condition for one resident. The resident was an older woman with Huntington’s disease, bipolar disorder, mild cognitive impairment, major depressive disorder, gait and mobility abnormalities, and lack of coordination. She had a documented history of multiple falls, including a prior fall with major injury to the right clavicle and a fall in December 2025 associated with a brain bleed and need for stitches. She had recently been admitted to hospice for terminal Huntington’s disease and had also been hospitalized for pneumonia shortly before the events described. Video review showed that on 04/02/2026 at 12:42 a.m., the resident walked from her bathroom toward her bed, turned with her back to the bed, and appeared to intentionally lean back to sit or fall into the bed but missed and fell backward to the floor. A lounge chair in the room made it unclear whether she struck her head on the floor or wall, but her body motion made it appear she most likely hit her head. The resident struggled to get up, and the video did not show when she eventually got herself back into bed. Later that morning, staff observed bruising on her face and, upon further assessment, identified multiple injuries including facial bruising, a facial skin tear, an abrasion to the back of the head, and bruising to the right upper arm. The resident reported headache-like pain, and neuro checks were initiated with results documented as intact. An x-ray of the facial bones was ordered and completed, showing no acute fracture or dislocation. Interviews and record review showed gaps and delays in physician notification and incomplete communication of the extent of the resident’s injuries and recent clinical events. The incident report listed that the physician/NP/PA was notified on the morning of 04/02/2026, but the attending MD later stated he was not notified of the fall on that date and was also unaware that the resident had recently had pneumonia. The NP who regularly followed the resident reported that she was not called about the fall; she only became aware of it indirectly when someone sent her the facial x-ray result without explaining that a fall had occurred, and she was not informed of the abrasion to the back of the head. She also stated she had not been told about the resident’s recent pneumonia hospitalization or hospice enrollment. Family members and the private caregiver reported that the facility did not initially recognize or report the head injury at the back of the resident’s head and that this injury was first noticed and brought to staff’s attention by the private caregiver. The facility’s own policies required physician notification for significant changes in condition and for falls with major injury, but the survey findings showed that the physician was not immediately and fully consulted about the fall, the pneumonia diagnosis, and the full extent of the resident’s injuries. The facility’s Change of Condition policy required the licensed nurse to evaluate signs and symptoms, notify the physician of changes in condition, and document the date and time the physician and responsible party were notified, particularly for significant changes such as falls with major injury and infections. The Fall Prevention policy required that after any fall, staff assess the resident, complete a post-fall assessment and incident report, notify the physician and family, and document all assessments and actions. In this case, although some assessments and notifications occurred, the surveyors determined that the facility failed to ensure timely and complete physician notification of the fall on 04/02/2026, failed to notify the physician of the resident’s pneumonia diagnosis when she was hospitalized, and failed to notify the NP of the full extent of the injuries from the fall, including the head abrasion. This failure, as stated in the report, could result in physicians not being able to provide thorough care and could lead to negative or adverse outcomes to the resident’s health.
Failure to Prevent Cross Contamination of Resident Snack
Penalty
Summary
The deficiency involves a failure to prevent cross contamination of food during snack preparation for a resident. The resident was an older woman with Huntington's disease and other conditions including bipolar disorder, mild cognitive impairment, major depressive disorder, gait and mobility abnormalities, and lack of coordination. During an observation, the resident was unable to communicate strongly but could indicate she wanted a nurse. A CNA responded and set up a snack by placing an unpackaged cookie on a plate on the resident’s bedside table. The CNA then picked up wrapped chocolate candies from the resident’s floor and placed them on the same plate with the unpackaged cookie. In a subsequent interview, the CNA acknowledged that placing the wrapped candies from the floor onto the plate was a risk because the items were contaminated and recognized that she had contaminated the cookie by doing so. She stated she normally did not do that and expressed regret, noting the resident could get sick from the contamination. Another CNA stated she would not pick up food from the floor to give to residents and cited concerns about choking, chemical residue on the floor, and residents becoming sick, and indicated she had been in-serviced on infection control and proper protocols. The DON confirmed awareness of the incident, stated that an in-service on infection control had been done, and acknowledged it was a problem because germs from the floor could transfer. The facility’s Infection Prevention and Control Program policy indicated that all staff are responsible for following all policies and procedures related to the program, including prevention and control of infections based on accepted national standards and guidelines.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation. For one resident with a diagnosis of attention deficit hyperactivity disorder (ADHD), the care plan did not address this diagnosis, despite it being documented in psychological assessments and confirmed by both the resident and staff. Interviews with the Social Services Director, LVN, MDS Coordinator, and DON confirmed that the ADHD diagnosis was not included in the care plan due to a lack of entry in the electronic system and oversight during MDS look-back periods. Staff acknowledged the importance of care planning for all diagnoses to ensure resident needs are met. Another resident, who was dependent on staff for activities of daily living (ADLs) including personal hygiene, did not have a care plan addressing ADL assistance or fingernail care. Observation revealed the resident's fingernails were excessively long, and the resident expressed a desire for staff assistance with nail care, which had not been provided. Staff interviews confirmed the resident's dependence and the absence of a care plan for these needs. Similarly, a resident with diabetes and insulin dependence did not have a care plan addressing these conditions, despite physician orders for insulin administration and severe cognitive impairment. Staff interviews highlighted the lack of tailored care planning for this resident's specific needs. Additionally, a resident with a history of multiple falls did not have timely updates to the care plan reflecting fall interventions after each incident. Although interventions were discussed and implemented immediately, the care plan was not updated promptly, particularly when falls occurred on weekends. Another resident with multiple complex diagnoses, including severe cognitive impairment and heart failure, had no comprehensive care plan initiated at all. Staff interviews consistently indicated that care plans are essential for guiding care and that the absence or delay in care planning could result in unmet resident needs.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for four residents who were unable to perform these tasks independently. Observations and interviews revealed that multiple residents had excessively long, dirty, and untrimmed fingernails, despite being dependent on staff for personal hygiene. In several cases, residents expressed dissatisfaction with the state of their nails and reported that staff had not offered or provided nail care. For example, one resident with hemiplegia and a history of stroke was found with nails up to 1.5 inches long and a brown/black substance under her nails, and she stated that her sister, not staff, last trimmed her nails. Staff interviews indicated confusion or lack of awareness regarding responsibility for nail care. Certified Nursing Assistants (CNAs) and nurses gave inconsistent accounts of who was responsible for trimming nails, with some stating it was done on shower days or as needed, and others indicating that restorative aides or the staffing coordinator were also responsible. In some cases, staff admitted they had not noticed the residents' nail conditions or had not reported refusals or missed care to supervisors. One staff member stated she assumed others would take care of nail trimming if she was unable to do so. Record reviews showed that care plans for some residents did not include specific interventions for personal hygiene or nail care, despite documentation of self-care deficits and the need for assistance. Facility policy required daily cleaning and regular trimming of nails to prevent infection, but this was not consistently implemented. The Director of Nursing and other staff acknowledged that assigned individuals were responsible for ensuring nails were kept clean and trimmed, but residents were still found with long, dirty nails during the survey.
Failure to Implement and Document Range of Motion Interventions for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to prevent further decline in her condition. The resident, a cognitively intact female with a history of stroke, hemiplegia, and diabetes, had a contracture in her left hand. Her care plan indicated the use of supportive devices such as splints as recommended by occupational therapy (OT), but there was no evidence that these interventions were consistently implemented. Documentation showed that the carrot splint was to be applied daily, yet there was no record of its application or refusal for a period of several days. Observations and interviews revealed that the resident's left hand was drawn up in a fist, and she was unable to open it. The splints intended for her use were found in her room but not in use, and the resident reported not having seen the splint in a while. Certified Nursing Assistants (CNAs) were unaware of the need to apply the splint or perform ROM exercises, and these tasks were not included on their task lists. The restorative aide also confirmed that the resident was not on her list for restorative care and had not documented any refusals or issues due to lack of access to the new electronic system. Further interviews with facility staff, including the MDS nurse, restorative aide, and Director of Rehabilitation (DOR), confirmed a lack of communication and documentation regarding the resident's restorative needs. The facility did not have a formal restorative program, and there was no specific restorative care plan in place for the resident. The failure to implement and document the prescribed interventions for the resident's contracture led to a deficiency in providing appropriate care to maintain or improve her range of motion.
Failure to Secure and Properly Handle Controlled Medications
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring the secure storage and handling of controlled medications on three medication carts. During observations, surveyors found that blister packs containing tramadol 50 mg tablets for three different residents had broken seals, with the pills still inside the damaged blisters. In one instance, a broken blister was taped over rather than properly discarded. Nursing staff, including LVNs and an RN, reported that while narcotic counts were performed at shift changes, they did not check the integrity of the blister packs during these counts and were unaware of when or how the seals were broken. The staff acknowledged that the correct procedure would be to discard any pills from broken blisters with another nurse present, but this was not consistently followed. The Director of Nursing (DON) confirmed that the facility's expectation was for any medication with a broken seal to be discarded and that it was unacceptable to keep pills in opened blister packs. The DON also stated that nurses were responsible for checking blister packs for broken seals during shift changes, and that the ADON and DON were to check carts weekly, with the pharmacy consultant auditing monthly. Facility policy required all drugs to be stored in a safe, secure, and orderly manner, and not to use deteriorated drugs, but these procedures were not adhered to in the cases observed.
Failure to Properly Store and Cover Food Items in Kitchen Freezer
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. Specifically, a packet of frozen pork and vegetable eggrolls was found loosely wrapped in a plastic bag and kept in an open cardboard box inside the walk-in freezer. This food item was not properly covered, labeled, or dated, as required by both facility policy and the Food and Drug Administration Food Code. Multiple staff interviews confirmed that it was the expectation and responsibility of all kitchen staff, including cooks, dietary aides, and the dietary manager, to ensure all food items were appropriately covered, labeled, and dated at all times. The facility's policy on food storage and the FDA Food Code both require that frozen foods be covered, labeled, and dated to prevent cross-contamination and maintain food safety. Staff interviews revealed a consistent understanding of these requirements and the risks associated with non-compliance, such as cross-contamination, freezer burn, and potential foodborne illness. The deficiency was identified through direct observation and confirmed by staff acknowledgment that the uncovered food item was not in compliance with established standards.
Failure to Obtain Physician Orders for Immediate Care Needs
Penalty
Summary
The facility failed to ensure that two residents had physician's orders for their immediate care needs upon admission, specifically regarding oxygen therapy and colostomy care. One resident, a female with diagnoses including morbid obesity, heart failure, acute and chronic respiratory failure with hypoxia, and pneumonia, was admitted with a need for oxygen. Despite being on 4 liters of oxygen via nasal cannula, there was no physician order for continuous or as-needed oxygen supplementation, nor for related care such as changing the cannula, tubing, or humidifier, or for assessing the resident’s nares. Multiple staff interviews confirmed that an order should have been present and that the absence of such orders was a deviation from facility policy and standard practice. Another resident, a male with heart failure, chronic kidney disease, and acute respiratory failure, had a colostomy appliance but did not have an active physician order for colostomy care upon readmission. Although the care plan noted the presence of a colostomy and staff reported changing the pouch daily, there was no corresponding physician order in the treatment administration record after a certain date. Staff interviews revealed that the omission was not noticed during the readmission process, and the DON acknowledged that a physician order for colostomy care should have been present and care planned. Facility policy reviews confirmed that all treatments, including oxygen administration and colostomy care, require a physician's order to be recorded in the medical record. The lack of such orders for these two residents was identified through observation, record review, and staff interviews, and was not in accordance with the facility’s own procedures for ensuring safe and appropriate care.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the current status and diagnoses of two residents. For one resident, the quarterly MDS completed after readmission did not indicate the presence of a colostomy, despite documentation in the care plan and previous MDS, as well as confirmation from the resident and staff that the colostomy appliance was in place and being managed. The MDS Coordinator acknowledged that the ostomy status should have been selected and was unsure why it was missed. For another resident, the quarterly MDS did not include a diagnosis of attention deficit hyperactivity disorder (ADHD), even though this diagnosis was documented in psychological assessments, the care plan, and confirmed by the resident, the Social Services Director, and the DON. The Social Services Director noted that the diagnosis should have been added to the electronic health record, and the MDS Coordinator confirmed it was not included in the MDS. The DON indicated that the omission may have occurred during a transition to a new electronic health record system and emphasized the responsibility of nursing and the MDS Coordinator to ensure accurate and updated diagnoses during admission and readmission. Interviews with staff and review of facility policy confirmed that comprehensive and accurate assessments are required at specified intervals. The failure to accurately code the colostomy and include the ADHD diagnosis in the MDS assessments resulted in incomplete documentation of the residents' needs and conditions.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use a gait belt while transferring a resident from her bed to a wheelchair. The resident, who had severe cognitive impairment and required maximal assistance with transfers due to weakness and abnormal gait, was instead lifted by her clothes and under her arms. During the transfer, the resident expressed pain, stating it hurt under her breasts. The resident's care plan specifically required the use of a gait belt and assistance of one staff member for all transfers to prevent injury. Observation confirmed that the CNA did not follow the care plan or facility policy, which mandates the use of a transfer belt for any patient needing assistance with transfers or ambulation. The CNA acknowledged awareness of the requirement and had received training on gait belt use. The facility's policy and the resident's care plan both documented the necessity of a gait belt for safe transfers, but this protocol was not followed during the observed incident.
Deficient Catheter and Perineal Care Leading to Infection Risk
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate catheter and perineal care to a female resident with a suprapubic catheter and frequent bowel incontinence. During incontinence care, the CNA did not separate the labia or clean under the resident's skin folds, nor did she clean around the suprapubic catheter insertion site, despite visible leakage and redness. The resident was found with a strong urine odor, saturated brief, and a large bowel movement, but the required cleaning steps to prevent infection were not followed. Additionally, a registered nurse (RN) did not maintain sterile technique while re-inserting the resident's suprapubic catheter. The RN failed to set up a sterile field before donning sterile gloves, removed the sterile gloves after cleaning the stoma, and then continued the catheter insertion using utility gloves. The catheter was inserted and connected to the drainage bag, but urine was allowed to drain onto the resident's side, requiring further cleaning. The resident involved was cognitively intact, dependent on staff for toileting, and had diagnoses including multiple sclerosis and neurogenic bladder. Physician orders and care plans required regular catheter care and monitoring for infection, but the observed care did not adhere to facility policies for perineal and catheter care, as confirmed by staff interviews and policy review.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program for two residents observed for infection control. For one resident with multiple sclerosis and a neurogenic bladder, who had an indwelling urinary catheter and was on Enhanced Barrier Precautions, a registered nurse did not use the required personal protective equipment (PPE) while changing the suprapubic catheter. Specifically, the nurse wore gloves but did not don a gown as required by the facility's Enhanced Barrier Precautions policy, despite signage and available PPE in the resident's room. The nurse acknowledged the oversight and confirmed understanding of the required precautions for residents with indwelling medical devices. In a separate incident, a certified nursing assistant (CNA) did not follow proper glove and hand hygiene protocols while providing incontinence care to another resident. The CNA changed gloves without performing hand hygiene and, at one point, used soiled gloves to place a clean brief under the resident. The CNA also assisted the resident with dressing and transferring without changing gloves or performing hand hygiene between tasks. The CNA later stated awareness of the correct procedures but did not realize the lapse during care. Both incidents were observed directly by surveyors and confirmed through interviews with the involved staff and the Director of Nursing. Facility policies on Enhanced Barrier Precautions, perineal care, and hand hygiene were reviewed and found to require the use of gowns and gloves for certain care activities and hand hygiene between glove changes, which were not followed in these cases.
Incorrect G-tube Formula Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was administered the correct G-tube feeding as ordered by the physician. The resident, an elderly male with a history of stroke, hypertension, diabetes, hyperlipidemia, anxiety disorder, depression, and malnutrition, was observed to have been given a different enteral formula than prescribed. The physician had ordered Isosource 1.5 Cal Oral Liquid to be administered via G-tube, but the nurse administered Fibersource HN 1.2 instead. This discrepancy was noted during an observation, and the nurse admitted to not verifying the physician's order before administering the formula. The nurse acknowledged that the incorrect formula was less calorically dense than the prescribed one, which could lead to inadequate nutrition for the resident, who was NPO and reliant on the G-tube for all nutritional needs. The Assistant Director of Nursing and the Director of Nursing both emphasized the importance of following physician orders to prevent complications such as weight loss and decreased nutrition. The facility had the correct formula in stock, indicating that the error was due to a failure in following protocol rather than a supply issue.
Infection Control Deficiency Due to Inadequate PPE Use
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of LVN A during the care of a resident requiring Enhanced Barrier Precautions (EBP). The resident, an elderly male with a history of stroke, hypertension, diabetes, hyperlipidemia, anxiety disorder, depression, and malnutrition, was observed to have a G-tube and was under EBP. Despite the presence of EBP signage on the resident's door, LVN A did not don the appropriate personal protective equipment (PPE) required for EBP, specifically a gown, while administering G-tube feeding. This oversight occurred despite LVN A's acknowledgment of the necessity of gowns and gloves for EBP to prevent infections. The Director of Nursing (DON) confirmed that the facility's policy required all direct care staff to follow EBP, which includes wearing gowns and gloves during high-contact resident care activities. The facility's policy on Enhanced Barrier Precautions, dated August 2020, specifies that gloves and gowns are to be applied prior to performing high-contact resident care activities, such as device care. The failure to adhere to these precautions was noted during the survey, and the facility was unable to provide competency skill checks for LVN A regarding EBP by the time of the survey exit.
Inadequate Pain Management for Resident with Multiple Fractures
Penalty
Summary
The facility failed to provide adequate pain management for a resident, leading to unnecessary pain and discomfort. The resident, a female with a history of metabolic encephalopathy, vascular dementia, and multiple fractures, was observed to be in severe pain during repositioning. Despite having a care plan that required staff to assess and manage her pain, the facility did not consistently document or address her pain levels, particularly during episodes of breakthrough pain. The resident's care plan included interventions for pain management, such as observing for behaviors indicating pain and administering scheduled pain medications. However, there were gaps in documentation and assessment, as evidenced by missing nurse notes on specific dates and inconsistent pain assessments. The resident was observed yelling in pain during repositioning, yet there was no documentation of PRN pain medication being administered on those occasions. Interviews with staff revealed a lack of consistent communication and documentation regarding the resident's pain. Caregivers reported the resident's pain to nurses, but there was no follow-up documentation or assessment noted. The Director of Nursing acknowledged the missing pain assessments and the lack of PRN medication documentation, indicating a failure to adhere to the facility's pain management policy. This oversight resulted in the resident experiencing unrelieved pain, which was later identified as a right subcapital hip fracture upon hospital evaluation.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring that staff did not stand over the resident while assisting with her meal. This incident involved a female resident with a diagnosis of metabolic encephalopathy, vascular dementia, low back pain, anorexia, fractures in the upper arm and forearm, and anxiety disorder. Despite having an intact cognition as indicated by a BIMS score of 13, the resident required extensive assistance with activities of daily living, including meals, due to impaired mobility and weight loss. On the date of the incident, a video observation showed a caregiver standing at the resident's bedside with one hand on her hip while feeding the resident. The Director of Nursing (DON) was unaware of this practice and acknowledged that the resident and staff should be at eye level during feeding. The facility's administrator also stated that there was no policy on feeding residents and expressed no major concerns about the caregiver's actions. The facility's policy on resident rights emphasized treating all residents with kindness, respect, and dignity, which was not adhered to in this instance.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. The deficiency was identified for a male resident who required extensive assistance with personal hygiene due to medical conditions including cerebral infarction and hemiplegia. Despite having an intact cognition as indicated by a BIMS score of 15, the resident's fingernails were observed to be unclean and untrimmed, with nails extending approximately 0.6 centimeters from the fingertips and discolored with dark brown residue underneath. Interviews with facility staff revealed that Certified Nursing Assistants (CNAs) were responsible for nail care unless the resident was diabetic, in which case licensed nurses would perform the task. The Director of Nursing (DON) stated that nail care should be provided as needed, particularly during shower times, and emphasized the resident's right to have clean and trimmed fingernails. The facility's policy indicated that nail care is part of the bathing process, yet this was not adhered to in the case of the resident, leading to the identified deficiency.
Failure to Label and Date Oxygen Tubing
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required continuous oxygen therapy. The resident, a female with a history of chronic obstructive pulmonary disease (COPD), diabetes mellitus, hyperlipidemia, and hypertension, was observed with nasal cannula tubing that was not labeled or dated. This oversight was contrary to the physician's order, which specified that oxygen tubing should be changed weekly and dated accordingly. The resident's comprehensive care plan also indicated the need for oxygen therapy to manage episodes of shortness of breath and prevent respiratory distress. Interviews with facility staff revealed that the nasal cannula tubing was changed by an LVN, who admitted to not labeling or dating the tubing due to being in a hurry. The LVN also failed to document the tubing change in the Medication Administration Record (MAR) because of uncertainty on how to do so. The Director of Nursing (DON) and the Nursing Manager both acknowledged the importance of dating the tubing to prevent infection control issues, although there was no formal facility policy in place for this procedure. The lack of proper labeling and documentation of the oxygen tubing change posed a risk of respiratory infections for the resident.
Failure to Provide Assistive Eating Device
Penalty
Summary
The facility failed to provide a resident with a divided plate, which was necessary for her to eat independently. The resident, a female with a history of hypertension, hyperlipidemia, hemiplegia, chronic obstructive pulmonary disorder, and respiratory failure, had a BIMS score indicating moderately impaired cognition. Despite being independent with suitable utensils, her physician had ordered a divided plate to be used every day, every shift. On a specific day, the resident was observed eating from a regular plate, which led to her consuming only a quarter of her meal before leaving the dining room. The resident expressed her preference and need for a divided plate due to wrist concerns, which had been in place for about a year. Interviews with facility staff revealed a breakdown in communication and procedure. The Regional Director of Nutrition Services expected kitchen staff to provide assistive devices as indicated on meal tickets, but was unaware of the specific needs of the resident. A cook acknowledged the divided plate was broken and replaced, but was not informed of the replacement. The Regional Director of Rehabilitation and the DON confirmed the necessity of the divided plate for the resident's independent feeding and dignity, noting the order was initiated by the nursing team. The facility's policy required adaptive equipment to be provided as ordered, but this was not adhered to in this instance.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of two CNAs during the care of a resident. The resident, a female with severe cognitive impairment and hemiplegia following a cerebral infarction, required extensive assistance with personal hygiene. During an observation, it was noted that the CNAs did not perform proper hand hygiene while providing incontinence care. Specifically, CNA D applied skin barrier cream and then handled a clean brief without changing gloves, while CNA E discarded soiled linen and assisted with dressing the resident without changing gloves. Both CNAs failed to perform hand hygiene between glove changes, which is a critical step in preventing the spread of infection. Interviews with the CNAs revealed that they were aware of the hand hygiene protocols but failed to adhere to them due to nervousness and forgetfulness. The Director of Nursing confirmed that the expectation was for staff to perform hand hygiene before and after care, and between glove changes, to prevent infection transmission. The facility's policy on hand hygiene, reviewed in August 2015, emphasized the importance of using an alcohol-based hand rub before moving from a contaminated body site to a clean one and after removing gloves.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in ensuring the availability of Hydromorphone, a medication used for pain management. The resident, a cognitively intact female with multiple diagnoses including pain, schizoaffective disorder, and heart failure, missed two doses of Hydromorphone due to the facility not having the medication available. The resident's medication administration record indicated that the doses scheduled for 12:00 AM and 8:00 AM on a specific date were not administered, as the medication was not available until later that evening. Interviews with facility staff revealed a lack of communication and coordination in managing the resident's medication needs. The Director of Nursing (DON) was unaware of the medication issue until the resident reported it. The Licensed Vocational Nurse (LVN) on duty during the missed doses was informed by the resident about the lack of medication and notified the physician, but the medication was not available until the evening. The Regional Nurse and the Vice President of Pharmacy Operations highlighted challenges with insurance restrictions and the need for timely reordering, but the facility did not have a policy in place to manage medication refills effectively. The physician confirmed that the prescription for Hydromorphone could not be refilled before a certain date due to insurance restrictions, and the medication was reordered as soon as possible. Despite the missed doses, the resident did not exhibit withdrawal symptoms or report severe pain, as she had access to OxyContin for pain management. The facility's lack of a medication ordering/refill policy contributed to the oversight, and staff interviews indicated a misunderstanding of responsibilities regarding medication reordering.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. The resident, an 89-year-old male with multiple diagnoses including cognitive communication deficit, heart failure, and dementia, required maximal assistance with personal hygiene, dressing, bathing, and toileting. Despite this, the resident was observed with fingernails that were roughly a quarter of an inch or longer, with dried brown and yellow matter under each nail. The resident could not recall when his nails were last trimmed and mentioned that he had scratched his scalp due to their length. Interviews with the resident's day shift nurse and aide revealed a lack of awareness and communication regarding the resident's nail care needs. The nurse stated that the aides were able to cut the resident's nails as he was not diabetic, while the aide believed that only the nurse was responsible for trimming the nails due to the resident's diabetic status. The Director of Nursing (DON) and the Executive Director (ED) both stated that it was the responsibility of the nursing staff to ensure residents' nails were clean, dry, and trimmed. The facility's policy on activities of daily living also emphasized the importance of providing appropriate care and services to maintain good grooming and personal hygiene for residents unable to carry out ADLs independently.
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.
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What surveyors actually found near you
We read the 1,045 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Flower Mound
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cross Timbers Rehabilitation And Healthcare Center | 0.6 mi | ★★★★★ | 17 | 1 |
| Rambling Oaks Courtyard Extensive Care Community | 2.5 mi | ★★★★★ | 17 | 0 |
| Lake Village Nursing And Rehabilitation Center | 3.8 mi | ★★★★★ | 14 | 0 |
| Vista Ridge Nursing & Rehabilitation Center | 6.6 mi | ★★★★★ | 13 | 0 |
| Avir At Grapevine | 6.8 mi | ★★★★★ | 11 | 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.