Below 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 Holly Manor Rehab And Nursing during CMS and state inspections, most recent first.
Facility staff did not resolve ongoing resident grievances about shortages of washcloths and towels, as documented in resident council meetings over several months. Multiple residents and staff reported delays in care, such as bathing and getting out of bed, due to insufficient linens. Observations confirmed low linen supplies, and repeated complaints were not effectively addressed, despite periodic linen orders and staff education.
A resident with schizophrenia received prn lorazepam without the physician documenting the intended duration of use, and staff failed to attempt or document non-pharmacological interventions before administering the medication, contrary to facility policy.
Nursing staff did not administer multiple medications within the required timeframes for four residents, resulting in significant delays for treatments addressing conditions such as pain, high blood pressure, allergies, and seizures. Facility policy and staff interviews confirmed that medications should be given within one hour of the scheduled time, but audit records showed repeated late administrations.
Staff did not provide or document required personal hygiene care, including mouth care and washing, for a resident unable to perform these activities independently on multiple shifts, as shown by missing entries in ADL records. Interviews confirmed that such care should be provided and documented each shift, in accordance with facility policy.
A resident experienced multiple significant medication errors, including the incorrect application of fluorouracil cream to the neck instead of the chest, repeated administration of Debrox ear drops into the eye rather than the ear, and late administration of Baclofen. These incidents were confirmed through interviews, clinical record review, and facility documentation, highlighting failures in following medication administration protocols.
Staff served pureed food that lacked flavor and was not palatable, as confirmed by the dietary manager, who stated that no seasoning was added in the kitchen and only salt and pepper packets were available for residents who could have them. No salt substitute was provided for those on salt-restricted diets unless brought by family.
Staff failed to maintain sanitary food preparation practices, including not fully covering facial hair while plating meals, not changing gloves after handling kitchen equipment before touching food, and serving chicken salad at an unsafe temperature to a resident. The dietary manager confirmed these actions did not meet required standards.
Facility staff did not inform a resident or their representative about the risks, benefits, or alternative treatments for lorazepam, an anti-anxiety medication, despite a physician's order for its use. Documentation and staff interviews confirmed that this required information was not provided, contrary to facility policy.
Facility staff failed to promptly notify a resident's representative when the resident experienced vomiting and was placed on contact precautions, and also did not notify a physician when another resident complained of neck pain and requested medical attention after a chemical burn. Despite facility policy requiring prompt notification of changes in condition, staff did not inform the appropriate parties in these cases.
A resident with severe cognitive impairment experienced a fall, and although the incident was documented and appropriate immediate actions were taken, staff failed to review or revise the resident's comprehensive care plan as required by facility policy. There was no documentation to show that the care plan was updated or reviewed following the fall.
A resident with respiratory failure was observed receiving oxygen via nasal cannula without a physician's order in place at the time of administration. The order for continuous oxygen was documented only after the resident had already begun receiving therapy, as confirmed by the unit manager.
On a day when only one nurse was present to care for 54 residents, multiple residents did not receive timely or complete medication administration due to staffing shortages. The nurse on duty contacted a nurse practitioner for guidance but was told to use her own judgment, resulting in medications being given late or omitted without individualized physician input or documentation.
On a day when only one nurse was present to care for 54 residents, several residents experienced delays in receiving their scheduled medications. Staff interviews confirmed that two nurses were required for the shift, but only one was available, leading to late administration of multiple medications for residents with complex medical needs.
Staff failed to include the facility name on daily nurse staffing sheets for three days, as required by facility policy. The scheduler responsible for posting the information was unaware of the requirement, and administrative staff were informed of the deficiency during the survey.
The facility staff failed to maintain sanitary garbage areas, as observed with an open trash compactor door and two open trash bin lids, allowing access to pests. Interviews with maintenance staff confirmed that these should be kept closed, in line with the facility's policy on food-related garbage disposal.
The facility failed to maintain a comprehensive infection control program and implement effective practices. The infection control program lacked a systematic surveillance system, relying only on Antibiotic Timeout forms, which were inadequate for tracking infections. Additionally, a nurse improperly handled medications by picking up a dropped pill with bare hands and administering it to a resident, contrary to proper infection control practices.
The facility staff failed to promote resident dignity for four residents. A resident was left in soiled clothing after vomiting, another waited 11 minutes for lunch while others at the table were served, a third was left in a wheelchair all night without assistance, and a fourth was told to void in her brief. These incidents highlight a lack of dignified care and service provision.
The facility failed to provide written notification of hospital transfers to residents, their representatives, and the Ombudsman for five residents. Transfers were due to urgent medical needs, but notifications were missed, partly due to staff absence. The facility's process for notifying the Ombudsman was not consistently followed.
The facility staff failed to implement comprehensive care plans for residents, leading to deficiencies in diabetes management, fluid restriction monitoring, anticoagulant therapy, and wound care. Residents experienced missed medication doses, inadequate assistance with activities of daily living, and incomplete documentation of care provided.
Facility staff failed to provide adequate ADL care for four residents, leading to deficiencies in their care. A resident was left in soiled clothing for hours after vomiting, while another had missing documentation for incontinence care. Two other residents experienced inadequate toileting and mobility assistance, with gaps in care documentation. These incidents highlight a pattern of inadequate care and documentation for dependent residents.
The facility staff failed to provide appropriate care and services for several residents, including missed medication doses, improper insulin administration, and lack of necessary assessments. These deficiencies reflect inadequate adherence to physician orders and documentation, impacting resident well-being.
The facility failed to provide adequate care for pressure injuries for three residents, leading to deficiencies in treatment. A resident under hospice care did not receive prescribed treatments, and family members reported concerns about repositioning and care. Another resident with an unstageable pressure ulcer did not have treatments documented over several months. A third resident with a skin tear did not receive prescribed wound treatments, as confirmed by an LPN. Documentation failures contributed to these deficiencies.
The facility staff failed to provide respiratory care services per physician orders for two residents. One resident with COPD did not receive required respiratory assessments, and another with obstructive sleep apnea did not have their CPAP mask cleaned as ordered. An LPN confirmed that professional standards were not followed when physician orders were not adhered to.
Two residents experienced inadequate pain management due to the facility's failure to adjust scheduled pain medication despite frequent use of as-needed opioids. Both residents reported high pain levels, and staff interviews revealed that the facility's pain management policy was not effectively implemented.
The facility failed to provide adequate dialysis care for five residents, including missed treatments, lack of communication with dialysis centers, and improper monitoring of fluid restrictions. Staff interviews revealed systemic issues in transportation arrangements, documentation, and communication processes.
The facility failed to provide adequate nursing staff during the night shift for two residents on multiple occasions. Despite the requirement for one licensed nurse and two CNAs, the unit was often staffed with only one CNA due to call-outs, affecting the care of residents with a census of 25 to 30. The staffing shortfall was confirmed by the staff scheduler and the DON, highlighting a breach in the facility's staffing policy.
Two residents in the facility were not properly administered and monitored for anticoagulant therapy. One resident experienced delays in receiving Enoxaparin injections, while another was not monitored for adverse reactions to Apixaban, despite being severely cognitively impaired. Interviews with an LPN confirmed that professional standards were not followed, and the facility's administration was informed of these deficiencies.
The facility failed to provide palatable and appropriately heated meals to residents, as reported by several residents and confirmed by a meal test tray. Residents described the food as cold and lacking flavor, with one resident noting weight loss due to the poor quality. The dietary manager acknowledged the issues with the food's taste and temperature.
The facility failed to ensure CNAs completed the required 12 hours of annual in-service training. Three CNAs had incomplete training hours, with one completing only 10 hours, another 4.5 hours, and the third 2.75 hours. The administrator and DON acknowledged the issue, noting the recent use of a computer software for training and the need for a system to ensure compliance.
The facility failed to ensure call light accessibility for two residents, leaving them unable to alert staff when needed. Additionally, a resident's request for grab bars was not assessed or documented, indicating a lack of communication and assessment of resident needs.
Facility staff failed to notify physicians and responsible parties of changes in condition or treatment for three residents. One resident's medication change was not communicated, another missed dialysis without physician notification, and a third resident's fall was not reported to their responsible party. Interviews confirmed these notifications should have occurred per facility policy.
A resident was discharged from a Medicare-covered stay without timely receiving a beneficiary notice of non-coverage. The notice, which should inform the resident of potential out-of-pocket costs, was signed by the discharge planner well before the resident's discharge but not by the resident until the day of discharge. This delay violated the facility's policy requiring timely notice to allow informed decision-making. The issue was later reported to the facility's administrator and DON.
A facility failed to maintain a complete and accurate MDS assessment for a resident. The admission assessment had incomplete sections in Cognitive Patterns, with dashes documented instead of required information. Despite the resident being coded as usually understood, the necessary interviews were not conducted. The MDS coordinator confirmed the oversight, and the facility's use of the RAI manual was noted. Administrative and clinical staff were informed of the findings.
The facility failed to include critical therapies in baseline care plans for two residents. One resident, admitted with fractures and hypertension, was on anticoagulation therapy, but the care plan lacked monitoring interventions. Another resident, with obstructive sleep apnea, required CPAP therapy, which was also omitted from the care plan. Staff interviews confirmed these omissions, despite facility policy requiring such inclusions.
The facility staff failed to update comprehensive care plans for three residents, leading to deficiencies in care. One resident's plan did not include the use of grab bars, another's lacked treatment for a skin condition, and a third's was not revised after a fall. These omissions indicate a lack of thorough documentation and care planning by the interdisciplinary team.
Facility staff failed to follow professional standards for medication administration and order clarification for three residents. A resident had conflicting insulin orders without clarification, another received medications outside the prescribed timeframe, and a third had unclear prn pain medication orders, leading to potential confusion in administration. The facility's policies did not adequately address these issues.
Two residents in a facility did not receive consistent urinary catheter care as required by their care plans and physician orders. One resident, under hospice care, had multiple missed catheter care instances, while another resident with a suprapubic catheter experienced similar lapses. Staff interviews indicated that catheter care was supposed to be documented in the eTAR, but several dates showed missing entries, suggesting care was not consistently provided.
A resident at risk for significant weight gain did not receive physician-ordered daily weight monitoring, with several days missing documentation. Additionally, the facility failed to conduct a quarterly nutritional assessment between December 2023 and May 2024, despite the resident's significant weight gain. The facility's policy requires comprehensive nutritional evaluations, but these were not adhered to, as confirmed by the dietician and missing records.
A resident was observed with raised bed rails without a documented safety assessment. The facility failed to conduct necessary evaluations by PT and OT to determine the resident's need and ability to use side rails safely. The Director of Nursing confirmed the absence of such assessments in the resident's clinical records.
The facility failed to provide adequate physician oversight for four residents, leading to deficiencies in pain management and diabetes care. Two residents experienced frequent use of prn pain medications without proper assessment or adjustment to scheduled pain management. Additionally, two residents lacked timely orders for blood sugar checks and insulin upon admission, highlighting lapses in medication reconciliation and care management.
Two residents in the facility did not receive their prescribed medications as ordered. A resident with multiple sclerosis did not receive Avonex on the scheduled days, with a 10-day gap between doses, due to the family's failure to bring the medication and lack of facility communication. Another resident did not receive Meclizine for vertigo on two occasions because it was not available in the facility's pharmacy system. Staff interviews revealed confusion about medication responsibilities, and the facility's policy on unavailable medications was not followed.
A resident continued to receive Ramelteon at a higher dose than recommended due to the facility's failure to ensure a physician reviewed and acted upon a pharmacy recommendation. The recommendation to taper the medication was initially made on 5/20/24 but was not addressed until 8/23/24, following a repeated recommendation. The DON was unaware of the delay, despite facility policy requiring timely physician review.
A resident was kept on an unnecessary psychoactive medication at a higher dose for three months due to the facility's failure to address a pharmacy recommendation for gradual dose reduction. The Director of Nursing was unaware of why the recommendation was not timely addressed, and the issue was discussed with the facility's administrative and clinical staff.
The facility failed to maintain safe and sanitary conditions in food storage and preparation areas. Sugar was left exposed, pots and pans were stored on dirty shelves, and an ice scoop was improperly stored. The sanitizer solution was below recommended levels, and the dishwasher operated at insufficient temperatures. Coleslaw was served at unsafe temperatures, and watermelon was found spoiled and unlabeled.
The facility staff failed to maintain a sanitary environment in the kitchen, with visible debris and stains on the floor under various equipment and in the dry goods storage room. The dietary manager acknowledged the need for regular cleaning and had requested housekeeping assistance for stain removal, as per facility policy.
Failure to Resolve Resident Grievances Regarding Linen Shortages
Penalty
Summary
Facility staff failed to resolve ongoing grievances regarding shortages of washcloths and towels, as voiced by residents during council meetings in 10 out of 11 months reviewed. Multiple residents reported delays in receiving care, such as getting out of bed or attending breakfast, due to insufficient linen supplies. Residents also noted that the facility had stopped using disposable wipes for incontinence care, increasing the demand for washcloths and towels. Resident council meeting minutes and grievance forms repeatedly documented complaints about linen shortages, with some months lacking evidence of follow-up or resolution. Interviews with residents, CNAs, and other staff confirmed that linen shortages were a persistent issue, leading to delays in bathing, bed changes, and other personal care activities. Staff reported that when linens ran out, they had to request more from the laundry, which sometimes resulted in residents waiting for care. Observations of linen closets and the laundry area revealed low quantities of towels and washcloths relative to the number of beds on each unit. The LTC ombudsman corroborated these findings, stating that residents consistently complained about linen shortages and that her own spot checks found linen closets empty at times. Facility documentation showed that orders for additional linens were placed periodically, but the problem persisted over several months. Staff and management interviews indicated that some believed the shortages were due to hoarding or disposal of soiled linens, but audits and room checks did not substantiate widespread hoarding. Despite efforts to monitor and restock linens, the facility did not make prompt or effective efforts to resolve the residents' grievances, as required by policy.
Failure to Document PRN Psychotropic Duration and Non-Pharmacological Interventions
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary psychotropic medication use. Specifically, for a resident with schizophrenia, the physician's order for prn (as needed) lorazepam did not include documentation of the intended duration of use, as required by facility policy. The nurse practitioner continued the prn lorazepam order without specifying the duration, and there was no documentation from the physician or nurse practitioner regarding how long the prn medication should be used. Additionally, the clinical record and medication administration records showed that lorazepam was administered on several occasions without evidence that non-pharmacological interventions were attempted prior to giving the medication. Staff interviews confirmed that non-pharmacological interventions should be individualized and attempted before administering prn lorazepam, and that such attempts should be documented in the progress notes. However, no such documentation was found for the dates when lorazepam was given.
Failure to Administer Medications Within Required Timeframes
Penalty
Summary
Facility staff failed to administer medications in accordance with professional standards of practice for four residents, as evidenced by medication administration records and staff interviews. For each of these residents, multiple medications were not given within the facility's policy of 60 minutes before or after the scheduled time. The medications involved included treatments for conditions such as seasonal allergies, spinal stenosis, high cholesterol, rhabdomyolysis, muscle spasms, high blood pressure, increased eye pressure, seizure-like activity, pain, arthritic pain, and constipation. For one resident, medications such as pseudoephedrine, baclofen, azelastine, simvastatin, and magnesium oxide were administered several hours after their scheduled times. Another resident experienced delays in receiving hydralazine, carvedilol, and brimonidine tartrate, with administration occurring up to several hours late. A third resident did not receive levetiracetam and Tylenol at the scheduled time, with both being administered six hours late. The fourth resident had tramadol, diclofenac gel, and Miralax administered outside the required time window. Interviews with nursing staff confirmed that medications should be administered within one hour before or after the scheduled time to ensure proper dosing and avoid overmedication. The facility's own policy also requires medications to be given within 60 minutes of the scheduled time. These findings were communicated to the facility administrator, and no additional information was provided prior to the survey exit.
Failure to Provide and Document Personal Hygiene ADL Care
Penalty
Summary
Facility staff failed to provide activities of daily living (ADL) care, specifically personal hygiene, to one resident who was unable to perform these tasks independently. Review of the resident's ADL records for March and May 2025 showed that personal hygiene tasks such as combing hair, brushing teeth, and washing/drying face and hands were not documented as provided on several day and evening shifts, as indicated by blank spaces in the records. Interviews with a CNA confirmed that personal hygiene should be performed and documented every shift, and the facility's policy requires assistance with ADLs for residents unable to perform them independently. The administrator was made aware of the concern, and no further information was provided prior to exit.
Failure to Prevent Significant Medication Errors
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors, as evidenced by multiple incidents involving incorrect medication administration. On one occasion, fluorouracil 5% cream, prescribed for application to a skin cancer lesion on the chest, was instead applied to the resident's neck. This resulted in redness and a burning sensation, requiring subsequent treatment with hydrocortisone. The error was confirmed by both the resident and the LPN involved, and the pharmacist explained that the medication should only be applied to the specific lesion due to its cell-killing properties. Additionally, there were three separate incidents where Debrox ear drops were administered into the resident's eye instead of the ear. Each time, the resident experienced burning and discomfort, and the errors were documented in facility reports. The pharmacist clarified that Debrox is intended solely for ear use and can cause significant irritation if placed in the eye. The reports indicated that the errors occurred due to confusion between medication containers and a failure to properly check medication labels before administration. A further deficiency was identified when Baclofen, a muscle relaxant prescribed for muscle spasms and spinal stenosis, was administered several hours later than scheduled. Facility policy requires medications to be given within one hour of the scheduled time, and both nursing and pharmacy staff confirmed the importance of timely administration for this medication. The resident's clinical record and medication administration audit confirmed the late administration, and staff interviews acknowledged the deviation from protocol.
Unseasoned Pureed Food Served Without Palatability Consideration
Penalty
Summary
Facility staff failed to ensure that food served on one of three observed units was palatable, as required by facility policy. During a survey, a test tray containing pureed fish, pureed broccoli, mashed potatoes, whole broccoli florets, and a whole fish fillet was sent to the unit and food temperatures were taken, all of which were within safe ranges. However, after tasting the pureed items, the dietary manager acknowledged that the pureed food lacked flavor and was not palatable. The dietary manager also confirmed that no seasoning was added to the food in the kitchen, and that only salt and pepper packets were supplied on the units for residents who were allowed them. No salt substitute was provided for residents on salt-restricted diets unless supplied by the resident's family. These findings were communicated to the administrator and director of clinical services.
Food Preparation and Sanitation Deficiencies in Kitchen
Penalty
Summary
Facility staff failed to prepare and serve food in a sanitary manner in one of two facility kitchens. During observation, a cook was seen plating lunch trays with a beard and mustache, but only the beard was covered, leaving the mustache exposed. The cook acknowledged that both beard and mustache should be covered to prevent hair from falling into food but was unaware his mustache was not covered at the time. Another staff member was observed cooking fish filets and handling them with the same gloves used to operate the deep fry baskets, and admitted she should not have touched the resident's food with her hands after handling equipment. Additionally, a container of chicken salad was found on an accessory table with a temperature of 53 degrees, above the required holding temperature of 41 degrees or lower. Despite this, a sandwich was made from the chicken salad and served to a resident. The dietary manager confirmed that all facial hair should be covered, gloves should be changed before handling food, and food should not be served if it is above the safe holding temperature. The administrator and director of clinical services were made aware of these findings.
Failure to Inform Resident of Medication Risks, Benefits, and Alternatives
Penalty
Summary
Facility staff failed to inform a resident or the resident's representative about the risks, benefits, and alternative treatments associated with the use of lorazepam, an anti-anxiety medication. A physician's order was present for lorazepam to be administered as needed for anxiety, sleeplessness, seizure activity, or shortness of breath, but there was no documentation in the clinical record indicating that the required information was provided to the resident or their representative. Staff interviews confirmed that such information should be communicated, including details about targeted behaviors, side effects, and alternative treatments, but this was not done in this case. The facility's own policy states that residents have the right to be fully informed in advance about care and treatment, but this was not followed for the resident in question.
Failure to Notify Physician and Resident Representative of Change in Condition
Penalty
Summary
Facility staff failed to promptly notify the resident representative when a resident experienced vomiting and was placed on contact precautions. Review of the clinical record showed that the resident was placed on contact isolation due to vomiting, but there was no documentation that the resident's representative was informed of this change in condition. Interviews with staff confirmed that notification should have occurred, and facility policy required prompt notification of changes in a resident's condition to the resident, physician, and representative. In another instance, staff did not notify the physician when a resident complained of burning and pain to the neck and repeatedly requested that the on-call physician be contacted for treatment. The resident, who was cognitively intact, reported that a chemotherapy cream had been mistakenly applied to the neck, resulting in a chemical burn. Despite the resident's insistence and repeated requests for hydrocortisone cream and for the on-call physician to be contacted, the nurse assessed the area, found no visible irritation, and decided not to call the on-call provider, instead placing the request in the nurse practitioner communication book for follow-up the next day. Progress notes documented the resident's ongoing complaints and the nurse's repeated assessments, which did not reveal visible signs of injury. Staff interviews indicated that the protocol was to call the on-call provider for medication needs or acute symptoms, and that it was the resident's right to have the provider contacted upon request. The facility's policy required prompt notification of changes in condition, but this was not followed in these cases.
Failure to Review or Revise Care Plan After Resident Fall
Penalty
Summary
Facility staff failed to review or revise the comprehensive care plan for one resident following a fall incident. The resident, who had a diagnosis including dementia and was severely cognitively impaired as indicated by a low BIMS score, experienced a fall that was documented in both nursing notes and a fall investigation. The documentation showed that the resident was found on the floor, was alert and oriented, sustained no injuries, and appropriate notifications and protocols were followed at the time of the incident. Despite the fall and the facility's policy requiring care plan review and updating after significant changes in a resident's condition, there was no evidence that the comprehensive care plan was reviewed or revised following the incident. The MDS coordinator confirmed that although the care plan was reviewed, there was no documentation to support this, and the care plan itself did not reflect the fall event. The administrator and director of clinical services were made aware of these findings.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
Facility staff failed to provide appropriate respiratory care for one resident by not obtaining a physician's order for oxygen therapy prior to administration. The resident was admitted with diagnoses including respiratory failure and was assessed as cognitively intact. During an observation, the resident was found to be receiving oxygen at three liters per minute via nasal cannula. At the time of the observation, there was no documented physician's order for the oxygen therapy being administered. The physician's order for continuous oxygen at three liters per minute by nasal cannula was only created later that same day, after the resident had already been observed receiving oxygen. This lapse was confirmed by the unit manager, who acknowledged that no order was present at the time of the surveyor's observation.
Failure to Provide Individualized Physician Oversight During Medication Administration
Penalty
Summary
Facility staff failed to provide physician services for three residents by not ensuring individualized physician oversight and response to a nurse's inquiry regarding medication administration. On a specific date, only one nurse was present on a unit with 54 residents, instead of the scheduled two nurses. The nurse on duty reported being unable to administer medications as scheduled due to the overwhelming workload and the absence of a second nurse. The nurse attempted to seek guidance from a nurse practitioner, who stated she could not provide orders for all residents and advised the nurse to use her own judgment and critical thinking. No individualized physician direction was documented for the affected residents. For the residents involved, clinical records showed that multiple medications, including those for allergies, spinal stenosis, nasal congestion, rhabdomyolysis, muscle spasms, high blood pressure, increased eye pressure, pain, and constipation, were administered late or not at all. Medication administration audit reports confirmed that scheduled doses were significantly delayed, and in some cases, medications ordered to be given three times a day were omitted because the late administration would have resulted in doses being too close together. The nurse on duty made decisions about which medications to administer based on her own judgment without specific physician input for each resident. Interviews with staff, including the nurse, nurse practitioner, pharmacist, and administrator, confirmed the lack of individualized physician response and documentation regarding the medication administration issues. The facility's policy required the attending physician to participate in assessment, care planning, and to provide consultation or treatment when called by the facility. However, this process was not followed, resulting in a failure to ensure that residents were under appropriate physician care during the incident.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Medication Administration
Penalty
Summary
Facility staff failed to provide sufficient nursing staff to meet the needs of residents on the [NAME] unit during the day shift on 12/25/24. On that day, only one nurse was present to care for 54 residents, despite facility policy and staff statements indicating that two nurses are required for this shift. The night shift nurse, who had already worked 16 hours, remained until approximately 9:30 a.m. but did not provide resident care or administer medications between 7:00 a.m. and 9:30 a.m., instead attempting to find coverage for the absent second nurse. As a result of the staffing shortage, several residents experienced delays in the administration of their scheduled medications. For example, one resident with orders for pseudoephedrine, baclofen, azelastine, and magnesium oxide received these medications several hours after their scheduled times. Another resident with orders for hydralazine and brimonidine tartrate also received medications later than scheduled. A third resident with orders for tramadol and Miralax experienced similar delays in medication administration. Interviews with staff confirmed that only one nurse was present during the day shift, and the nursing scheduler was unable to verify the intended schedule for that day due to limitations in the scheduling system. The administrator was made aware of the concern, and the facility's policy states that sufficient numbers of staff with the necessary skills and competency are to be provided in accordance with resident care plans and the facility assessment. No further information was presented prior to exit.
Incomplete Nurse Staffing Information Posted
Penalty
Summary
Facility staff failed to post complete daily nurse staffing information for three consecutive days, as required. Specifically, the daily nurse staffing sheets for the reviewed dates did not include the facility name, which is a required element according to the facility's own policy. During an interview, the scheduler responsible for posting the nurse staffing information acknowledged that the facility name was missing from the sheets and stated she was unaware that this information was required. The deficiency was confirmed through observation, staff interviews, and review of facility documents. Administrative staff were made aware of these findings during the survey.
Improper Garbage Disposal Practices
Penalty
Summary
The facility staff failed to maintain the garbage areas in a sanitary manner, as observed with one trash compactor and two trash bins. During an observation, the side door of the trash compactor was found open with multiple bags of trash inside. Additionally, two outside trash bins were observed with their lids open, also containing multiple bags of trash. Interviews with the regional director of maintenance and the maintenance director confirmed that the doors and lids should be kept closed to prevent animal access. The facility's policy on food-related garbage and refuse disposal requires that garbage containing food waste be stored in a manner inaccessible to pests. This policy was not adhered to, leading to the deficiency.
Inadequate Infection Control Program and Practices
Penalty
Summary
The facility staff failed to maintain a comprehensive infection control program and implement effective infection control practices. A review of the facility's infection control program for the year 2023 revealed the absence of a systematic surveillance system. The only documentation available was a binder containing multiple Antibiotic Timeout forms for various residents, which was insufficient for tracking and identifying clusters of infections. During an interview, the infection control nurse, who was not employed at the facility during 2023, confirmed that the existing documentation was inadequate for identifying infection control challenges. The facility's policy on infection prevention and control emphasized the need for surveillance tools to recognize infections, record their frequency, and detect outbreaks, but no further information was provided before the survey exit. Additionally, a registered nurse failed to implement proper infection control practices while preparing and administering medications to a resident. The nurse was observed dropping a tablet on the medication cart, picking it up with bare hands, and placing it in a medication cup with other pills. Upon realizing the tablet was incorrect, the nurse used a finger to hold the remaining pills while discarding the wrong one, then continued to administer the medications to the resident. An LPN later stated that dropped pills should be discarded, and if a pill needs to be removed from a cup, all pills should be discarded and re-poured, or gloves should be used. The facility lacked a specific policy regarding this concern, and no further information was provided before the survey exit.
Failure to Promote Resident Dignity in Care and Services
Penalty
Summary
The facility staff failed to provide care and services in a manner that promoted resident dignity for four residents. For Resident #96, the staff did not treat him with dignity after he vomited. Despite calling out for help, the resident was left in soiled clothing and bed linens for several hours, which made him feel dirty and humiliated. The incident was not documented in the resident's clinical record, and the staff involved did not ensure the resident was cleaned up promptly. Resident #31 experienced a lack of dignity during meal service. While other residents at the same table were served lunch, Resident #31 was left waiting for 11 minutes before receiving food. The dietary manager acknowledged that all residents at the same table should be served simultaneously to avoid such situations. The facility's policy on food and nutrition services did not address the importance of a dignified dining experience. For Resident #67, the staff failed to provide necessary ADL assistance during the night shift. The resident, who was dependent on staff for personal care, was left sitting in a wheelchair all night without being assisted to bed or cleaned up. The progress notes did not document any attempts to provide care or the resident's refusal of care. Additionally, Resident #157 reported that staff instructed her to void in her brief, which she found embarrassing and undignified. The staff allegedly told her they were going on break and could not assist her at that time, leading to her being left in wet clothing.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility staff failed to provide written notification of facility-initiated hospital transfers to residents, their representatives, and the Ombudsman for five residents. For Resident #52, the staff did not provide a written notice to the resident's representative for a hospital transfer due to shortness of breath and chest heaviness. The Discharge Planner/Social Worker admitted to not sending the notification due to being out with COVID. The facility's policy requires notification to be made as soon as practicable before transfer or discharge, especially in cases of urgent medical needs. Resident #69 was transferred to the hospital due to tachycardia and confusion, but the facility failed to provide written notice to the resident's representative and the Ombudsman. The Discharge Planner/Social Worker again cited absence due to COVID as the reason for the oversight. The transfer list used by the facility did not include residents who went to the emergency room and returned the same day, leading to missed notifications. For Resident #22, the facility did not provide written notice to the Ombudsman for a hospital transfer following a nosebleed. Similarly, Resident #45 did not receive written notification for multiple transfers, and the Ombudsman was not notified for some of these transfers. Resident #11's transfer to the emergency department also lacked notification to the Ombudsman. Interviews with staff revealed that the facility's process for notifying the Ombudsman was not consistently followed, particularly when the Discharge Planner was absent.
Deficiencies in Care Plan Implementation and Documentation
Penalty
Summary
The facility staff failed to develop and implement comprehensive care plans for several residents, leading to multiple deficiencies. For one resident with diabetes, the staff did not adhere to the scheduled times for blood sugar monitoring and insulin administration as per physician orders. The blood sugar levels were often checked after meals, which could result in inaccurate insulin dosing. Additionally, there was a failure to administer insulin and antibiotics as ordered, with no documentation provided for missed doses. Another resident, who was at risk for malnutrition and on a fluid restriction due to end-stage renal disease, did not have their fluid intake monitored as per the care plan. The medication administration record showed gaps in documentation, indicating that the fluid restriction was not consistently implemented. Similarly, a resident on anticoagulant therapy reported missing doses of their medication, Xarelto, despite the medication being available in the facility's pharmacy system. The facility also failed to provide necessary assistance with activities of daily living for a resident who was severely impaired and dependent on staff for care. The documentation did not reflect the care provided, and there were reports of the resident being left in soiled clothing and not repositioned regularly. Additionally, there were deficiencies in wound care management for residents with pressure injuries and skin tears, as treatments were not documented as completed on multiple occasions. These failures highlight significant lapses in the implementation of care plans and documentation practices within the facility.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care for four residents, leading to deficiencies in their care. Resident #96 experienced an incident where he vomited and was left in soiled clothing and bed linens for several hours. Despite calling for assistance, the staff did not clean him up until much later, and there was no documentation of the incident in his clinical record. This oversight indicates a failure to adhere to the facility's policy on providing proper daily personal attention and care. Resident #108's care was compromised due to missing documentation of incontinence care, bathing, and dressing on specific dates. The resident, who was dependent on staff for these activities, did not have evidence of care provided in the facility's records. Interviews with staff revealed that incontinence care should be documented in the Point Click Care system, but this was not done consistently, leading to gaps in the resident's care documentation. Residents #32 and #67 also experienced deficiencies in their ADL care. Resident #32 reported being left wet and not changed in a timely manner, with documentation showing multiple dates where assistance with toileting was not recorded. Similarly, Resident #67 was left in a wheelchair overnight without being assisted back to bed, and there was a lack of documentation for care provided on several dates. These incidents highlight a pattern of inadequate care and documentation for residents who are dependent on staff for their daily living activities.
Medication and Care Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to provide appropriate care and services to promote the highest level of well-being for several residents. For Resident #157, the staff did not obtain blood sugars as ordered by the physician, leading to insulin being administered at inappropriate times, potentially affecting the resident's blood sugar levels. Additionally, insulin and antibiotic medications were not administered as ordered, with no documentation provided for the missed doses. This lack of adherence to physician orders and documentation requirements indicates a significant lapse in medication management and monitoring. Resident #34 experienced missed doses of Xarelto, a medication used to prevent blood clots, due to the medication not being on hand, despite being available in the facility's pharmacy system. The facility's policy on unavailable medications was not followed, as there was no evidence of notification to the attending physician or responsible party. This oversight in medication availability and communication further highlights the facility's failure to ensure residents receive necessary medications as prescribed. Other residents, including Resident #114, #113, #108, #112, #117, and #53, also experienced deficiencies in care. These included failures in administering medications, conducting necessary assessments, and obtaining appropriate orders upon admission. The facility's inability to adhere to physician orders, document care accurately, and ensure medication availability and administration reflects a broader issue of inadequate care and oversight, impacting the well-being of multiple residents.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility staff failed to provide adequate care and services to promote the healing of pressure injuries for three residents, leading to deficiencies in their treatment. Resident #67, who was severely impaired in making daily decisions and under hospice care, did not receive the prescribed treatments for pressure injuries on multiple occasions. The resident's family member expressed concerns about the lack of regular repositioning and the application of prescribed creams, which were not consistently documented in the electronic treatment administration record (eTAR). Resident #111 also experienced a lack of proper treatment for a pressure injury. The resident had an unstageable pressure ulcer on the sacrum, and the facility failed to document the completion of the prescribed treatments on several dates over a four-month period. Interviews with nursing staff revealed that wound care was supposed to be documented on the eTAR, but there were multiple instances where this was not done, indicating a failure to provide the necessary care. Resident #116, who was severely cognitively impaired and dependent on staff for daily activities, did not receive the prescribed wound treatments for a skin tear on the right shin. The medication administration record (MAR) showed missing evidence of wound treatments on several dates over three months. An LPN confirmed that if there was no documentation of wound care on the TAR, it was not performed. The facility's policy required documentation of treatments, but this was not adhered to, resulting in a deficiency in care.
Failure to Provide Respiratory Care Services per Physician Orders
Penalty
Summary
The facility staff failed to provide respiratory care services per physician orders for two residents. Resident #108, who was admitted with diagnoses including coronary artery disease, COPD, hyponatremia, and asthma, did not receive the required respiratory assessments as per physician orders. The treatment administration record (TAR) for May 2024 showed missing documentation for respiratory assessments on specific shifts. An LPN confirmed that the evidence of respiratory assessments should be on the TAR and acknowledged that professional standards were not followed when physician orders were not adhered to. Similarly, Resident #407, admitted with conditions such as a fracture, obstructive sleep apnea, asthma, and paroxysmal atrial fibrillation, did not have their CPAP mask cleaned as ordered by the physician. The nursing task administration record for August 2024 lacked evidence of CPAP cleaning for a specified period. The resident confirmed that no one was cleaning the mask due to their inability to do so because of a broken bone. An LPN confirmed that the evidence of CPAP mask cleaning should be on the TAR and acknowledged that professional standards were not followed when physician orders were not adhered to.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility staff failed to implement a complete pain management program for two residents, leading to deficiencies in their care. Resident #96, who has no cognitive impairment and requires assistance with activities of daily living, expressed concerns about frequently needing to request pain medication. Despite receiving 51 doses of as-needed Oxycodone for breakthrough pain related to multiple sclerosis, the resident's pain levels remained high, ranging from 6 to 9. The attending physician and nurse practitioner acknowledged that the frequent use of as-needed medication indicated a need for adjustment in the resident's scheduled pain management, which was not done. Similarly, Resident #72 also experienced inadequate pain management. This resident received 49 doses of as-needed Oxycodone or Percocet, with pain levels primarily between 7 and 10. The attending physician and nurse practitioner recognized that the frequent administration of as-needed medication suggested the need for a change in the resident's scheduled pain medication. However, no adjustments were made to address the resident's ongoing pain. Interviews with facility staff, including a licensed practical nurse and the nurse practitioner, revealed that the facility's pain management policy was not effectively implemented. The staff acknowledged that frequent requests for as-needed pain medication should have prompted a reassessment and adjustment of the residents' scheduled pain management. The facility's policy emphasizes a multidisciplinary approach to pain management, including monitoring and modifying interventions as necessary, which was not adequately followed in these cases.
Deficiencies in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate dialysis care and services for five residents, leading to multiple deficiencies. For one resident, the facility staff did not ensure transportation to a scheduled dialysis session, resulting in a missed treatment. The staff was unable to locate the necessary contact information for transportation, and there was no backup plan in place to address the issue. Additionally, the facility did not maintain proper communication with the dialysis center, as evidenced by the lack of pre and post-dialysis review forms and communication records. Another resident experienced a similar lack of communication with the dialysis center. The facility failed to provide documentation of communication with the dialysis center for scheduled treatments. Interviews with staff revealed that necessary paperwork, such as medication lists and face sheets, was not consistently sent with residents to the dialysis center. This lack of communication and documentation was a recurring issue for multiple residents, indicating a systemic problem within the facility's processes. Furthermore, the facility did not adequately monitor and document physician-ordered fluid restrictions for residents undergoing dialysis. In one case, the facility's medication administration records showed missing or incorrect documentation of fluid intake, and staff interviews revealed confusion about the documentation process. This failure to implement and monitor fluid restrictions was noted for multiple residents, highlighting a significant deficiency in the facility's care for residents requiring dialysis.
Inadequate Night Shift Staffing for Residents
Penalty
Summary
The facility failed to provide adequate nursing staff for two residents during the night shift on multiple occasions. For one resident, the facility did not meet the required staffing levels on several nights in September and October 2023, with only one licensed nurse and one CNA present, despite the unit having a census of 25 to 30 residents. The staff scheduler and the director of nursing both confirmed that the unit should have a minimum of one licensed nurse and two CNAs on the night shift, based on the staffing grid provided by corporate and the unit's acuity and census. However, due to call-outs, the unit was often left with insufficient staff. Similarly, another resident experienced inadequate staffing on a specific night in August 2023, with only one licensed nurse and one CNA on duty for a unit with 26 residents. The staff scheduler and the director of nursing reiterated the staffing requirements, which were not met on this occasion. The facility's policy states that staffing should be sufficient to meet the needs of all residents according to their care plans, but this was not adhered to, leading to the deficiency.
Failure to Administer and Monitor Anticoagulant Therapy
Penalty
Summary
The facility staff failed to ensure that two residents were free from unnecessary medications due to improper administration and monitoring of anticoagulant therapy. Resident #113, who was admitted with fractures and hypertension, was prescribed Enoxaparin Sodium Injection to be administered every 12 hours. However, the medication administration record (MAR) showed multiple instances of delayed administration, with times significantly deviating from the prescribed schedule. The baseline care plan did not include any focus or interventions related to anticoagulation therapy, and the facility's medication administration policy, which emphasizes the 5 Rights, was not adhered to. Resident #26, admitted with diagnoses including congestive heart failure, diabetes mellitus, and chronic obstructive pulmonary disease, was on anticoagulant therapy for atrial fibrillation. The comprehensive care plan required monitoring for adverse reactions to the anticoagulant therapy, but the medication administration record-treatment administration record (MAR-TAR) showed no evidence of such monitoring. The resident was severely cognitively impaired, as indicated by a BIMS score of 03 out of 15, and was dependent on staff for most activities of daily living. Interviews with an LPN revealed that the facility did not follow professional standards for medication administration and monitoring, as evidenced by the lack of adherence to physician orders and the facility's own medication administration policy. The facility's administrative staff, including the administrator and director of nursing, were made aware of these findings, but no further information was provided prior to the survey exit.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility staff failed to serve palatable food at an appetizing temperature for five residents. Residents reported that the food was often cold and lacked flavor. One resident mentioned losing weight due to the poor quality of the food, while another stated that the food was not suitable even for a pet. The residents involved were cognitively intact or moderately impaired, as indicated by their BIMS scores, and were able to express their dissatisfaction with the meals provided. A meal test tray conducted with the dietary manager revealed that the food did not have a palatable flavor or appetizing temperature. The ground pork was found to be bland and not warm enough, the coleslaw was overly vinegary, and the pureed pork and vegetables were also bland and not at the desired temperature. The facility's policy requires that food be served at a safe and appetizing temperature, but this standard was not met, as evidenced by the observations and resident interviews.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility staff failed to ensure that certified nursing assistants (CNAs) completed the required in-service training hours. Specifically, three out of five CNA records reviewed showed deficiencies in meeting the 12-hour annual training requirement. CNA #3, hired on May 19, 2022, completed only 10 hours of training. CNA #4, hired on June 22, 2022, completed 4.5 hours, and CNA #5, hired on March 24, 2023, completed 2.75 hours. During an interview, the administrator and the director of nursing acknowledged the issue and mentioned the recent implementation of a computer software for training, indicating a need for a system to ensure compliance with training requirements. The facility's policy mandates no less than 12 hours of annual in-service training per employment year or as required by state law.
Failure to Ensure Call Light Accessibility and Assess Resident Needs
Penalty
Summary
The facility staff failed to accommodate the needs of three residents by not ensuring that call lights were accessible. For Resident #92, who was admitted with diagnoses including congestive heart failure, Parkinson's disease, and dementia, the call light was found coiled behind the headboard, out of reach. Despite the resident's severe cognitive impairment and need for supervision, the call light was not accessible, as confirmed by a CNA who later clipped it to the bedspread. The facility's policy required call lights to be within easy reach, but this was not adhered to. Resident #50, who was severely impaired in making daily decisions and required substantial assistance, also had issues with call light accessibility. Observations showed the call light on the floor and later clipped to a pillow, out of reach. Interviews with staff confirmed that the call light should be within reach to allow residents to alert staff when needed. However, the call light was not consistently placed within reach, compromising the resident's ability to communicate needs. For Resident #91, the facility failed to assess the need for grab bars, despite the resident's request and history of slipping off the bed. There was no documented assessment or physician order for grab bars, and the care plan did not include them. The director of therapy was unaware of the resident's request, indicating a lack of communication and assessment regarding the resident's needs. The facility's failure to assess and provide necessary accommodations for these residents highlights deficiencies in meeting individual resident needs.
Failure to Notify of Changes in Condition and Treatment
Penalty
Summary
The facility staff failed to notify the physician and/or the resident's representative of a change in condition or treatment for three residents. For one resident, the staff did not document any discussion or notification regarding a change in medication. The physician's progress note did not mention the addition of Sacubitril-Valsartan, and there was no evidence of communication with the resident or their responsible party about this change. Interviews with facility staff confirmed that such notification should have occurred, as per the facility's policy. Another resident missed a scheduled dialysis treatment because transportation did not arrive, and the facility staff failed to notify the physician. The nurse's notes indicated attempts to contact the transportation company and the dialysis center, but there was no documentation of notifying the physician about the missed treatment. An interview with a unit manager confirmed that the provider and responsible party should be informed if a resident misses dialysis. For a third resident, the facility staff did not notify the responsible party after the resident experienced a fall. The clinical record lacked documentation of any notification to the responsible party following the incident. Interviews with facility staff revealed that the responsible party should have been informed, but the notes and care plan did not reflect this communication. The facility's administrative and clinical leadership were made aware of these findings, but no further information was provided before the survey's conclusion.
Failure to Timely Issue Beneficiary Notice of Non-Coverage
Penalty
Summary
The facility staff failed to issue a beneficiary notice of non-coverage in a timely manner for a resident, identified as Resident #257. The resident was discharged from a Medicare-covered Part A stay with benefit days remaining on 5/22/24. However, the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage, which informs the resident that Medicare may not cover certain services and that they may have to pay out of pocket, was signed by the discharge planner on 5/14/24 but not by the resident until 5/22/24. This delay in obtaining the resident's signature did not comply with the facility's policy, which requires the notice to be provided within forty-eight hours of the last anticipated covered day. During an interview, the discharge planner, identified as OSM #4, admitted to discussing the notice with the resident on 5/14/24 but failed to obtain the resident's signature at that time. OSM #4 speculated that the papers might have been left in the resident's room, leading to the delay. The issue was brought to the attention of the facility's administrator and director of nursing on 8/27/24. The facility's policy emphasizes the importance of providing the notice in a timely manner to allow residents or their representatives enough time to make informed decisions about their care and financial responsibilities.
Incomplete MDS Assessment for a Resident
Penalty
Summary
The facility staff failed to maintain a complete and accurate Minimum Data Set (MDS) assessment for one resident in the survey sample. The MDS assessment, specifically the admission assessment with a reference date of 5/7/23, contained inaccuracies in Section C - Cognitive Patterns. The section for the resident interview and the staff interview were left incomplete, with dashes documented instead of the required information. Additionally, under item C0100, which determines if a Brief Interview for Mental Status should be conducted, a dash was also documented. This was despite the resident being coded as usually understood and usually understands, indicating that the interview should have been completed. During an interview with RN #6, the MDS coordinator, it was revealed that the social worker typically completes Section C, although RN #6 sometimes does it. RN #6 was not employed at the facility at the time of the assessment but confirmed that the staff interview should have been conducted if the resident could not do the interview. The facility uses the Resident Assessment Instrument (RAI) manual to complete MDS assessments. The RAI Manual, Version 1.18.11, specifies that if the resident interview was not conducted within the look-back period, item C0100 must be coded as 'Yes,' and the standard no information code (a dash) should be entered in the resident interview items. The staff assessment for mental status items should not be completed if the resident interview should have been conducted but was not done. The administrative and clinical staff were made aware of these findings, but no further information was provided before the exit.
Failure to Include Critical Therapies in Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans for two residents, which led to deficiencies in monitoring critical therapies. Resident #113, who was admitted with fractures and hypertension, was prescribed anticoagulation therapy with Enoxaparin Sodium Injection. However, the baseline care plan did not include any focus or interventions related to this therapy, despite the resident's need for monitoring due to the medication's potential side effects. Interviews with facility staff confirmed that the baseline care plan should have included this information, but it was omitted. Similarly, Resident #407, admitted with a fracture, obstructive sleep apnea, asthma, and paroxysmal atrial fibrillation, required CPAP therapy as per physician orders. The baseline care plan for this resident also failed to include any focus or interventions related to CPAP use or monitoring. Staff interviews revealed an understanding that such therapies should be included in the baseline care plan, yet this was not done. The facility's policy mandates that baseline care plans should address immediate care needs based on orders, services, medications, and treatments, which was not adhered to in these cases.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for three residents, leading to deficiencies in their care. For one resident, the care plan did not include the use of grab bars, which were ordered by the physician and used by the resident for independent bed mobility. Despite the presence of grab bars being documented in the physician's orders and a risk assessment, the care plan was not updated to reflect this, leaving a gap in the documentation of the resident's needs and the interventions required. Another resident's care plan was not updated to include treatment for a non-pressure related skin condition. The physician had ordered Nystatin cream for the resident's skin redness, but the electronic treatment administration record (eTAR) showed multiple instances where the treatment was not documented as completed. The care plan only mentioned the potential for skin integrity impairment due to incontinence, without addressing the specific treatment for the skin condition, indicating a lack of comprehensive care planning. A third resident experienced a fall, but the care plan was not reviewed or revised following the incident. The existing care plan documented the resident's risk for falls and included various interventions, but there was no update after the fall to address any new needs or changes in the resident's condition. Interviews with staff revealed that the interdisciplinary team was responsible for updating care plans, but this was not done in this case, resulting in an incomplete care plan that did not reflect the resident's current situation.
Medication Administration and Order Clarification Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of practice for three residents, leading to deficiencies in medication administration and order clarification. For Resident #157, there were two conflicting physician orders for insulin administration documented in the medication administration record (MAR) simultaneously. Despite nurses noting the duplicate order, no action was taken to clarify or discontinue the incorrect order, as confirmed by RN #5 during an interview. The facility's medication administration policy did not address handling duplicate orders, contributing to the oversight. Resident #34 experienced a delay in receiving medications as per physician orders. The resident reported not receiving Metformin and Seroquel at the scheduled times, with documentation showing administration occurred significantly later than prescribed. The facility's policy allows for a one-hour window around the scheduled time for medication administration, but this was not adhered to, resulting in the resident receiving medications outside the acceptable timeframe. For Resident #72, the facility staff did not clarify two as-needed orders for pain medication, leading to potential confusion in administration. The resident's MAR showed frequent administration of both Oxycodone and Percocet without clear parameters for when each should be used. LPN #5 acknowledged the lack of specific guidelines for administering these medications based on pain levels, indicating a gap in the facility's protocol for managing prn orders. The absence of clarification could lead to inconsistent pain management for the resident.
Deficient Catheter Care for Two Residents
Penalty
Summary
The facility staff failed to provide adequate urinary catheter care for two residents, leading to deficiencies in care. Resident #67, who was severely impaired in making daily decisions and under hospice care, did not receive catheter care on multiple occasions between June and August 2024. The resident's family expressed concerns about the care provided, noting uncertainty about the specific catheter care being administered. The facility's comprehensive care plan and physician orders required catheter care every shift, but the electronic treatment administration record (eTAR) showed missed care on several dates. Similarly, Resident #24, who was cognitively intact, also experienced lapses in catheter care from June to July 2024. The resident had a suprapubic catheter and reported that staff changed the catheter when it leaked and emptied the bag daily. However, the resident was unsure about the regularity of catheter care. The care plan and physician orders specified catheter care every shift, but the eTAR indicated that care was not documented on several dates. Interviews with facility staff, including a CNA and an RN, revealed that catheter care was supposed to be provided every shift as per physician orders, and documentation in the eTAR was meant to evidence the completion of care. However, the lack of documentation suggested that care was not consistently provided. The facility's administrative and clinical leadership were informed of these concerns, but no further information was provided before the survey exit.
Failure to Monitor Resident's Weight and Conduct Nutritional Assessments
Penalty
Summary
The facility staff failed to adhere to physician orders for daily weight monitoring for a resident identified as being at risk for significant weight gain. The resident reported that she was supposed to have daily weights taken, but if she did not go to the scales herself, no staff would assist her. The physician's order, dated July 12, 2024, required daily weights to monitor for significant weight gain, yet there were missing entries on the medication administration record for several days in July 2024. The comprehensive care plan also highlighted the resident's risk for nutritional status alteration and the need for daily weight monitoring. Additionally, the facility staff did not complete a quarterly nutritional assessment for the resident between December 6, 2023, and May 1, 2024. The resident's clinical chart showed a significant weight gain, which was noted in a nutritional assessment on December 6, 2023, but no follow-up assessment was conducted until May 1, 2024. The facility's policy required quarterly assessments, and the dietician confirmed that an assessment should have been completed if the resident triggered for weight gain in December 2023. The facility's policy on nutritional assessments mandates a comprehensive evaluation of each resident's nutritional status, risk factors, and preferences. However, the facility failed to conduct the required assessments and follow physician orders, as evidenced by the lack of documentation and missed weight recordings. The administrative and clinical staff were informed of these deficiencies, but no further information was provided before the survey exit.
Failure to Assess Resident for Safe Use of Bed Rails
Penalty
Summary
The facility staff failed to perform a safety assessment for the use of side rails for Resident #93. On August 27, 2024, the resident was observed sitting up in bed with both quarter side rails raised while eating breakfast. A review of the resident's clinical record, including assessments, physician orders, and care plan, showed no evidence of an assessment for the need or safe use of side rails. On August 28, 2024, the Director of Nursing confirmed the absence of a safety assessment for the resident's use of side rails. Further interviews revealed that before a resident's bed is equipped with side rails, assessments by physical therapy and occupational therapy are required to determine the resident's ability to use the side rails safely and the necessity of the side rails. However, these assessments were not completed for Resident #93, and no orders were entered into the system by PT or OT.
Deficiencies in Pain Management and Diabetes Care
Penalty
Summary
The facility staff failed to provide adequate physician oversight for the care of four residents, leading to deficiencies in pain management and diabetes care. For two residents, the facility physician and nurse practitioner did not properly assess the frequent use of as-needed (prn) pain medications. One resident expressed concern about having to frequently request pain medication, and the medication administration record showed high usage of prn pain medication with pain levels ranging from 6 to 9. Interviews with the attending physician and nurse practitioner revealed that adjustments to the resident's scheduled pain medication were necessary but not made, indicating a lack of proactive management. Similarly, another resident also experienced frequent administration of prn pain medications, with pain levels primarily between 7 and 10. The attending physician and nurse practitioner acknowledged the need for adjustments to the resident's pain management regimen, yet no changes were implemented. Both cases highlight a failure to transition residents from prn to scheduled pain management, which could have alleviated the need for frequent requests for pain relief. In addition to pain management issues, the facility failed to identify and address the need for blood sugar checks and insulin administration for two residents upon admission. One resident's spouse raised concerns about the absence of orders for blood glucose monitoring and insulin, which were only addressed after the resident had been in the facility for over 24 hours. Another resident also lacked orders for blood sugar checks and insulin until the responsible party notified the facility. These oversights in medication reconciliation and timely implementation of necessary medical orders demonstrate a significant lapse in the facility's admission process and ongoing care management.
Medication Administration Failures for Two Residents
Penalty
Summary
The facility staff failed to provide a physician-ordered medication, Avonex, for timely administration to Resident #96, who was being treated for multiple sclerosis. Despite the resident's cognitive ability to make daily decisions and his reliance on staff assistance for activities of daily living, the medication was not administered on the scheduled Saturdays in August 2024. Instead, it was given on subsequent Tuesdays, resulting in a 10-day gap between doses. The facility did not communicate with the pharmacy or the family regarding the medication's availability, and the staff were unsure of the protocol if the family did not bring the medication. Resident #34 also experienced a failure in medication administration, as the facility did not ensure the availability of Meclizine, prescribed for vertigo. The medication was not available on two documented occasions, and the facility's onsite pharmacy system did not have Meclizine in stock. The nursing staff indicated that they would contact the pharmacy and check the backup system if a medication was unavailable, but there was no evidence of notifying the provider or the resident's responsible party when the medication was not found. Interviews with various staff members, including the LPN, registered pharmacist, and director of nursing, revealed a lack of clarity and communication regarding the responsibility for obtaining and administering medications. The facility's policy on unavailable medications requires notifying the attending physician and explaining the circumstances, but there was no documentation of such actions being taken. The facility's administrative staff were made aware of these findings, but no further information was provided before the survey exit.
Failure to Address Pharmacy Recommendation for Medication Tapering
Penalty
Summary
The facility staff failed to ensure that a physician reviewed and acted upon a pharmacy recommendation for a resident during the monthly pharmacy regimen review. On 5/20/24, a pharmacy note indicated that the resident was receiving Ramelteon 8 mg every night for hypnotic therapy, which exceeded the manufacturer's recommended duration of use. The pharmacy recommended considering a gradual tapering of the medication to ensure the resident was on the lowest dose possible or to assess the continued need for the medication. However, the physician did not review or address this recommendation, and the resident remained on the higher dose for an additional three months. The issue was identified when the pharmacy repeated the recommendation on 8/12/24, and the physician subsequently decreased the dose to 4 mg on 8/23/24. During an interview, the Director of Nursing stated that pharmacy forms are provided to the provider for review and sign-off, but she was unaware of why this particular recommendation was not addressed in a timely manner. The facility's policy requires that if the attending physician does not respond within 30 days, the medical director should review the recommendations and document any actions taken. Despite this policy, the deficiency was not addressed until the second recommendation was made.
Failure to Address Pharmacy Recommendation for Psychoactive Medication
Penalty
Summary
The facility staff failed to ensure that a resident was free of an unnecessary psychoactive medication. The resident was prescribed Ramelteon, an oral tablet for insomnia, at a dose of 8 mg to be taken every night at bedtime. A pharmacy recommendation dated six days after the initial prescription advised a gradual tapering of the medication to ensure the resident was on the lowest dose possible or to assess the continued need for the medication. However, the physician did not review or address this recommendation, resulting in the resident remaining on the higher dose for an additional three months. The issue was identified during a survey, and the Director of Nursing acknowledged receiving the pharmacy forms and providing them to the provider for review. However, she was unaware of why the recommendation was not addressed in a timely manner. The deficiency was discussed with the facility's administrative and clinical staff, including the Administrator, Director of Nursing, Director of Clinical Operations, Regional Director of Clinical Operations, Regional Director of Operations, and Assistant Director of Nursing. No further information was provided by the end of the survey.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to maintain safe and sanitary conditions in the kitchen and nourishment areas, as observed during a survey. In the kitchen's dry goods storage room, a container of sugar was found with its lid open, exposing the contents to potential contamination. Additionally, pots and pans were stored on a shelf with visible stains and food debris, compromising their cleanliness. An ice scoop was improperly stored on a cart beside the ice machine instead of being placed in a sanitary holder or bag. Further deficiencies were noted in the facility's dishwashing and food preparation processes. The sanitizer solution in the three-compartment sink was tested and found to be at 170 ppm, below the manufacturer's recommended range of 272-700 ppm, indicating improper sanitization of kitchenware. The dishwasher was observed operating at temperatures below the manufacturer's minimum requirement of 120 degrees Fahrenheit, with readings between 114 and 118 degrees, which could affect the effectiveness of dish sanitization. The facility also failed to maintain proper food storage and serving temperatures. Coleslaw was served at 69 degrees Fahrenheit, above the safe serving temperature of 40 degrees, posing a risk for bacterial growth. In the grace unit nourishment room, a container of watermelon was found without a date label, and the contents appeared mushy and emitted an unpleasant odor, suggesting spoilage. These observations highlight significant lapses in food safety and sanitation practices within the facility.
Sanitation Deficiency in Kitchen Area
Penalty
Summary
The facility staff failed to maintain a sanitary environment in the kitchen, as observed on two separate occasions. Black and brown debris were visible on the floor under the three-compartment sink, under shelves, under the dishwasher, and in a gap between the stove and ovens. Additionally, similar debris and stains were noted on the floor in the dry goods storage room. During an interview, the dietary manager acknowledged that the dietary staff should sweep and mop the kitchen floors after every meal, including the areas under the sink, shelves, dishwasher, and between the stove and ovens. The dietary manager also mentioned that the stains in the dry goods storage room could not be removed by dietary staff and had requested housekeeping to strip and wax the floor. The facility's policy requires floors to be maintained in a clean, safe, and sanitary manner.
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 19 citations issued within 25 miles in the last 12 months — including the 2 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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Farmville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Farmville Health & Rehab Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Heritage Hall Dillwyn | 16.3 mi | ★★★★★ | 0 | 0 |
| Appomattox Health & Rehabilitation Center | 22.3 mi | ★★★★★ | 9 | 0 |
| Amelia Rehabilitation And Healthcare Center | 24.1 mi | ★★★★★ | 10 | 2 |
| Wayland Nursing And Rehabilitation Center | 24.7 mi | ★★★★★ | 0 | 0 |
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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.