Above 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 Pulaski Hlth & Rehab Cntr during CMS and state inspections, most recent first.
Staff did not consistently implement a resident's care plan intervention requiring fall mats on both sides of the bed, leaving one side without a mat despite the resident's high fall risk and history of falls. The omission was observed during a survey, and staff confirmed the intervention was not in place as required.
Facility staff did not document a skin assessment in the clinical record after an allegation of staff-to-resident abuse, despite a nurse performing the assessment and the DON's expectation for such documentation. A resident with severe cognitive impairment and multiple medical conditions had prior bruising noted, but no new findings were recorded or documented after the incident.
The facility failed to ensure a safe environment by not maintaining adequate documentation for a pet, Pet #1, regarding its health, vaccinations, and training. The pet was observed walking unleashed and growling in a kennel. The facility's policy required pets to be disease-free, cleared by a veterinarian, and trained, but documentation was incomplete. The Administrator confirmed the lack of documentation and stated they were awaiting further information.
A resident, severely cognitively impaired and with multiple diagnoses, was not provided a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) when discharged from Medicare Part A services with days remaining. The facility's social worker communicated with the resident's POA about the transition to long-term care but did not issue the SNFABN, citing the resident's move to private pay for comfort care. This was contrary to the facility's policy, which requires an SNFABN in such situations.
A resident's care plan was not updated to reflect a change from thickened to thin liquids as per a physician's order, despite the facility's policy requiring ongoing updates. The resident, with diagnoses including Dementia and Dysphagia, had a swallow study indicating the need for thin liquids, but the care plan still focused on thickened liquids. This issue was discussed with facility leadership, but no additional information was provided before the survey exit conference.
A resident with Type 2 Diabetes Mellitus did not have a verbal order for insulin transcribed, nor was the administration documented, despite a high blood sugar reading. An LPN administered the insulin after consulting with an NP, but failed to document it, and the DON confirmed that a verbal order should have been entered. Facility policies on documenting verbal orders and medication administration were not adhered to.
A resident on a 1,200 ml/day fluid restriction due to hyponatremia was not properly monitored or educated about their fluid intake. Staff interviews revealed a lack of understanding and communication regarding the restriction, and the facility's policy on fluid restriction was not followed. The resident's fluid intake exceeded the restriction, and there was no documentation of education or compliance monitoring.
The facility failed to act on drug regimen review recommendations for two residents, leading to deficiencies in medication management. One resident, with severe cognitive impairment, had multiple DRRs unreviewed by the medical provider, including a recommendation for an AIMS test that was delayed. Another resident, with severe decision-making and communication impairments, had unaddressed recommendations for lab work and medication dose reduction. The facility's policy required physician review and signature within 30 days, which was not followed.
A resident with severe cognitive impairment and multiple health conditions did not receive the prescribed 14-day course of Invanz and Culturelle due to a transcription error. The medications were administered for only 10 days, contrary to the provider's orders. The error was acknowledged by the facility's staff, including the DON, and discussed with the administration.
A resident was found with medications at their bedside without proper orders or a locked storage box, contrary to facility policy. The resident, who was cognitively intact, had been using these medications routinely, but staff were unaware, and no safety assessment had been conducted.
A resident did not receive ordered laboratory tests, including a CMP, CBC, and lactic acid level, due to facility staff's failure to obtain them. The tests were ordered following a nurse practitioner's visit for cellulitis and generalized weakness. The DON confirmed the oversight, and the facility's policy requires licensed nurses to ensure completion and communication of such tests.
A resident with severe cognitive impairment and other medical conditions was not provided with a recommended divided plate to aid in self-feeding. Despite the recommendation from a COTA, the resident was observed with a regular glass plate. The deficiency was due to a lack of communication and documentation, as the COTA did not document the need, and dietary staff were unaware of the request. The facility's policy on assistive devices was not followed.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
Facility staff failed to consistently implement the comprehensive care plan for a resident with multiple risk factors for falls, including dementia, repeated falls, muscle weakness, anxiety, and osteoporosis. The resident's care plan specifically required fall mats to be placed on each side of the bed due to their high fall risk and history of falls, including incidents resulting in minor injury. During a surveyor's observation, it was noted that there was no fall mat on the left side of the resident's bed, contrary to the care plan's directive. Both fall mats were found on the right side of the bed, which was confirmed by the unit manager as not meeting the care plan's requirements. Review of facility documentation and staff interviews revealed that the omission occurred after the certified nursing assistant had assisted the resident to the toilet and failed to return the fall mat to its proper position. The facility's Falls Management Program policy requires that identified interventions, such as fall mats, be incorporated into the care plan and implemented accordingly. Despite these policies and the resident's documented need for bilateral fall mats, the intervention was not consistently maintained, as evidenced by the surveyor's findings and staff acknowledgment.
Failure to Document Post-Abuse Allegation Skin Assessment
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for one resident following an allegation of staff-to-resident abuse. After the allegation was reported, a registered nurse performed a skin assessment on the resident but did not document the assessment in the clinical record, as she stated she found no new findings. The resident had significant medical conditions, including congestive heart failure, altered mental status, aphasia, cerebral infarction, and cognitive communication deficit, with a recent assessment indicating severe cognitive impairment. Previous skin assessments noted bruising attributed to medication injections and blood draws, but no new documentation was made after the abuse allegation. Interviews with staff revealed that the nurse did not document the post-allegation skin assessment because she believed documentation was only necessary if new findings were present. The director of nursing stated that the expectation was for a head-to-toe skin assessment to be documented in the clinical record following any abuse allegation, either under the assessments tab or in a nursing progress note. The facility was unable to provide a specific policy regarding the accuracy of documentation in the clinical record, only a general policy on nursing care and services.
Inadequate Documentation for Facility Pet
Penalty
Summary
The facility staff failed to ensure a safe environment due to inadequate documentation regarding the training, health, and vaccinations of a pet, referred to as Pet #1, present at the facility. The surveyor observed Pet #1, a dog, walking unleashed within the facility and later heard it growling from a wire pet kennel. The facility's Administrator confirmed that Pet #1 was considered a center pet and reported no injuries related to animals at the facility. However, the facility's policy required that pets be disease-free, cleared by a veterinarian, and have obedience training, none of which were adequately documented for Pet #1. The documentation for Pet #1 was incomplete, lacking the veterinarian's name, address, and contact information. The records showed that Pet #1 received parasite control and vaccinations, but there was no evidence of a veterinarian's clearance or obedience training by a certified trainer. The Administrator acknowledged the absence of this documentation and stated they were awaiting information from the veterinarian. Additionally, it was confirmed that Pet #1 was not required to be on a leash while in the facility, and it would only interact with residents if its owner was present.
Failure to Provide SNFABN for Resident Transitioning from Medicare Part A
Penalty
Summary
The facility staff failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) for a resident who was discharged from Medicare Part A services while still having skilled benefit days remaining. The resident, who was severely cognitively impaired with a BIMS score of 1 out of 15, had diagnoses including pneumonitis, dysphagia, generalized muscle weakness, and dementia. The facility's social worker communicated with the resident's power of attorney (POA) about the Notice of Medicare Non-coverage (NOMNC) and the transition to long-term care, but did not issue a SNFABN as required by the facility's policy. The surveyor reviewed the facility's policy, which mandates the issuance of an SNFABN when a patient is coming off a Part A stay with days left in the benefit period and remaining in the facility. Despite this policy, the social worker did not provide the SNFABN, reasoning that the resident transitioned from skilled care to private pay for comfort care. The survey team discussed this concern with the facility's administration, but no further information was provided before the exit conference.
Failure to Update Care Plan for Dietary Changes
Penalty
Summary
The facility staff failed to revise the comprehensive care plan for a resident, identified as Resident #53, to reflect the discontinuation of thickened liquids as per the physician's order. The resident had a diagnosis list that included Dementia, Dysphagia, Transient Ischemic Attack (TIA), and Cognitive Communication Deficit. The most recent Minimum Data Set (MDS) assessment indicated that the resident was moderately impaired in cognition. Despite a physician's order dated June 15, 2023, indicating a regular diet with thin liquids, the care plan was not updated to reflect this change. The care plan still focused on a mechanically altered diet with thickened liquids, with the last revision noted on July 1, 2024. The surveyor's review of the clinical record revealed a skilled note from June 15, 2023, indicating that the resident was now on thin liquids following a swallow study. However, the care plan was not updated accordingly, despite the facility's policy stating that care plans should be updated on an ongoing basis as changes in the patient occur. This deficiency was discussed with the facility's administration and clinical services team during meetings on July 23 and 24, 2024, but no further information was provided to the survey team before the exit conference.
Failure to Document Insulin Administration for a Resident
Penalty
Summary
The facility staff failed to provide services that met professional standards of clinical practice for a resident diagnosed with Type 2 Diabetes Mellitus, among other conditions. On a specific date, the staff did not transcribe a verbal medical provider order for administering ten units of insulin to the resident, whose blood sugar level was recorded at 410. The medication administration record (MAR) indicated a code that referred to a progress note, but there was no documentation of the insulin administration or a provider order in the resident's clinical record. During an interview, a licensed practical nurse (LPN) stated that she administered the insulin after consulting with a nurse practitioner, assuming the note would verify the administration. However, there was no documentation to confirm the medication was given, including the time and amount. The director of nursing (DON) acknowledged that a verbal order should have been entered to allow documentation on the MAR. Facility policies reviewed by the surveyor outlined the procedures for documenting verbal orders and medication administration, which were not followed in this instance.
Failure to Maintain Fluid Restriction for Resident
Penalty
Summary
The facility staff failed to maintain an appropriate fluid and electrolyte balance for a resident, identified as Resident #66, who was on a 1,200 ml/day fluid restriction due to hyponatremia. Despite the physician's order, the resident was not aware of the fluid restriction, and the staff did not adequately monitor or document the fluid intake. The resident's tray cards indicated fluid amounts that exceeded the restriction, and there was no documentation of the resident's noncompliance or education about the restriction. Interviews with staff revealed a lack of understanding and communication regarding the fluid restriction, with CNAs unsure of how to monitor or document fluid intake and the RN unable to explain the reason for the restriction. The facility's policy on fluid restriction required patient education and documentation of fluid intake, but these procedures were not followed. The Treatment Administration Records (TAR) lacked a section to document the amount of fluid provided per shift, and the resident's clinical record did not show any indication of education or compliance monitoring. The Registered Dietician confirmed the fluid restriction was for hyponatremia, but the Nurse Practitioner noted no clinical indications for the restriction after reviewing the resident's medical records. The deficiency was discussed with the facility's administration, but no further information was provided before the exit conference.
Failure to Act on Drug Regimen Review Recommendations
Penalty
Summary
The facility staff failed to act upon drug regimen review (DRR) recommendations for two residents, leading to deficiencies in medication management. For Resident #32, the facility did not provide evidence that the medical provider acted upon DRRs conducted on multiple dates, including 8/26/23, 9/26/23, 1/26/24, and 3/25/24. The resident, diagnosed with Dementia, Anxiety Disorder, and Generalized Muscle Weakness, was severely cognitively impaired with a BIMS score of 7 out of 15. The DRR on 10/27/23 recommended an AIMS test due to the resident's antipsychotic medication, but the test was not conducted until 6/20/24. The medical provider failed to review or sign the DRRs, and the facility's policy required such reviews within 30 days. For Resident #54, the facility did not provide evidence that the medical provider reviewed or acted upon DRRs dated 1/26/24 and 3/25/24. The resident, with diagnoses including Zoster Encephalitis and Hemiplegia, was severely impaired in decision-making and communication. The January DRR recommended routine lab work for Depakote, which was not found in the clinical record, and the March DRR suggested a dose reduction for Omeprazole, which was not implemented. The facility's policy required the physician to review and sign the DRRs within 30 days, but this was not done, leading to unaddressed medication recommendations.
Medication Administration Error for a Resident
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, specifically in the administration of Invanz and Culturelle. The resident, who was severely cognitively impaired with a BIMS score of 5 out of 15, had multiple diagnoses including Type 2 Diabetes Mellitus, Heart Failure, and a Urinary Tract Infection. The provider's orders dated 7/5/24 specified that Invanz and Culturelle were to be administered for 14 days. However, the medications were only administered for 10 days as per the July 2024 MAR, indicating a discrepancy between the provider's orders and the actual administration. The nurse practitioner confirmed that the order was transcribed incorrectly, leading to the medications being administered for only 10 days instead of the prescribed 14 days. This error was acknowledged by the Director of Nursing, who agreed that the order was entered incorrectly, necessitating an additional 4 days of medication to be added to the resident's treatment. The facility's policy on Non-Controlled Medication Orders requires accurate transcription of medication orders, which was not adhered to in this case. This issue was discussed with the facility's administration and clinical services team, but no further information was provided to the survey team before the exit conference.
Medication Storage Deficiency
Penalty
Summary
The facility staff failed to ensure the safe and secure storage of medications for one resident, who was found to have a bottle of Tums, a bottle of saline nasal spray, and a partial tube of diclofenac sodium topical gel on their bedside table. The resident, who was cognitively intact, stated that they had been taking these medications routinely for years and that the nurses applied the diclofenac gel on their legs. Upon review of the clinical record, there were no orders for these medications, indicating a lack of documentation and oversight. When interviewed, the resident mentioned that they did not have a locked box for their medications and were unsure if the staff was aware of their possession of these medications. A registered nurse confirmed that residents should not have medications at bedside and was unaware of the resident's situation. The facility's policy on self-administration of medications requires a safety assessment and interdisciplinary team review, which had not been conducted for this resident. This oversight led to the deficiency in medication management and storage.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility staff failed to provide necessary laboratory services for a resident, identified as Resident #22, who had a medical provider's order for a comprehensive metabolic panel (CMP), complete blood count (CBC), and a lactic acid blood level. These tests were ordered on 7/12/24 to be conducted on 7/13/24 following a nurse practitioner's visit for cellulitis and generalized weakness. Despite the order, the surveyor's review of the clinical record revealed that the results of these tests were not available, indicating that the tests were not performed. The Director of Nursing (DON) confirmed to the surveyor that the lab tests were not obtained after speaking with the laboratory. The facility's policy on Laboratory/Diagnostic Testing, effective from 1/29/24, mandates that a licensed nurse is responsible for obtaining and tracking all provider-ordered laboratory tests to ensure completion and communication of results. The deficiency was discussed with the Administrator, Regional Director of Clinical Services, and the DON, but no further information was provided before the exit conference on 7/24/24.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility staff failed to provide appropriate assistive devices to a resident, identified as Resident #21, who required a divided plate to aid in self-feeding. Despite the recommendation from a Certified Occupational Therapy Assistant (COTA) for the use of a divided plate, the resident was observed on multiple occasions with a regular glass plate instead. The resident, who has severe cognitive impairment and other medical conditions such as Type 2 Diabetes Mellitus, Dementia, and Dysphagia, was not provided with the necessary assistive device to maintain or improve her ability to eat independently. The deficiency was further compounded by a lack of communication and documentation. The COTA did not document the need for a divided plate in the resident's notes or issue a diet communication slip, as dietary staff had informed her that there were not enough divided plates available. Additionally, the dietary manager and other staff members were unaware of how the divided plate request appeared on the meal ticket, indicating a breakdown in communication. The facility's policy on providing assistive devices was not adhered to, as evidenced by the absence of a divided plate for the resident, despite it being listed on the meal ticket.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Pulaski
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Ridge Rehab Center | 5.2 mi | ★★★★★ | 18 | 0 |
| Radford Health And Rehab Center | 11.3 mi | ★★★★★ | 0 | 0 |
| Holston Health & Rehabilitation | 19.4 mi | ★★★★★ | 0 | 0 |
| Wythe Cnty Community Hosp Ecu | 20.2 mi | ★★★★★ | 4 | 0 |
| The Wybe And Marietje Kroontje Health Care Center | 20.7 mi | ★★★★★ | 0 | 0 |
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