Deficiencies (last 3 years)
Deficiencies (over 3 years)
18.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
358% worse than Louisiana average
Louisiana average: 4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
44% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 27, 2025
Visit Reason
The inspection was conducted due to complaints and allegations regarding resident abuse, failure to timely report injuries, inadequate investigation of abuse allegations, failure to notify the Ombudsman of facility-initiated transfers, and failure to implement comprehensive care plans for residents requiring 1:1 supervision.
Complaint Details
The complaint investigation substantiated multiple deficiencies including failure to protect residents from abuse, failure to timely report injuries, inadequate abuse investigations, failure to notify the Ombudsman of transfers, and failure to implement required 1:1 supervision care plans.
Findings
The facility was found deficient in protecting residents from physical abuse by other residents, timely reporting of injuries of unknown origin, conducting thorough investigations of abuse allegations, notifying the State Long-Term Care Ombudsman of facility-initiated transfers, and implementing comprehensive person-centered care plans with required 1:1 supervision for residents with behavioral needs.
Deficiencies (5)
F 0600: The facility failed to protect Resident #2 from physical abuse when Resident #3 slapped Resident #2 in the face on 08/09/2025.
F 0609: The facility failed to timely report an injury of unknown origin to the Administrator and state agency within 2 hours for Resident #4's hematoma discovered on 08/03/2025.
F 0610: The facility failed to conduct a thorough investigation of an abuse allegation involving Resident #4, interviewing only one employee despite policy requiring multiple staff interviews.
F 0628: The facility failed to notify the State Long-Term Care Ombudsman of a facility-initiated transfer for Resident #1 in July 2025.
F 0656: The facility failed to implement a comprehensive person-centered care plan with 1:1 supervision for Residents #1 and #3 after documented suicidal ideation and resident-to-resident altercation.
Report Facts
Residents reviewed for abuse: 4
Incident date: Aug 9, 2025
Incident time: 1520
Injury report date: Aug 3, 2025
Transfer date: Jul 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S6CNA | Certified Nursing Assistant | Witnessed and reported resident-to-resident altercation involving Resident #2 and Resident #3. |
| S4LPN | Licensed Practical Nurse | Intervened during resident-to-resident altercation and confirmed abuse incident. |
| S3ADON | Assistant Director of Nursing | Confirmed awareness of abuse incidents and reviewed investigations and documentation. |
| S1ADM | Administrator | Responsible for submitting critical incident reports and investigations. |
| S5LPN | Licensed Practical Nurse | Failed to timely report Resident #4's injury of unknown origin. |
| S10NP | Nurse Practitioner | Issued orders for 1:1 supervision for Residents #1 and #3 after suicidal ideation and altercation. |
Inspection Report
Routine
Census: 88
Deficiencies: 11
Date: Apr 15, 2025
Visit Reason
Routine inspection of Holly Hill House nursing facility to assess compliance with regulatory requirements including resident rights, safety, medication management, dietary services, and quality assurance.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity by providing plastic utensils and disposable cups, inadequate cleanliness in resident rooms, failure to refer a resident for PASARR evaluation, failure to follow physician orders, improper respiratory equipment labeling and storage, insufficient RN coverage, medication availability and review issues, unlocked medication cart, dietary noncompliance, improper food storage, and lack of effective QAPI documentation.
Deficiencies (11)
F 0550: The facility failed to maintain dignity for 2 residents by providing plastic utensils and disposable drinking cups instead of metal utensils and non-disposable cups during dining.
F 0584: The facility failed to maintain cleanliness in 3 resident rooms and their property, including dust accumulation on floors and wheelchairs.
F 0644: The facility failed to refer 1 resident with a diagnosed mental disorder to the appropriate state authority for Level II PASARR evaluation.
F 0656: The facility failed to follow physician's orders for 1 resident by continuing to administer Buspirone after a discontinuation order.
F 0695: The facility failed to ensure respiratory equipment was labeled, dated, and stored properly for 4 residents.
F 0727: The facility failed to ensure an RN was on duty for at least 8 consecutive hours on 3 dates.
F 0755: The facility failed to ensure routine drugs were available for 1 resident and failed to respond timely to pharmacist recommendations for 4 residents.
F 0761: The facility failed to ensure medication cart was locked when unattended.
F 0803: The facility failed to serve 1 resident her recommended gastroparesis diet and failed to honor her food dislikes.
F 0812: The facility failed to properly label and date food items and failed to discard spoiled vegetables in the kitchen.
F 0865: The facility failed to maintain effective Quality Assurance and Performance Improvement (QAPI) documentation and monitoring.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 4
Dates without RN coverage: 3
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7DM | Dietary Manager | Confirmed dietary noncompliance and food storage issues |
| S3ADON | Assistant Director of Nursing | Confirmed medication administration and pharmacist recommendation issues |
| S9LPN | Licensed Practical Nurse | Confirmed medication cart was left unlocked |
| S1ADM | Administrator | Acknowledged RN coverage gaps and QAPI documentation issues |
| S2DON | Director of Nursing | Confirmed RN coverage gaps and lack of QAPI documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 26, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to resolve a resident grievance within the required timeframe.
Complaint Details
The complaint was substantiated. The grievance filed on 01/07/2025 regarding odor and a soiled brief for Resident #3 was not resolved until 01/28/2025, exceeding the facility's 5 working day policy.
Findings
The facility failed to resolve a grievance within 5 working days as required by its grievance policy for one resident. The grievance related to odor and a soiled brief and was resolved 21 days after it was filed.
Deficiencies (1)
F 0585: The facility failed to resolve a resident grievance within 5 working days as required by the grievance policy. The grievance concerning odor and a soiled brief was resolved 21 days after filing.
Report Facts
Days to resolve grievance: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding grievance resolution delay | |
| Administrator | Interviewed regarding grievance resolution delay |
Inspection Report
Complaint Investigation
Capacity: 82
Deficiencies: 3
Date: Feb 12, 2025
Visit Reason
The inspection was conducted to investigate allegations of failure to timely report suspected abuse, neglect, or injury and to ensure accurate resident assessments and appropriate treatment according to orders.
Complaint Details
The complaint investigation found the facility failed to timely report critical incidents involving abuse, neglect, or injury for 9 residents. The facility also failed to complete accurate resident assessments and neurological checks post-fall as required.
Findings
The facility failed to timely report critical incidents involving abuse, neglect, or injury for 9 residents. Additionally, the facility failed to complete accurate Minimum Data Set assessments for one resident and failed to perform complete neurological checks following unwitnessed falls for two residents.
Deficiencies (3)
F 0609: The facility failed to timely report suspected abuse, neglect, or injury and failed to report investigation results to proper authorities for 9 residents.
F 0641: The facility failed to ensure accurate Minimum Data Set assessments for 1 resident, incorrectly indicating medication use.
F 0684: The facility failed to provide appropriate neurological checks for 72 hours following unwitnessed falls for 2 residents.
Report Facts
Residents affected: 9
Total census: 82
Residents reviewed for accident/hazards: 3
Residents with incomplete neuro checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1ADM | Administrator | Responsible for reporting critical incidents; confirmed lack of access to state reporting system and unawareness of pending incidents |
| S4MDS | Minimum Data Set Coordinator | Confirmed inaccurate MDS medication reporting for Resident #1 |
| S3ADON | Assistant Director of Nursing | Confirmed incomplete neurological checks for Resident #1 |
| S2ADON | Assistant Director of Nursing | Confirmed incomplete neurological checks for Resident #3 |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 11, 2024
Visit Reason
The inspection was conducted to evaluate compliance with hospice service provision and collaboration between the facility and hospice agency as part of a plan of correction.
Findings
The facility failed to ensure the hospice agency provided services according to the agreement and facility policy for one of three sampled residents by not maintaining up-to-date hospice nurse visit notes in the resident's hospice binder. The last documented hospice nurse visit notes were dated 09/27/2024, and the facility administrator acknowledged a lack of follow-up with the hospice agency regarding missing notes.
Deficiencies (1)
F 0849: The facility failed to collaborate with the hospice agency to ensure hospice nurse visit notes were current in the resident's hospice binder. The last hospice nurse visit notes were dated 09/27/2024, missing subsequent documentation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Facility administrator (S1ADM) interviewed regarding missing hospice visit notes and failure to follow up with hospice agency. |
Inspection Report
Routine
Capacity: 78
Deficiencies: 3
Date: Oct 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, abuse prevention, and care plan implementation at Holly Hill House nursing facility.
Findings
The facility failed to notify the physician or charge nurse of a significant change in a resident's condition, failed to protect a resident from physical abuse by another resident, and failed to ensure services were provided as outlined in the comprehensive care plan, including monitoring urinary output and anticoagulant side effects.
Deficiencies (3)
F 0580: The facility failed to ensure a Licensed Practical Nurse notified the physician and/or charge nurse when a resident had a significant change in condition related to decreased urinary output.
F 0600: The facility failed to protect a resident from physical abuse by another resident, with the abuse confirmed as a willful and intentional act.
F 0656: The facility failed to provide services as outlined in the comprehensive care plan for a resident by not monitoring and recording foley catheter urinary output and side effects of anticoagulants as required.
Report Facts
Total census: 78
Urinary output: 100
Urinary output range: 350
Urinary output range: 800
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4LPN | Licensed Practical Nurse | Named in failure to notify physician of significant change in resident condition |
| S1DON | Director of Nursing | Confirmed significance of resident's urinary output change and abuse incident |
| S2ADON | Assistant Director of Nursing | Confirmed documentation failures and care plan requirements |
| S6LPN | Licensed Practical Nurse | Witnessed and documented resident abuse incident |
| S5LPN | Licensed Practical Nurse | Interviewed regarding anticoagulant monitoring documentation |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 5, 2024
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements related to resident care, nutrition, and facility operations at Holly Hill House nursing home.
Findings
The facility failed to ensure residents were weighed as ordered, resulting in unaddressed significant weight loss for some residents. Nutritional interventions and dietitian recommendations were not consistently implemented. Dietary services were inadequately staffed, causing delayed meal delivery and missed snacks. Residents did not consistently receive meals matching their prescribed diets and preferences.
Deficiencies (4)
F 0656: The facility failed to develop and implement complete care plans ensuring residents were weighed per physician orders, with no documentation of weights for multiple residents over the required monitoring period.
F 0692: The facility failed to provide enough food and fluids to maintain residents' health, including failure to assess and intervene for severe weight loss and to implement registered dietitian recommendations.
F 0802: The facility failed to provide sufficient dietary staff to serve meals within 45 minutes of scheduled times for 84 residents, resulting in delayed meal and snack delivery.
F 0806: The facility failed to ensure residents received diets and preferences as described on diet cards, with frequent substitutions and missing items, negatively impacting nutritional intake and dining experience.
Report Facts
Residents reviewed for nutrition: 20
Residents affected by weight monitoring deficiency: 20
Residents affected by nutritional support deficiency: 2
Residents affected by dietary staffing deficiency: 84
Residents affected by diet and preference errors: 5
Percent weight loss: 9.39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2ADON | Assistant Director of Nursing | Confirmed residents' admission dates, orders for weights, and failure to obtain weights as ordered; confirmed dietitian recommendations were not implemented |
| S7DM | Dietary Manager | Reported meal service delays, confirmed missed snacks, and acknowledged substitutions without resident notification |
| S9CNA | Certified Nursing Assistant | Reported inconsistent meal service times and delays |
| S4CNA | Certified Nursing Assistant | Confirmed residents received incorrect milk types and did not check diet slips before serving |
| S3LPN | Licensed Practical Nurse | Reported Hall 3 did not receive 2:00 p.m. snacks regularly |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 2
Date: Jun 10, 2024
Visit Reason
The inspection was conducted due to complaints regarding inadequate supplies of incontinence briefs and clean linens, and failure to follow physician's orders for timely x-rays.
Complaint Details
The investigation was complaint-driven based on reports of insufficient supplies of incontinence briefs and linens, and failure to follow physician's orders for x-rays. The complaint was substantiated with findings of inadequate supplies and delayed x-ray care.
Findings
The facility failed to provide appropriate sized incontinence briefs to 74 incontinent residents and failed to maintain a sufficient number of clean linens, including towels and washcloths, affecting 89 residents. Additionally, the facility failed to follow physician's orders for obtaining an x-ray timely for one resident, causing a delay in care.
Deficiencies (2)
F 0600: The facility failed to protect residents from neglect by not providing sufficient clean linens, including towels and washcloths, and appropriate sized incontinence briefs for 74 residents.
F 0656: The facility failed to develop and implement a complete care plan by not following physician's orders for timely x-rays for one resident, causing a delay in care.
Report Facts
Residents affected by insufficient briefs: 74
Residents census affected: 89
Incontinence brief packs observed: 20
Incontinence brief boxes observed: 10
Towels available at 1st observation: 51
Washcloths available at 1st observation: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2DON | Director of Nursing | Confirmed inadequate linen and brief supplies and participated in observations and interviews |
| S1ADN | Administrator | Responsible for supply orders and confirmed no extra linens in storage |
| S6CNA | Certified Nursing Assistant | Observed assembling incontinence briefs due to lack of appropriate sizes |
| S3ADON | Assistant Director of Nursing | Confirmed frequent lack of appropriate sized briefs and delayed x-ray completion |
| S12MR/CS | Medical Records/Central Supply | Responsible for order supply lists and confirmed supply shortages |
| S4LPN | Licensed Practical Nurse | Confirmed resident fall and delayed x-ray order completion |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, infection control, food safety, and implementation of Enhanced Barrier Precautions.
Findings
The facility was found deficient in ensuring accurate resident assessments, timely referrals for PASARR evaluations, comprehensive care plans including monitoring for antibiotic adverse reactions, proper food storage and sanitation, and implementation of Enhanced Barrier Precautions for residents with indwelling devices or wounds. Several residents were not on required precautions, and staff lacked awareness of policies.
Deficiencies (6)
F0641: The facility failed to ensure the MDS assessment accurately reflected antidepressant use for Resident #61, who was not prescribed antidepressants but was coded as using them.
F0644: The facility failed to refer Resident #55 with a newly diagnosed Delusional Disorder for a Level II PASARR evaluation as required.
F0656: The facility failed to implement a comprehensive care plan for Resident #10 that included monitoring for adverse reactions to antibiotic use, with no documentation of such monitoring.
F0812: The facility failed to store food properly and maintain sanitary kitchen conditions, including expired foods in refrigerators, freezers, and dry storage, and unclean food carts.
F0835: The facility failed to implement Enhanced Barrier Precautions for 8 residents with indwelling devices or wounds, and administration was unaware of the policy requirements.
F0880: The facility failed to provide and implement an infection prevention and control program by not ensuring Enhanced Barrier Precautions were in place for residents with indwelling catheters or PEG tubes, with staff unaware of the precautions and lack of signage and PPE.
Report Facts
Residents sampled: 33
Residents investigated for PASARR: 4
Residents affected by Enhanced Barrier Precautions deficiency: 8
Total residents reviewed for infection control: 74
Residents affected by food safety deficiency: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4MDS nurse | Confirmed Resident #61 was not prescribed antidepressants and MDS coding error | |
| S3ADON (Assistant Director of Nursing) | Confirmed failure to resubmit Level II PASARR for Resident #55 and lack of Enhanced Barrier Precautions knowledge | |
| S7LPN (Licensed Practical Nurse) | Confirmed no monitoring orders for antibiotic adverse reactions for Resident #10 and lack of knowledge of Enhanced Barrier Precautions | |
| S1DietarySup (Dietary Supervisor) | Confirmed kitchen sanitation deficiencies and expired food items | |
| S4ADON (Assistant Director of Nursing) | Confirmed lack of Enhanced Barrier Precautions implementation and unawareness of policy requirements | |
| S2ADM (Administrator) | Confirmed awareness of Enhanced Barrier Precautions policy but lack of implementation | |
| S8RDO (Regional Director of Operations) | Confirmed facility administration failed to implement Enhanced Barrier Precautions | |
| S9IMD (Interim Medical Director) | Unaware of Enhanced Barrier Precautions policy and lack of implementation | |
| S6LPN (Licensed Practical Nurse) | Confirmed lack of Enhanced Barrier Precautions knowledge and absence of PPE and signage for Residents #35 and #68 | |
| S5LPN (Licensed Practical Nurse) | Confirmed Resident #75 had urinary catheter and no knowledge of Enhanced Barrier Precautions |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 4
Date: Apr 9, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, and failure to provide proper care at the nursing home.
Complaint Details
The complaint investigation substantiated multiple abuse incidents including sexual abuse of Resident #1 by Resident #2 on 03/02/2024, physical abuse of Resident #2 by Resident #5 on 03/14/2024, and physical abuse of Resident #3 by Resident #4 on 03/09/2024. The facility also failed to protect residents from abuse and neglect.
Findings
The facility failed to protect residents from abuse, failed to develop comprehensive care plans for some residents, and failed to provide proper respiratory care and personal funds management. Multiple incidents of physical and sexual abuse among residents were documented, along with deficiencies in care plan implementation and medication administration.
Deficiencies (4)
F 0568: The facility failed to provide quarterly statements of personal funds for Resident #7, affecting the potential census of 80 residents.
F 0600: The facility failed to protect residents #1, #2, and #3 from sexual and physical abuse by other residents, resulting in psychosocial and physical harm.
F 0656: The facility failed to develop comprehensive care plans for Residents #2, #4, and #7, including failure to identify sexual dysfunction, follow medication orders, and plan for BiPAP use.
F 0695: The facility failed to properly store respiratory equipment for Resident #7, including BiPAP and nebulizer masks, and lacked a respiratory equipment storage policy.
Report Facts
Residents affected: 80
Residents affected: 7
Missed medication doses: 43
Missed oxygen tubing changes: 3
Missed oxygen concentrator filter cleanings: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Licensed Practical Nurse | Reported and confirmed abuse incident involving Resident #2 grabbing Resident #1's breast and Resident #5 hitting Resident #2 |
| S1ADON | Assistant Director of Nursing | Confirmed incidents of abuse, care plan deficiencies, and respiratory equipment storage issues |
| S6ADM | Administrator | Acknowledged awareness of sexual abuse incident and lack of respiratory equipment storage policy |
| S8CNA | Certified Nursing Assistant | Witnessed and reported physical abuse incidents between residents |
| S10CNA | Certified Nursing Assistant | Witnessed and reported physical abuse incidents between residents |
| S2MDS | Minimum Data Set Nurse | Confirmed care plan deficiencies for Resident #2 and Resident #7 |
| S5LPN | Licensed Practical Nurse | Verified medication administration and care for Resident #4 |
| S7LPN | Licensed Practical Nurse | Confirmed improper storage of Resident #7's respiratory equipment |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 26, 2024
Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to provide ordered medications to a resident.
Complaint Details
The investigation was triggered by a complaint regarding medication administration errors for Resident #3. The complaint was substantiated as the facility failed to provide ordered medications, confirmed by record reviews and staff interviews.
Findings
The facility failed to obtain and administer routine medications as ordered by the physician for Resident #3, resulting in significant medication errors. Medications scheduled for administration on 03/02/2024 were not available or administered, despite physician orders and nurse documentation.
Deficiencies (2)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of Resident #3 by not obtaining routine medications as ordered by the physician. Medications were not available or administered on 03/02/2024.
F 0760: The facility failed to ensure residents were free from significant medication errors for Resident #3. Medications scheduled for 03/02/2024 were not administered due to unavailability, despite physician orders.
Report Facts
Residents sampled: 3
Residents affected: 1
Medication administration date: Mar 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 LPN | Licensed Practical Nurse | Provided care for Resident #3 and reported no medications were available on 03/02/2024 |
| S2 DON | Director of Nursing | Confirmed medications were not available and should have been administered |
| S3 ADON | Assistant Director of Nursing | Reviewed medication administration records and confirmed medications were not administered |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 3
Date: Jan 30, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, notification procedures, and treatment standards.
Findings
The facility failed to notify the State Long Term Care Ombudsman of a facility-initiated transfer, did not document monitoring of behaviors and adverse reactions for residents on antipsychotic and antidepressant medications, and failed to complete required neuro checks after an unwitnessed fall with head injury.
Deficiencies (3)
F 0623: The facility failed to notify the State Long Term Care Ombudsman of a facility-initiated transfer for 1 of 3 sampled residents. The Emergency Transfer Log did not document the hospital transfer of Resident #1 on 12/31/2023.
F 0656: The facility failed to implement a complete care plan by not documenting monitoring of behaviors and adverse reactions for 2 of 3 residents receiving antipsychotic or antidepressant medications.
F 0684: The facility failed to provide appropriate treatment by not completing 72 hours of neuro checks after an unwitnessed fall with head injury for 1 of 3 sampled residents.
Report Facts
Residents affected: 61
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4SSD | Responsible for Emergency Transfer Log and interviewed regarding transfer documentation | |
| S2DON | Director of Nursing interviewed regarding transfer and medication monitoring | |
| S3ADON | Assistant Director of Nursing interviewed regarding medication monitoring and neuro checks |
Inspection Report
Census: 64
Deficiencies: 1
Date: Dec 28, 2023
Visit Reason
The inspection was conducted to assess compliance with physician's orders and care plan implementation for residents, focusing on medication administration and treatment adherence.
Findings
The facility failed to ensure nursing personnel followed physician's orders for three sampled residents, resulting in multiple missed applications of prescribed creams and medications given contrary to orders.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions. Nursing personnel did not follow physician's orders for three sampled residents.
Report Facts
Missed doses of barrier cream: 43
Hydralazine doses administered below systolic BP threshold: 19
Facility census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed and confirmed nursing shifts and medication administration issues | |
| S3LPN | Licensed Practical Nurse | Confirmed administration of Hydralazine against physician's orders |
| Director of Nursing | Confirmed missing doses and medication errors |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 25, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medication, failure to provide basic life support and notify EMS during an emergency, failure to monitor and assess a resident with significant respiratory status changes, and failure to maintain documented evidence of staff training.
Deficiencies (4)
F 0554: The facility failed to assess 1 of 1 residents for self-administration of medication by the Interdisciplinary Team to determine clinical appropriateness.
F 0678: The facility failed to ensure nursing staff provided Basic Life Support, including notifying EMS for an unresponsive resident with full code status according to policy.
F 0726: The facility failed to assess and monitor a resident with a significant change in respiratory status, including failure to document and report changes and provide timely interventions.
F 0940: The facility failed to maintain documented evidence of an effective training program for all new and existing staff members.
Report Facts
Residents sampled: 3
Residents affected: 1
Personnel records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4RN | Registered Nurse | Named in findings related to failure to provide BLS, failure to assess respiratory status, and lack of training documentation |
| S5CNA | Certified Nursing Assistant | Named in findings related to failure to provide BLS and lack of training documentation |
Inspection Report
Census: 63
Deficiencies: 1
Date: Apr 10, 2023
Visit Reason
The inspection was conducted to evaluate the facility's management of residents' personal money, specifically the provision of individual financial records through quarterly statements or upon request.
Findings
The facility failed to provide individual financial records to two of five sampled residents, with quarterly trust statements not being mailed or given to residents as required. Interviews confirmed the lack of documentation and inability to locate confirmation of statement distribution.
Deficiencies (1)
F 0568: The facility failed to properly hold, secure, and manage each resident's personal money by not providing individual financial records through quarterly statements or upon request for 2 of 5 sampled residents.
Report Facts
Residents affected: 2
Sampled residents: 5
Census: 63
Monthly amount received: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Confirmed quarterly trust statements had not been mailed or given to residents | |
| S1Adm | Confirmed inability to locate confirmation of quarterly trust statements distribution |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 4
Date: Mar 1, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations, including feeding tube care, antibiotic stewardship, immunization policies, and COVID-19 vaccination procedures.
Findings
The facility failed to properly label enteral feeding for residents, did not implement an antibiotic stewardship program, failed to provide pneumococcal immunizations to eligible residents, and lacked policies and documentation for COVID-19 vaccinations and refusals.
Deficiencies (4)
F 0693: The facility failed to ensure enteral feeding bags were properly labeled with resident name, formula type, date/time prepared, infusion rate, and staff initials for 2 residents receiving enteral nutrition.
F 0881: The facility failed to implement an antibiotic stewardship program and did not monitor antibiotic use as required by policy. The census was 52.
F 0883: The facility failed to provide pneumococcal immunization for 1 of 5 residents sampled, lacking documentation of vaccination, contraindication, or refusal.
F 0887: The facility failed to develop and implement policies and procedures to ensure residents were offered and educated on the COVID-19 vaccine and failed to document refusals for 5 residents sampled.
Report Facts
Facility census: 52
Residents prescribed antibiotics: 7
Residents prescribed antibiotics: 8
Residents prescribed antibiotics: 6
Residents sampled for immunizations: 33
Residents affected by pneumococcal immunization deficiency: 1
Residents affected by COVID-19 vaccination deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3DON/IP | Director of Nursing/Infection Preventionist | Named in antibiotic stewardship and vaccination deficiencies |
| S4LPN | Licensed Practical Nurse | Named in enteral feeding labeling deficiency |
| S2AADM | Assistant Administrator | Named in pneumococcal and COVID-19 vaccination deficiencies |
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