Federal Nursing-Home Survey Record
Holston Health and Rehabilitation
Does Holston Health and Rehabilitation have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Holston Health and Rehabilitation (CCN 495349), in WYTHEVILLE, VA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 32 deficiencies; the most serious carries scope/severity K on CMS's A–L scale, a level CMS classifies as Immediate Jeopardy. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $111,911 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
At its most recent federal inspection, CMS cited this facility for an Immediate Jeopardy deficiency.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Civil money penalties on file
$111,911
CMS has $111,911 in civil money penalties on file against this facility.
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 1 · CMS state average: 3.0
Deficiency timeline — full federal history
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide safe, appropriate pain management for a resident who requires such services.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure services provided by the nursing facility meet professional standards of quality.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Allow residents to self-administer drugs if determined clinically appropriate.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Prepare residents for a safe transfer or discharge from the nursing home.
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide enough food/fluids to maintain a resident's health.
Provide safe and appropriate respiratory care for a resident when needed.
Provide care or services that was trauma informed and/or culturally competent.
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure that residents are free from significant medication errors.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Provide timely, quality laboratory services/tests to meet the needs of residents.
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Employ staff that are licensed, certified, or registered in accordance with state laws.
Provide and implement an infection prevention and control program.
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
28 citations from earlier inspection cycles — historical, not current (expand)
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide enough food/fluids to maintain a resident's health.
Provide and implement an infection prevention and control program.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Keep all essential equipment working safely.
Assess the resident when there is a significant change in condition
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Ensure services provided by the nursing facility meet professional standards of quality.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide safe and appropriate respiratory care for a resident when needed.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Perform COVID19 testing on residents and staff.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Document what happened
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