Deficiency Records for The Suites at Holly Creek Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for The Suites at Holly Creek Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-08-29 | 2023-09-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-29 | 2023-09-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-29 | 2023-09-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-29 | 2023-09-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-29 | 2023-09-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-30 | 2023-09-06 | Y |
| Install proper backup exit lighting. | Fire Safety | 2023-08-29 | 2023-09-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-29 | 2023-09-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-29 | 2023-09-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-29 | 2023-09-06 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-08-29 | 2023-09-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-29 | 2023-09-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-31 | 2023-08-31 | N |
| 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. | Health | 2022-08-17 | 2022-09-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-22 | 2022-08-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-25 | 2022-06-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-25 | 2022-06-24 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-05-25 | 2022-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-12 | 2020-01-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-12 | 2019-12-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-12 | 2019-12-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-12 | 2019-12-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-01 | 2019-12-10 | N |
| Keep all essential equipment working safely. | Health | 2019-11-01 | 2019-11-25 | N |
