Deficiency Records for The Suites at Holly Creek Care Center
Updated as of September 01, 2023
This is not the most recent data for The Suites at Holly Creek Care Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-09-10 | 2020-10-23 | Y |
| 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 |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-04 | 2018-12-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-04 | 2018-12-13 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-10-04 | 2018-12-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-31 | 2018-12-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-31 | 2018-12-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-31 | 2018-12-10 | N |
| Provide activities to meet all resident's needs. | Health | 2018-10-04 | 2018-12-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-10-04 | 2018-11-26 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-10-31 | 2018-11-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-31 | 2018-11-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-10-04 | 2018-11-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-10-04 | 2018-11-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-04 | 2018-11-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-04 | 2018-11-15 | N |
| 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. | Health | 2018-10-04 | 2018-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-04 | 2018-11-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-04 | 2018-11-07 | 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 | 2018-10-04 | 2018-11-07 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-10-04 | 2018-11-07 | N |
