A list of the most recent deficiencies for Holly Hill House. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-28 | 2024-01-26 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-25 | 2023-10-30 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-09-25 | 2023-10-30 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-09-25 | 2023-10-30 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-09-25 | 2023-10-30 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-04-10 | 2023-04-26 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-01 | 2023-04-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-01 | 2023-04-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-01 | 2023-04-26 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-03-01 | 2023-04-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-01 | 2023-04-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-01 | 2022-11-30 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-11-01 | 2022-11-30 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-01 | 2022-11-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-20 | 2022-02-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-06 | 2020-02-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-06 | 2020-02-28 | N |
| 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. | Health | 2020-02-06 | 2020-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-06 | 2020-02-28 | 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 | 2020-02-10 | 2020-02-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-30 | Not Fixed | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-30 | Not Fixed | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-30 | Not Fixed | Y |
