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 |