Deficiency Records for Holly Hill House
Updated as of April 01, 2021
This is not the most recent data for Holly Hill House. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-10 | 2020-03-20 | 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 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 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-02 | 2019-08-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-02 | 2019-08-23 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-08-02 | 2019-08-23 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-08-02 | 2019-08-23 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-08-02 | 2019-08-23 | 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 | 2019-06-25 | 2019-07-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-03-14 | 2019-04-15 | 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 | 2019-03-14 | 2019-04-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-14 | 2019-04-15 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2019-01-10 | 2019-02-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-01-10 | 2019-02-11 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-01-10 | 2019-02-11 | N |
| 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. | Health | 2019-01-10 | 2019-02-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-01-10 | 2019-02-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-10 | 2019-02-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-01-10 | 2019-02-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-10 | 2019-02-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-10 | 2019-02-11 | 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 | 2019-01-10 | 2019-02-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-10 | 2019-02-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-10 | 2019-02-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-01-10 | 2019-02-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-10 | 2019-02-11 | 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 | 2019-01-07 | 2019-01-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-01-07 | 2019-01-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-07 | 2019-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-07 | 2019-01-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-07 | 2019-01-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-01-07 | 2019-01-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-07 | 2019-01-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-07 | 2019-01-21 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-08-29 | 2018-09-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-28 | 2018-04-10 | N |
| Dispose of garbage and refuse properly. | Health | 2018-02-28 | 2018-04-10 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-02-28 | 2018-04-10 | 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 | 2018-02-26 | 2018-04-04 | N |
