Deficiency Records for Holly Hill Healthcare Center

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Updated as of March 01, 2024

A list of the most recent deficiencies for Holly Hill Healthcare 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?
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2023-12-15 2024-01-10 Y
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 2023-12-15 2024-01-10 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-12-15 2024-01-10 Y
Ensure each resident receives an accurate assessment. Health 2023-12-15 2024-01-10 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-12-15 2024-01-10 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-12-15 2024-01-10 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-12-15 2024-01-10 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-12-15 2024-01-10 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-12-15 2024-01-10 Y
Ensure that residents are free from significant medication errors. Health 2023-12-15 2024-01-10 Y
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 2023-12-15 2024-01-10 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-12-15 2024-01-10 Y
Provide and implement an infection prevention and control program. Health 2023-12-15 2024-01-10 Y
Develop, implement, and/or maintain an effective training program for all new and existing staff members. Health 2023-12-15 2024-01-10 Y
Respond appropriately to all alleged violations. Health 2022-06-22 2022-08-24 Y
Provide care by qualified persons according to each resident's written plan of care. Health 2022-06-22 2022-08-24 Y
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2022-06-22 2022-08-24 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-06-22 2022-08-24 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2022-06-22 2022-08-24 Y
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Health 2022-06-22 2022-08-24 Y
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2022-06-22 2022-08-24 Y
Reasonably accommodate the needs and preferences of each resident. Health 2021-08-03 2021-09-03 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-08-03 2021-09-03 Y
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2021-08-03 2021-09-03 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-08-03 2021-09-03 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-08-03 2021-09-03 Y
Observe each nurse aide's job performance and give regular training. Health 2021-08-03 2021-09-03 Y
Post nurse staffing information every day. Health 2021-08-03 2021-09-03 Y
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 2021-08-03 2021-09-03 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-08-03 2021-09-03 Y
Provide and implement an infection prevention and control program. Health 2021-08-03 2021-09-03 Y
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2021-08-03 2021-09-03 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-08-03 2021-07-19 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2019-07-08 2019-07-31 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 2019-07-08 2019-07-31 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2019-07-08 2019-07-31 N
Install an approved automatic sprinkler system. Fire Safety 2019-07-08 2019-07-31 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2019-07-08 2019-07-31 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-07-08 2019-07-31 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-04-16 2019-06-07 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 2019-04-16 2019-06-07 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2019-04-16 2019-06-07 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 2019-04-16 2019-06-07 N
Respond appropriately to all alleged violations. Health 2019-04-16 2019-06-07 N
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2019-04-16 2019-06-07 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-04-16 2019-06-07 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2019-04-16 2019-06-07 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2019-04-16 2019-06-07 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-04-16 2019-06-07 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-04-16 2019-06-07 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2019-04-16 2019-06-07 N
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2019-04-16 2019-06-07 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 2019-04-16 2019-06-07 N
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2019-04-16 2019-06-07 N
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Health 2019-04-16 2019-06-07 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-04-16 2019-06-07 N
Provide and implement an infection prevention and control program. Health 2019-04-16 2019-06-07 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2019-04-16 2019-06-07 N
Have enough outside ventilation via a window or mechanical ventilation, or both. Health 2019-04-16 2019-06-07 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2018-01-10 2018-02-16 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 2018-01-10 2018-02-16 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2018-01-10 2018-02-16 N
Install corridor and hallway doors that block smoke. Fire Safety 2018-01-10 2018-02-16 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2018-01-10 2018-02-16 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2018-01-10 2018-02-16 N
Have simulated fire drills held at unexpected times. Fire Safety 2018-01-10 2018-02-16 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2017-12-13 2018-01-22 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 2017-12-13 2018-01-22 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2017-12-13 2018-01-22 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 2017-12-13 2018-01-22 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2017-12-13 2018-01-22 N
Assist a resident in gaining access to vision and hearing services. Health 2017-12-13 2018-01-22 N
Provide enough food/fluids to maintain a resident's health. Health 2017-12-13 2018-01-22 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Health 2017-12-13 2018-01-22 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2017-12-13 2018-01-22 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2017-12-13 2018-01-22 N
Ensure medication error rates are not 5 percent or greater. Health 2017-12-13 2018-01-22 N
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2017-12-13 2018-01-22 N
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2017-12-13 2018-01-22 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2017-12-13 2018-01-22 N
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Health 2017-12-13 2018-01-22 N
Provide special eating equipment and utensils for residents who need them and appropriate assistance. Health 2017-12-13 2018-01-22 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2017-12-13 2018-01-22 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2017-01-04 2017-03-15 N
Install proper backup exit lighting. Fire Safety 2017-01-04 2017-03-15 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2017-01-04 2017-03-15 N
Install corridor and hallway doors that block smoke. Fire Safety 2017-01-04 2017-03-15 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2017-01-04 2017-03-15 N
Have restrictions on the use of portable space heaters. Fire Safety 2017-01-04 2017-03-15 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2017-01-04 2017-03-15 N
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Health 2016-12-02 2017-01-06 N
Provide housekeeping and maintenance services. Health 2016-12-02 2017-01-06 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2016-12-02 2017-01-06 N
Provide care by qualified persons according to each resident's written plan of care. Health 2016-12-02 2017-01-06 N
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Health 2016-12-02 2017-01-06 N
Develop policies and procedures for influenza and pneumococcal immunizations. Health 2016-12-02 2017-01-06 N
Store, cook, and serve food in a safe and clean way. Health 2016-12-02 2017-01-06 N
Keep accurate, complete and organized clinical records on each resident that meet professional standards. Health 2016-12-02 2017-01-06 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Health 2016-12-02 2017-01-06 N