Deficiency Records for Holly Hill Healthcare Center
Updated as of January 01, 2019
This is not the most recent data for Holly Hill Healthcare Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-07-03 | 2018-10-05 | Y |
| 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 ne | Health | 2018-07-03 | 2018-10-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-03 | 2018-10-05 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-07-03 | 2018-08-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-07-03 | 2018-08-17 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-07-03 | 2018-08-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-07-03 | 2018-08-17 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-07-03 | 2018-08-17 | Y |
| Post nurse staffing information every day. | Health | 2018-07-03 | 2018-08-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-03 | 2018-08-17 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-07-03 | 2018-08-17 | 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 | 2018-07-03 | 2018-08-17 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-02-13 | 2018-03-01 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2018-02-13 | 2018-03-01 | Y |
| 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 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 |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2017-12-13 | 2018-01-22 | Y |
| 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 |
| 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 |
| Provide housekeeping and maintenance services. | Health | 2016-12-02 | 2017-01-06 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-12-02 | 2017-01-06 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-10-18 | 2016-12-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-10-18 | 2016-12-09 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2016-05-18 | 2016-07-01 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-05-18 | 2016-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-05-18 | 2016-07-01 | Y |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2016-05-18 | 2016-07-01 | Y |
| Quickly tell the resident's doctor the results of laboratory tests. | Health | 2016-05-18 | 2016-07-01 | Y |
| Approved construction type or materials. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Corridors that are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Protected exits that allow the resident to escape the building. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Exit stairways and towers that are smoke proof. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Exits that are accessible at all times. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Proper backup exit lighting. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Properly located and lighted "Exit" signs. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Properly protected cooking facilities. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Exits that are free from obstructions and can be used at all times. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Properly sized and located linen or trash receptacles. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Have other fire safety features required by fire safety codes. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2015-09-22 | 2015-11-23 | N |
| Send unopened mail from residents and promptly deliver unopened mail to residents. | Health | 2015-09-21 | 2015-10-23 | 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 | 2015-09-21 | 2015-10-23 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2015-09-21 | 2015-10-23 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2015-09-21 | 2015-10-23 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-09-21 | 2015-10-23 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2015-09-21 | 2015-10-23 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2015-09-21 | 2015-10-23 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2015-09-21 | 2015-10-23 | 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 | 2015-09-21 | 2015-10-23 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2015-09-21 | 2015-10-23 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-09-21 | 2015-10-23 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2015-09-21 | 2015-10-23 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2015-09-21 | 2015-10-23 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2015-09-21 | 2015-10-23 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2015-09-21 | 2015-10-23 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-09-13 | Not Fixed | Y |
