A list of the most recent deficiencies for Holly Manor 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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-06-02 | 2023-06-23 | Y |
| 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 | 2023-06-02 | 2023-06-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-02 | 2023-06-23 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-27 | 2023-04-26 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-01-27 | 2023-03-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-27 | 2023-03-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-27 | 2023-03-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-27 | 2023-03-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-27 | 2023-03-03 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-27 | 2023-03-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-27 | 2023-03-03 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-27 | 2023-03-03 | N |
| 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 necessary and PRN use is limited. | Health | 2023-01-27 | 2023-03-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-27 | 2023-03-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-27 | 2023-03-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-27 | 2023-02-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-27 | 2023-01-30 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-07-13 | 2021-07-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-02-05 | 2021-03-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-02-05 | 2021-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-07 | 2019-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-07 | 2019-10-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-07 | 2019-10-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-07 | 2019-10-25 | N |
