Deficiency Records for Holly Manor Rehab and Nursing
Updated as of February 01, 2021
This is not the most recent data for Holly Manor Rehab and Nursing. For the most recent information, click here.
A list of the most recent deficiencies for Holly Manor Rehab and Nursing. 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? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2019-06-04 | 2019-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-06-04 | 2019-07-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-04 | 2019-07-04 | Y |
| 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 | 2019-03-08 | 2019-04-22 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-03-08 | 2019-04-22 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-03-08 | 2019-04-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-08 | 2019-04-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-08 | 2019-04-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-08 | 2019-04-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-27 | 2019-04-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-27 | 2019-04-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-27 | 2019-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-27 | 2019-04-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-27 | 2019-04-01 | N |
| Meet other general requirements. | Fire Safety | 2018-02-26 | 2018-04-12 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-02-26 | 2018-04-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-02-26 | 2018-04-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-26 | 2018-04-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-02-26 | 2018-04-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-26 | 2018-04-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-02-26 | 2018-04-12 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| Develop a communication plan. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| Establish methods for sharing information. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-02-08 | 2018-03-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-02-08 | 2018-03-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-02-08 | 2018-03-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-02-08 | 2018-03-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-08 | 2018-03-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-08 | 2018-03-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-02-08 | 2018-03-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-02-08 | 2018-03-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-02-08 | 2018-03-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-02-08 | 2018-03-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-08 | 2018-03-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-01-27 | 2017-03-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-01-27 | 2017-03-30 | N |
| Meet other general requirements. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Use approved construction type or materials. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-01-27 | 2017-03-16 | 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 | 2017-01-27 | 2017-03-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-01-27 | 2017-03-16 | N |
| Upon the death of a resident, convey the resident?s personal funds and an accounting of those funds to the appropriate party. | Health | 2017-01-11 | 2017-02-15 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-01-11 | 2017-02-15 | N |
| Keep complete, dated laboratory records in the resident's file. | Health | 2017-01-11 | 2017-02-15 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-01-11 | 2017-02-15 | N |
