CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Holly Manor Rehab and Nursing
View the most recent health deficiencies and inspection results for Holly Manor Rehab and Nursing. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Holly Manor Rehab and Nursing. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2025-06-05 | 2025-08-26 | Y |
| Post nurse staffing information every day. | Health | 2025-06-05 | 2025-08-26 | 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 | 2025-06-05 | 2025-08-26 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2025-06-05 | 2025-08-26 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-06-05 | 2025-08-26 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-06-05 | 2025-08-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-06-05 | 2025-08-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-06-05 | 2025-08-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-06-05 | 2025-08-26 | 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 | 2025-06-05 | 2025-08-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-06-05 | 2025-08-26 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2025-06-05 | 2025-08-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-06-05 | 2025-08-26 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2025-06-05 | 2025-08-26 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-06-05 | 2025-08-26 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2025-06-05 | 2025-08-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-06-05 | 2025-08-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-30 | 2024-10-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-30 | 2024-10-30 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-08-30 | 2024-10-30 | Y |
| Dispose of garbage and refuse properly. | Health | 2024-08-30 | 2024-10-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-08-30 | 2024-10-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-30 | 2024-10-30 | 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 | 2024-08-30 | 2024-10-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-08-30 | 2024-10-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-30 | 2024-10-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-30 | 2024-10-30 | 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 | 2024-08-30 | 2024-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-30 | 2024-10-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-30 | 2024-10-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-30 | 2024-10-30 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-08-30 | 2024-10-30 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2024-08-30 | 2024-10-30 | 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 | 2024-08-30 | 2024-10-30 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-08-30 | 2024-10-30 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-30 | 2024-10-30 | 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 necessary and PRN use is limited. | Health | 2024-08-30 | 2024-10-30 | 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 | 2024-08-30 | 2024-10-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-30 | 2024-10-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-08-30 | 2024-10-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-08-30 | 2024-10-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-30 | 2024-10-30 | 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 | 2024-08-30 | 2024-10-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-30 | 2024-10-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-30 | 2024-10-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-30 | 2024-10-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-08-30 | 2024-10-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-30 | 2024-10-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-07 | 2024-06-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-07 | 2024-06-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-07 | 2024-06-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-07 | 2024-06-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-07 | 2024-06-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-07 | 2024-06-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-12 | 2023-10-13 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-12 | 2023-10-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-12 | 2023-10-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-12 | 2023-10-13 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-11-17 | 2022-12-25 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-11-17 | 2022-12-25 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2022-11-17 | 2022-12-25 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-11-17 | 2022-12-25 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-11-17 | 2022-12-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-17 | 2022-12-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-17 | 2022-12-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-17 | 2022-12-25 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-11-17 | 2022-12-25 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-11-17 | 2022-12-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-17 | 2022-12-25 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-11-17 | 2022-12-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-17 | 2022-12-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-11-17 | 2022-12-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-17 | 2022-12-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-11-17 | 2022-12-25 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-11-17 | 2022-12-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-17 | 2022-12-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-17 | 2022-12-25 | 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 | 2022-11-17 | 2022-12-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-17 | 2022-12-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-17 | 2022-12-25 | 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 | 2022-11-17 | 2022-12-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-17 | 2022-12-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-17 | 2022-12-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-11-17 | 2022-12-25 | 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 | 2022-11-17 | 2022-12-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-17 | 2022-12-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-17 | 2022-12-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-17 | 2022-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-17 | 2022-11-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-30 | 2021-10-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-30 | 2021-10-08 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-30 | 2021-08-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-30 | 2021-08-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-30 | 2021-08-27 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-06-30 | 2021-08-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-30 | 2021-08-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-30 | 2021-08-01 | 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 | 2021-06-30 | 2021-08-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-30 | 2021-08-01 | 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 | 2021-06-30 | 2021-08-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-30 | 2021-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-30 | 2021-08-01 | N |