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? |
|---|---|---|---|---|
| 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 services provided by the nursing facility meet professional standards of quality. | 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 food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-12 | 2023-10-13 | Y |
| 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | 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 |
| Observe each nurse aide's job performance and give regular training. | 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 |
| Ensure that residents are free from significant medication errors. | 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 staff that are licensed, certified, or registered in accordance with state laws. | 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 |
| 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 the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-17 | 2022-12-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-17 | 2022-12-25 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-11-17 | 2022-12-25 | N |
| 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 | Y |
| 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 | 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 | 2022-11-17 | 2022-12-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-17 | 2022-12-25 | Y |
| 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 | 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 | 2022-11-17 | 2022-12-25 | Y |
| 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 | Y |
| 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 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2022-11-17 | 2022-12-25 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-11-17 | 2022-12-25 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-02 | 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 |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-06 | 2021-10-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-06 | 2021-10-08 | N |
| Use approved construction type or materials. | Fire Safety | 2021-07-06 | 2021-08-27 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-07-06 | 2021-08-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-06 | 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 | 2021-07-06 | 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 |
| 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 |
