A list of the most recent deficiencies for Holly Hall. 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 residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-08 | 2023-07-28 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-06-08 | 2023-07-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-08 | 2023-07-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-08 | 2023-07-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-08 | 2023-07-28 | 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 | 2023-06-08 | 2023-07-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-08 | 2023-07-28 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-06 | 2023-07-21 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-04-28 | 2022-06-13 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-28 | 2022-06-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-28 | 2022-06-13 | 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 | 2022-04-28 | 2022-06-13 | Y |
| Post nurse staffing information every day. | Health | 2022-04-28 | 2022-06-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-28 | 2022-06-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-28 | 2022-05-16 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-28 | 2022-05-16 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-10 | 2022-03-15 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-31 | 2019-08-23 | N |
| 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 | 2019-07-31 | 2019-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-31 | 2019-08-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-31 | 2019-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-31 | 2019-08-01 | N |
