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Deficiency Records for Holly Hill Healthcare Center
A list of the most recent deficiencies for Holly Hill Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Holly Hill Healthcare 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? |
|---|---|---|---|---|
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-14 | 2024-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-14 | 2024-06-14 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2024-03-14 | 2024-06-14 | 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 | 2024-03-14 | 2024-05-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-03-14 | 2024-05-16 | 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 | 2024-03-14 | 2024-05-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-14 | 2024-05-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-03-14 | 2024-05-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-14 | 2024-05-16 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-03-14 | 2024-05-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-14 | 2024-05-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-14 | 2024-05-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-03-14 | 2024-05-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-05 | 2024-04-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-05 | 2024-04-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-03-05 | 2024-04-15 | N |
| 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 | 2024-03-05 | 2024-04-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-05 | 2024-04-15 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-03-05 | 2024-04-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-03-05 | 2024-04-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-03-05 | 2024-04-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-05 | 2024-04-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-05 | 2024-04-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-03-05 | 2024-04-15 | 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 | 2024-03-05 | 2024-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-05 | 2024-04-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-05 | 2024-04-15 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-03-05 | 2024-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-05 | 2024-04-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-05 | 2024-04-15 | 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 | 2024-03-05 | 2024-04-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-03-05 | 2024-04-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-05 | 2024-04-15 | 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 | 2024-03-05 | 2024-04-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-05 | 2024-04-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-05 | 2024-04-15 | 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 | 2024-03-05 | 2024-04-15 | 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 | 2024-03-05 | 2024-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-05 | 2024-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-05 | 2024-04-15 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2024-03-05 | 2024-04-15 | N |
| Respond appropriately to all alleged violations. | Health | 2024-03-05 | 2024-04-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-05 | 2024-04-15 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-03-05 | 2024-04-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-05 | 2024-04-15 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-12-15 | 2024-01-10 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-12-15 | 2024-01-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-15 | 2024-01-10 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-15 | 2024-01-10 | 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 | 2023-12-15 | 2024-01-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-15 | 2024-01-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-15 | 2024-01-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-15 | 2024-01-10 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-15 | 2024-01-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-15 | 2024-01-10 | Y |
| 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 | 2023-12-15 | 2024-01-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-15 | 2024-01-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-15 | 2024-01-10 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-12-15 | 2024-01-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-22 | 2022-08-24 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2022-06-22 | 2022-08-24 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-22 | 2022-08-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-22 | 2022-08-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-22 | 2022-08-24 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-06-22 | 2022-08-24 | 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 | 2022-06-22 | 2022-08-24 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-08 | 2019-07-31 | 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 | 2019-07-08 | 2019-07-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-08 | 2019-07-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-08 | 2019-07-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-08 | 2019-07-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-08 | 2019-07-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-16 | 2019-06-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-04-16 | 2019-06-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-16 | 2019-06-07 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-04-16 | 2019-06-07 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-16 | 2019-06-07 | N |
| 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 | 2019-04-16 | 2019-06-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-16 | 2019-06-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-04-16 | 2019-06-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-16 | 2019-06-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-16 | 2019-06-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-16 | 2019-06-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-16 | 2019-06-07 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-04-16 | 2019-06-07 | 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 | 2019-04-16 | 2019-06-07 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-04-16 | 2019-06-07 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2019-04-16 | 2019-06-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-16 | 2019-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-16 | 2019-06-07 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-04-16 | 2019-06-07 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2019-04-16 | 2019-06-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-01-10 | 2018-02-16 | 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 | 2018-01-10 | 2018-02-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-01-10 | 2018-02-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-01-10 | 2018-02-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-01-10 | 2018-02-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-01-10 | 2018-02-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-10 | 2018-02-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-13 | 2018-01-22 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2017-12-13 | 2018-01-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-13 | 2018-01-22 | 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 | 2017-12-13 | 2018-01-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2017-12-13 | 2018-01-22 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2017-12-13 | 2018-01-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2017-12-13 | 2018-01-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2017-12-13 | 2018-01-22 | 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 | 2017-12-13 | 2018-01-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2017-12-13 | 2018-01-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2017-12-13 | 2018-01-22 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2017-12-13 | 2018-01-22 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2017-12-13 | 2018-01-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2017-12-13 | 2018-01-22 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2017-12-13 | 2018-01-22 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2017-12-13 | 2018-01-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2017-12-13 | 2018-01-22 | N |
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