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Deficiency Records for Holly Manor Center

A list of the most recent deficiencies for Holly Manor 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 Manor 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?
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2023-06-02 2023-06-23 Y
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 2023-06-02 2023-06-23 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-06-02 2023-06-23 Y
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-01-27 2023-04-26 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2023-01-27 2023-03-17 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-01-27 2023-03-17 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-01-27 2023-03-13 N
Reasonably accommodate the needs and preferences of each resident. Health 2023-01-27 2023-03-03 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2023-01-27 2023-03-03 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 2023-01-27 2023-03-03 N
Provide enough food/fluids to maintain a resident's health. Health 2023-01-27 2023-03-03 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 2023-01-27 2023-03-03 N
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 2023-01-27 2023-03-03 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-01-27 2023-03-03 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-01-27 2023-03-03 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2023-01-27 2023-02-17 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-01-27 2023-01-30 N
Provide and implement an infection prevention and control program. Health 2021-02-05 2021-03-23 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-02-05 2021-03-22 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-10-07 2019-10-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-10-07 2019-10-25 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-10-07 2019-10-25 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2019-10-07 2019-10-25 N

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