Holly Hall

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #37) of 4 residents and 3 of 3 confidential group residents reviewed for resident rights. The facility failed to provide showers to Resident #37 and 3 of 3 confidential group residents. This failure could affect the residents who require assistance with their ADLs from facility staff by placing them at risk for social isolation, loss of dignity, and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 1 (Resident #37) and 3 of 5 confidential residents reviewed for ADLs. The facility did not consistently provide Resident #37 and 3 of 5 confidential residents bed baths/showers on their scheduled shower days in the month of September 2025. This failure could place residents at risk of skin breakdown and reduced feelings of self-worth.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #9 ) reviewed for quality of care. 1. The facility failed to assess, follow-up with treatment, update the care-plan, obtain new order due to a change in resident #9's skin condition of the groin and resident's report of pain, at which time the penis split measured 1. 8 cm length by 0.5 cm width and appeared red and raw, which was first identified on 9/22/25 and failed to ensure that Resident #9's indwelling catheter (drains urine from your bladder into a bag outside your body) had a securement device to anchor catheter.2. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each resident had acceptable parameters of nutritional status such as usual body weight or desirable body weight range for discharged (DC #1) Resident and 8 of 8 residents reviewed for weight loss. 1. The facility failed to maintain acceptable parameters of nutritional status such as usual body weight or desirable body weight range for 1 of 1 discharged resident (DC) #1 and 8 of 8 (Resident #7, Resident #9, Resident #10, Resident #16, Resident #23, Resident #29, Resident #37 and Resident #42) residents, reviewed for weight loss. 2. The facility failed to ensure 3 of 3 scales used for weight were calibrated accurately. 3. The facility failed to follow up with significant weight losses discovered on 09/10/2025 for DC #1, Resident #7, Resident #9, Resident #10, Resident #23, Resident #29, and Resident #42. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that its medication error rate was not 5 percent or greater. The medication error rate was 22 percent with 8 errors out of 36 opportunities involving 3 of 3 staff members (MA A, MA B and LVN R) and 2 of 7 residents (Resident #14, Resident #39, Resident #37 and Resident #18) reviewed for medication administration. MA A did not administer Vitamin D (medicine used to maintain strong, healthy bones) and Carvedilol (a medication used to help your heart by lowering blood pressure) to Resident #14 as ordered by the physician on 9/30/25. MA A did not administer Ferrous Sulfate (a drug used to treat iron -deficiency anemia) as ordered by the Physician on 9/30/2025 to Resident #39. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents were free of significant medication errors for 2 (Resident #14 and Resident #18) of 5 residents reviewed for pharmacy services. MA A did not administer Carvedilol (medication used to help your heart by lowering blood pressure) to Resident #14 as ordered by the physician on 9/30/25. LVN did not administer Lisinopril (used to treat high blood pressure by relaxing your blood vessels) via Gastrostomy Tube. She crushed the medications into a powder form in each medication cup, dissolved it in water. LVN R did not ensure she got all the medication out of the medication cup during administration, as ordered by the physician to Resident#18 on 10/1/2025.

Inspectors wroteBased on record review and interview, the facility failed to file in the resident's clinical record of radiologic and other diagnostic services for 2 of 8 (Residents #3, #4) residents reviewed for clinical records. -Resident #3's blood test result ordered on 9/14/2025 was not in his medical records reviewed on 10/08/2025.-Resident #4's blood test results ordered on 2/8/2025, 3/16/2025, 3/18/2025 and 4/11/2025 were not in his medical records reviewed on 10/08/2025. This failure puts residents at risk of not having a complete picture of their current health status in their records.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 (Resident #18) of 3 residents for the administration of medication via gastrostomy in that: -LVN R did not administer medication by gravity via gastrostomy tube, per the facility policy, for Resident #18's medication on 10/1/25. This failure placed residents at risk for aspiration (choking), unwanted hospitalization, and decrease in quality of life.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for one (Nurse Cart A) of three medication carts reviewed for storage of medications. Nurse Cart A had multiple medications open, some had no names and the open date was not written on the medications. [BR1] This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion.

Inspectors wroteBased on record review and interview, the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 8 residents (Resident #5) reviewed for clinical records. -Resident #5's labs ordered on 07/31/2025 and 08/09/2025 had collection dates of 08/04/2025 and 08/12/2025 respectively. This failure puts residents at risk of not getting timely care for their conditions. Record review of Resident #5's face sheet dated 10/07/2025 reflected a [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE] with medical diagnoses including chronic kidney disease, Parkinson's Disease (a chronic and progressive neurological disorder affecting movement other bodily functions), atherosclerotic heart disease (plaque buildup leading to hardening of the arteries), and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation.-There were 5 boxes of angel hair spaghetti with a best if used by date of 01/29/2025 in the dry storage room. The failure could place residents at risk of foodborne illness and food contamination. During an observation on 09/30/2025 at 8:35am, the surveyor and the DM observed 5 rectangular boxes of angel hair spaghetti on a shelf of the dry storage room with best if used by date of 01/29/2025. The DM took the boxes, reviewed the dates and threw them in the trash in the main kitchen area. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 of 3 Residents (Residents #9) and 1 of 2 staff (CNA A) reviewed for infection control. 1. CNA A failed to perform hand hygiene between glove changes when providing incontinent care for Resident #9 on 10/2/25. These failures could place residents at risk for spread of infection and cross contamination. [...]

Inspectors wroteBased on observation, interview and review, the facility failed to dispose of garbage and refuse properly for their only dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster door was closed. This failure could place residents at risk of infection from improperly disposed garbage. Observation of the dumpster area and interview with the DM on 09/30/2025 at 8:35am, revealed the metal dumpster door was left a quarter of the way open, and some cardboard containers were observed in the dumpster. The DM said it wasn't supposed to be open and he fully closed the door which then began to compress the trash. He reminded staff to ensure the dumpster door was closed while walking back into the building. He said the door should be closed to maintain a clean area, and he had no concerns with pests. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene for 1 of 5 (Resident #1) residents reviewed for ADL care. The facility failed to provide Resident #1 showers as scheduled. The facility failed to provide, the necessary care and services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and care plan This failure could place residents who are dependent on staff for ADL care at risk for loss of dignity, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure personnel provided basic life support including CPR to a resident in an emergency situation and subject to related physician orders and the resident's advance directive. (CR #1). --CR #1 received CPR when he had a physician signed out of hospital DNR, which was not on the resident's electronic medical record. This failure placed residents with DNR status at risk of not having their preferences honored in the event of an emergency.

Inspectors wroteBased on observation, record review and interview the facility failed to provide a safe, clean and comfortable environment for 3 of 6 (Resident #1, Resident #2 and Resident 3) residents reviewed for resident rights, in that: 1. The facility failed to ensure Resident #1's shower was free of dried fecal residue on the floor and wall. 2. The facility failed to ensure Resident #2's room was free of clutter on the floors of her room. 3. The facility to ensure Resident #3's room was free of odors. This failure could have placed residents at risk of living in unsanitary, unclean living environments that could diminish their quality of life.

Inspectors wroteBased on observation, interview and record reviews the facility failed to ensure a resident that was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 4 (Resident #1 and Resident #3) reviewed for Activities of Daily Living. 1. The facility failed to ensure Resident #1's adult brief was checked and changed as needed. 2. The facility failed to ensure Resident #3 was given scheduled showers. This failure could affect all dependent residents that required staff assistance with activities of daily living and could result in poor hygiene and skin breakdown. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care for 3 (Residents #16, #179, #12) out of 35 residents reviewed for antipsychotics in that: 1. The facility failed to obtain a written consent for the administration of Seroquel (antipsychotic) 25mg 1 PO Q12hr from Resident #16 or his legal representative. 2. The facility failed to obtain a written consent for the administration of Risperidone (antipsychotic) 1mg PO BID and Seroquel (antipsychotic) 50mg PO QHS from Resident #179 or her legal representative. 3. The facility failed to obtain a written consent ftom Resident #12 or his legal representative, for the administration of Imipramine HCL (antidepressant) 10mg 1 PO QHS, until ten days after the resident had already been taking the medication. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement baseline care plan with the necessary information to provide care for each resident within 48 hours of admission for 3 residents reviewed for baseline care plans (Resident # 79, 179, 182). --The facility failed to include required components in the base-line care plans for Residents #79 admitted [DATE], #179 admitted [DATE], and #182 admitted [DATE]. This failure could affect newly admitted residents and place them at risk of not receiving proper care and services based on their current conditions for continuity of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from unnecessary anti-psychotropic drugs, and residents who use anti-psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, for 3 (Resident #16, Resident #179, Resident #12) of 35 residents reviewed for Psychotropic Medication use in that: 1. Resident #16 did not have an adequate indication for usage of Seroquel (antipsychotic) 25mg BID. Resident #16 did not have an adequate reason documented as to why a gradual dose reduction of the Seroquel 25mg BID was not done, and the resident had been on it since 10/5/22. 2. Resident #179 did not have an adequate indication for usage of Risperidone (antipsychotic) 1mg PO BID and Seroquel 50mg QHS. 3. Resident #12 did not have an adequate indication for usage of Imipramine (antidepressant) 10mg QD. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food preparation and storage in that: -One of one commercial can opener was not kept clean and in a sanitary condition. -The facility failed to ensure that dented can good were removed from the shelve. -The facility failed to ensure expired food items were removed from the dry goods storage. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after the facility completed the resident's assessment for 1 of 3 closed records reviewed for MDS assessments. (CR #6) The facility failed to transmit to the CMS system CR #6's discharge MDS assessment dated [DATE]. This failure could place the residents at risk for not having the MDS assessment transmitted as required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 (Resident #181) out of 1 resident sampled for respiratory care in that: LPN TS failed to assess Resident #181, including his lungs, before providing respiratory treatment. This failure could place residents at risk for a change in condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained for 1 (Hall 200 Nurse Cart) out of 3 medication carts sampled for medication storage in that: -Hall 200 Nurse's Cart (Labeled HC South) had an actual count of 8 Tramadol 50mg tablets for Resident #182, when the resident's-controlled drug receipt/record/disposition form documented 11. This failure could place residents at risk of running out of their medications by the facility not ordering the medication timely, and risk of maintaining their highest practicable mental, physical, and psychosocial well-being. Findings Include: [...]