Holly Hill Healthcare Center

Inspectors wroteBased on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure that residents received the necessary monitoring to promote their well-being. This was evident of one (Resident #5) out of six residents reviewed during this complaint survey.

Inspectors wroteBased on observations, staff and resident interviews, it was determined that the facility failed to ensure that call bells were kept within reach for residents to utilize. This was found to be evident in 5 (Residents #26, #9, #3, #43, and #46) of 36 residents reviewed during the investigation phase of the annual survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to 1) treat a resident with dignity by exposing the resident to a public area and 2) ensure that resident rights were maintained by knocking prior to entering a resident's room. This was found to be evident for 1 (Resident #35) of 1 residents reviewed for dignity and 2 out of several observations of Resident #1 and #6's room and during the annual survey.

Inspectors wroteBased on interviews and record review the facility failed to provide quarterly statements to the resident's representative. This was evident for 1 (Resident #8) of 3 residents reviewed for personal funds during the annual survey.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure Resident #23 was free from physical restraints. This was evident for 1 (Resident #23) of 1 residents reviewed for physical restraints during the annual survey.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of a resident enrollment in hospice. This was found to be evident for 1 (Resident #70) out of 1 resident reviewed for hospice services during the survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure a baseline care plan was developed and implemented for a resident who was unable to move or feel anything below their neck (including arms and legs). This was evident for 1 (Resident #1) out of 7 residents investigated for care planning.

Inspectors wroteBased on interview, record review, and observations, it was determined that the facility staff failed to maintain professional standards of practice related to signing off resident care orders. This was evident for 2 out of 2 days observed for Resident #1's arm splint.

Inspectors wroteBased on observations, medical record review, and interview, it was determined that the facility failed to ensure that residents with orders for orthopedic devices were wearing them as prescribed and device administration was being appropriately documented. This was found to be evident in 1 (Resident #3) of 2 residents reviewed for limited range of motion during the annual survey.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the facility staff implemented interventions consistent with a resident's plan of care to avoid a fall. This was evident for 1 (Resident #1) out of 4 residents reviewed for accidents.

Inspectors wroteBased on observations, medical record review, and staff interviews, it was determined that the facility failed to provide necessary respiratory care services by failing to maintain an ambu bag at bedside per physician order. The was found to be evident in 1 (Resident #9) of 1 resident reviewed for respiratory care during the annual survey.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to obtain informed consent and document alternatives attempted prior to initiation of bedrails. This was evident for 1 (Resident #1) out of 1 resident reviewed for bedrails for an annual survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure infection control practices were maintained during medication administration. This was evident for 1 (Resident #27) out of 4 residents observed for medication administration.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure a safe and comfortable environment for residents and staff. This was evident during multiple observations during the annual survey.

Inspectors wroteBased on review of a facility reported incident with investigation, medical record review, and interviews, it was determined the facility staff failed to protect a cognitively impaired resident from physical abuse from facility staff. This was evident for 2 (#6, and #11) of 3 residents reviewed for abuse during a complaint survey. This resulted in actual harm to resident #6.

Inspectors wroteBased on the interview with facility staff, it was determined that the facility failed to have a full time (Full-time means working 35 or more hours a week) clinically qualified Food Service Director. This was evident for 1 of 1 Food service Director reviewed for required credentialing.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents at the facility.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to ensure that all laundry was processed and handled in a manner that prevents cross contamination and the spread of infections by failing to keep the door closed that separated the clean from the soiled area of the laundry room. This was evident for 1 of 1 laundry rooms and had the potential to affect all residents.

Inspectors wroteBased on interview, observation and record review, it was determined that the facility failed to provide reasonable accommodations to maintain residents' independence by failing to provide adequate bed side lighting that was accessible to residents with decreased mobility. This was evident for 14 rooms out of 16 rooms, observed during a survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to notify the resident/resident's representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 3 (#27, #15 and #33) of 4 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to notify residents and/or their representatives in writing of the bed-hold policy upon transfer of residents to an acute care facility. This was evident for 3 (#27, #15, #33) of 4 residents reviewed for hospitalizations.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility staff failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory time frames to facilitate appropriate care planning and maintain current and accurate assessment records. This was evident for 3 (#37, #57, #59) of 44 residents reviewed during the survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility, 1) failed to ensure that interdisciplinary team (IDT) care plan meetings were scheduled after each Minimum Data Set (MDS) assessment, and 2) failed to ensure that resident care plans were reviewed and revised by the IDT after each MDS assessment. This was evident for 4 (Resident #6, #9, #21, #16) of 4 residents reviewed for care planning, and 1 (Resident #70) of 2 residents reviewed for activities of daily living.

Inspectors wroteBased on observation, interviews, and records review, it was determined that the facility failed to provide the resident with an ongoing program for activities based on individual preference and the comprehensive assessment. This was evident for 3 (Resident #33, #70, #16) of 6 residents reviewed for activities.

Inspectors wroteBased on observation, medical record review, and staff interviews, it was determined that the facility failed to maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. This was evident for 3 (#9, #49, #68) of 43 residents, reviewed during the survey. Maryland MOLST (Maryland Orders for Life Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. If an updated MOLST form is completed, all older forms shall be voided in accordance with the MOLST's instructions: Voiding the Form: [...]

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to maintain the residents' dignity, by staff standing over residents while assisting them to eat. This was evident for 2 Residents (Resident #38 and #42) observed in one dining area out of the three dining areas in the facility.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to residents who were discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 2 (#51, #57) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse. This was evident for 3 (Resident #68, # 23, and # 53) of 12 residents reviewed for abuse during a survey.

Inspectors wroteBased in record review and interview, it was determined that the facility failed to communicate the residents comprehensive care plan goal to the receiving healthcare institution to ensure safe and effective transition of care. This was evident for 1 (Resident #33) of 4 residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (Resident #27) of 4 residents reviewed for hospitalization.

Inspectors wroteBased on observation, medical record review and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (#15, #33, #6) of 44 residents reviewed during the survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that the Level II Preadmission screening and resident review (PASARR) screen was completed by Adult Evaluation and Review Services (AERS) before the resident's admission. This was evident for 1 (Resident #9) of 1 resident reviewed for PASARR compliance.

Inspectors wroteBased on the review of medical records, and staff interviews, it was determined that the facility failed to provide the resident and or their representative with a summary of the baseline care plan. This was evident for 1 (Resident # 119 ) of 33 residents reviewed for baseline care plans.

Inspectors wroteBased on interviews, record review and observation, it was determined that the facility failed to 1) provide a resident with the amount of assistance needed during meals, according to the facility's assessment of the resident ability to feed himself, and 2) ensure that a resident who required assistance with activities of daily living (ADL) was assisted with putting his/her dentures in their mouth during meal times. This was evident for 1 (Resident #23) of 2 residents reviewed for Activities of Daily Living (ADLs) and for 1 (#15) of 5 residents reviewed for Dental.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure the administration of a complete course of antibiotics as ordered. This was evidenced for 1 (Resident #118) out of 5 residents reviewed for un necessary medication.

Inspectors wroteBased on observation, record review, and staff interview, it was determined that the facility failed to ensure and check the functionality of the wander guard, as ordered. This was evident for 1 (Resident # 119) of 1 Resident reviewed for potential elopement during the survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that colostomy care was provided to a resident with a colostomy. This was evident for 1 (#15) of 1 resident reviewed with a colostomy.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to follow physicians' orders for the administration of oxygen. This was evident for 1 (Resident # 17) of 4 residents reviewed for respiratory care during a survey.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to ensure that pain managementwas provided to the resident that was consistent with professional standards of practice. This was evident for 1 (Resident #16) of 3 residents reviewed for pain management.

Inspectors wroteBased on the surveyor's observation, record review, and interview with facility staff, it was determined that the facility failed to assess safety or obtain a physician's order before initiating the usage of side rails, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent. This was evident for 2 (Residents #6, and #9) of 2 residents reviewed for side rails.

Inspectors wroteBased on records review, interviews, and observations, it was determined that the facility failed to develop a care plan that reflects an individualized, person-centered approach with measurable goals and specific interventions to care for and treat a resident with dementia. This was evident for 1 (Resident #38) of 1 resident reviewed for dementia care.

Inspectors wroteBased on review of medical records and narcotic count sheets, and interviews, it was determined that the facility failed to keep an accurate record of controlled substances. This was found to be evident for 1 of 2 medication carts reviewed during a facility recertification survey.

Inspectors wroteBased on pertinent documentation and interview, it was determined that the facility failed to implement the pharmacy and physician recommendations. This was evident for 1 (Resident # 17) out of 5 residents reviewed for unnecessary medication during a survey. On 2/21/24, review of records revealed that Resident #17 was a long-term care resident at the facility. On 2/23/24 at 12:26 PM, a review of the monthly pharmacy review, dated 1/1/24, for Resident #17 revealed the following pharmacist recommendation: Please consider monitoring a fasting lipid panel on the next convenient lab day and annually thereafter. On 2/23/24 at 12:30 PM, review of Resident # 17 physician orders failed to reveal an order for an annual lipid panel. On 2/23/24, the surveyor requested pharmacy reviews for Resident #17 and the physician or providers response to the recommendations. [...]

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to document adequate monitoring and indication after administering pain medication. This was evident for 1 (Resident #16) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, records review, and interviews, it was determined that the facility failed to have a medication administration error of less than 5%. This was evident for 2 of 3 nurses observed for medication administration.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure expired medications were disposed of properly. This deficient practice was found to be evident for 1 of 1 medication storage room and 2 of 2 medication carts observed during medication storage and labeling inspection.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to provide full visual privacy for residents in non-private rooms. This was evident for 6 beds of the 2 floors observed during the recertification survey.

Inspectors wroteBased on record review and interview it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the Office of Health Care Quality (OHCQ). This was evident for 4 (#25, #22, #7, #41) of 21 residents reviewed for incidents related to facility reported incidents during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#44, #30, #38, #47) of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that facility staff failed to ensure residents were free from significant medication errors as evidenced by failing to follow a physician's order related to holding blood pressure medications if outside of physician ordered parameters. This was evident for 1 (#30) of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on facility documentation and interview, it was determined the facility failed to develop, implement and maintain an effective training program for all new and existing staff for the care of residents with a tracheostomy (Resident #46). This was evident for 1 of 1 residents with tracheostomies in the facility reviewed during a complaint survey.

Inspectors wroteBased on observation and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was on 2 of 3 nursing units of the facility during a complaint survey.

Inspectors wroteBased on review of complaint, medical record review, and interview with staff, it was determined that the facility failed to ensure that a care plan meeting was held at least quarterly and included the resident's representative. This was evident for 1 (#11) of 30 complaints reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to administer medications as ordered by the physician (Resident #32). This was evident for 1 of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers per the Wound Specialist recommendations (Resident #4 and #6). This is evident for 2 of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, observation, and interview, the facility staff failed to supervise residents to prevent accidents (Resident #28 and #50) . This was evident for 2 of 25 residents on the 2nd floor of the facility.

Inspectors wroteBased on medical record review, facility policy review, observation and staff interview, the facility staff failed to provide services for a resident receiving oxygen therapy (Resident #46). This was evident for 1 of 3 residents reviewed with oxygen therapy during a complaint survey.

Inspectors wroteBased on observation and staff interview, it was determined that facility staff failed to keep medication carts locked when unattended. This was evident on 1 of 3 nursing units observed during random observations made during a complaint survey.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #16, #46) This was evident for 2 of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and interviews it was determined the facility staff failed to follow infection prevention and control practices. This was evident in the kitchen while preparing food for residents. The failure to follow effective infection prevention and control practices increased the risk for the spread of infection to all residents, staff, and visitors in the building during an active COVID-19 outbreak.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to post a notice of where the results of the most recent surveys, certifications, and complaint investigations were located. This was evident during the first day of the complaint survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#53) with the most dignified existence. This was evident for 1 of 37 residents selected for dignity during the annual survey process.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to ensure an advance directive was in place for Residents (#52 and #53). This was evident for 2 of 3 residents selected for review of advance directives and 2 of 37 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to notify the guardian of person of a change of condition for Resident (#11) and failed to complete a change of condition form for Resident (#11). This was evident for 1 of 1 resident reviewed for change of condition and 1 of 37 residents selected for review during the survey process.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Inspectors wroteBased on record review and staff interview it was determined that the facility failed to thoroughly investigate the allegation of abuse-misappropriation of property for a resident (#67). This was evident for 1 of 2 residents selected for review of misappropriation of property and 1 of 37 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility staff failed to have a system in place to ensure that the transfer of the resident's medical record and appropriate information is communicated to the receiving health care provider. This was found to be evident for 2 out of 3 (#55 and # 222) residents reviewed for hospitalization during the investigative portion of the survey.

Inspectors wroteBased on complaint, reviews of a closed record, and staff interview, it was determined that the facility staff failed to notify residents and/or representative and the Ombudsman of transfer and reason for transfer to the hospital in writing. This was evident for 2 (Resident #55 and #222) of 3 residents reviewed for hospitalization during an annual recertification survey.

Inspectors wroteBased on review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, at the time of the resident transfer for hospitalization. This was evident for 2 (Resident # 55 and #222) of 3 residents reviewed for Hospitalization during an annual recertification survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to assess Resident (#67) for PASARR. This was evident for 1 out of 2 residents reviewed for PASARR's during the annual survey process.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide an environment which produced the highest level for practicable well-being for Residents (#1, #26 and #49). This was evident for 3 of 37 residents selected for review of during the annual survey for well-being.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to apply leg rest to the wheel chair of Resident (#53) as ordered and failed to apply fall mats to both sides of the bed as ordered for Resident (#53). This was evident for 1 of resident selected for review of accidents and 1 of 37 residents selected for review during the survey process.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication and medicate Resident (#44). This was evident for 1 of 1 resident selected for review of pain assessment and 1 of 37 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff Social Worker (SW) failed to complete Preadmission Screening and Resident Review (PASARR) for Resident #67. This was evident for 1 of 2 residents reviewed for PASARR's during the annual survey process.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to ensure medications were thoroughly labeled with residents' name and dated the medication was open. This was evident for 1 of 37 medication carts observed during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood test as ordered for Residents (#44 and #52). This was evident for 2 of 37 residents selected for review of laboratory results in the survey sample.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#52) with nectar thick water as ordered by the physician. This was evident for 1 of 1 resident selected for review of nutrition and 1 of 37 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Residents (#49). This was evident for 2 of 37 residents selected for review during the survey process.

Inspectors wroteBased on medical record review, observations and interview, it was determined the facility staff failed to promote an environment that decreased the potential of transmission of communicable diseases or infections for Residents (#10, #52 and #65). This was evident for observations of dining in 2 of the 3 dining rooms and 3 out of 37 residents selected for infection control during the survey process.

Inspectors wroteBased on observations and interviews with staff it was determined that the facility failed to ensure residents had a means of directly contacting staff. This was evident in 1 public bathroom accessible to residents and 1 resident bathroom.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to have adequate ventilation in resident bathrooms. This was evident for 2 resident bathrooms observed on the 1st floor of the facility.