Holly Hill House

Inspectors wroteBased on observations, interview, and policy review, the facility failed to maintain a clean and sanitary kitchen, as evidenced by:1. A buildup of thick black residue on the wall approximately six inches high for the length of the three compartment sink,2. a buildup of thick black residue on the wall approximately six inches high for the length of the dirty side dish table of the dishwasher,3. a buildup of food particles on three clean dish storage trays; and4. a buildup of black residue on the inside top panel of the kitchen ice machine. This deficient practice had the potential to affect 74 residents who ate out of the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for use of antibiotic medication for 1 (#5) out of 34 sampled residents.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a resident's urinary drainage bag was below the resident's bladder according to facility policy for 1 (#13) out of 2 residents reviewed for urinary catheters or UTI (urinary tract infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff accurately measured nutritional supplements in accordance with residents assessed nutritional needs. This deficient practice had the potential to result in inadequate or inconsistent nutritional intake, altered nutritional status, and failure to meet the nutritional needs for 10 residents with supplements, being served the supplements from the kitchen.

Inspectors wroteBased on observations, interview, and policy review, the facility failed to ensure garbage and refuse were disposed of properly.

Inspectors wroteBased on observation, policy review, and interviews, the facility failed to implement and maintain an effective infection control and prevention program by failing to ensure ice scoops used for filling resident water pitchers were cleaned and sanitized daily. This deficient practice had the potential to affect all 74 residents residing in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure to facility was free from pests in the kitchen dishwashing area. The deficient practice had the potential to affect 74 residents who resided in the facility and ate meals from the kitchen.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure staff implemented a resident's established, individualized plan of care for 1 (Resident #1) of 3 sampled residents who required two person assistance with bed mobility. This deficient practice resulted in an actual harm for Resident #1 on 03/11/2026 at 1:45 p.m., when S4CNA failed to follow the resident's plan of care for using two person staff assistance. S4CNA provided bed mobility during ADL (activities of daily living) care for Resident #1 without assistance from another staff member resulting in the resident falling from her bed onto the floor sustaining an injury to her right lower extremity requiring hospitalization. [...]

Inspectors wroteBased on record review and interviews, the facility failed to protect the resident's right to be free from physical abuse by other residents for 1 (#2) out of 4 (#1, #2, #3 and #4) sampled residents. The facility failed to protect Resident #2 from physical abuse when Resident #3 slapped Resident #2 in the face on 08/09/2025. The deficient practice had the potential to effect a census of 79.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure allegations of injury of known origin were reported immediately to the Administrator or his/her designated representation, and reported to the state agency not later than 2 hours after the allegation was identified for 1 (#4) out of 4 (#1, #2, #3 and #4) residents reviewed for timely reporting of critical incidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an investigation of an allegation of abuse was thoroughly investigated for 1 (#4) of 3 (#2, #3, #4) sampled residents reviewed for abuse.

Inspectors wroteBased on record review and interview, the facility failed to notify the State Long Term care Ombudsman of a facility-initiated transfer for 1 (#1) out of 4 (#1, #2, #3 and #4) residents sampled.

Inspectors wroteBased on record review and interviews, the facility failed to implement a comprehensive person-centered plan of care that identified the resident's need for 1:1 (one on one) supervision to manage behaviors for 2 (#1, #3) out of 4 (#1, #2, #3 and #4) sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an RN (Registered Nurse) provided services for at least 8 consecutive hours a day.

Inspectors wroteBased on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner. The facility failed to maintain documentation of evidence of its ongoing facility QAPI program. This deficient practice has the potential to affect 88 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's respiratory equipment was labeled, dated ,and stored properly for 4 (Resident #20, #30, #63 and #237) out of 4 (Resident #20, #30, #63 and #237) sampled residents reviewed for respiratory care.

Inspectors wroteResident #58 Review of resident #58's medical record revealed resident was admitted to the facility on [DATE] with diagnoses including morbid obesity, mild cognitive impairment, insomnia, anxiety disorder, major depressive disorder, apraxia, unspecified anemia, and frontal lobe and executive function deficit. Review of resident #58's June 2024 physician's orders revealed: Sertraline HCl oral tablet 100 mg (milligrams), give 1 tablet by mouth one time a day for depression related to major depressive disorder; give with 50 mg daily to equal 150 mg; (start date 06/19/2024) Sertraline HCl oral tablet 50 mg, give 1 tablet by mouth one time a day for depression related to major depressive disorder; give with 100 mg to equal 150 mg daily; (start date 06/19/2024) Trazadone HCl oral tablet 50 mg, give 1 tablet by mouth at bedtime for sleep related to major depressive disorder; insomnia; [...]

Inspectors wroteBased on observation, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. Food storage: A. Refrigerated items: 1. One container of peaches not labeled with the date it had been prepared. 2. Two containers of brown gravy with meat not labeled with the date it had been prepared. 3. One container of white gravy not labeled with the date it had been prepared. 4. One bag of pepper jack cheese not labeled with the date it had been opened. 5. One bag of sausage not labeled with the date it has been opened. B. Freezer items: 1. One bag of fries opened and not labeled with the date it had been opened or placed in a closed bag. 2. One bag of mushrooms opened and not labeled with the date it had been opened or placed in a closed bag. C. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain dignity for 2 (Resident #27 and #61) out of 29 sampled residents by failing to provide residents with metal utensils and non-disposable drinking cups during dining.

Inspectors wroteBased on observations and interviews the facility failed to maintain 3 (#23, #41, and #75) of 3 (#23, #41, and #75) clients rooms and property observed for cleanliness. This had the potential to affect the census of 88 residents that reside in the facility.

Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #16) of 1 (Resident #16) residents investigated for PASARR in a final sample of 29 residents.

Inspectors wroteBased on record review and interviews, the facility failed to follow physician's orders for 1 (#46) resident in a sample of 29 residents. The deficient practice had a potential to affect a total census of 88 residents.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure routine drugs and biologicals were available for administration for 1 (#46) resident in a sample of 29 residents. The deficient practice had a potential to affect a total census of 88 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional practice by failing to ensure the medication cart was locked when unattended for 1 Medication Cart (Med Cart A) out of 3 (Med Cart A, Med Cart B, Med Cart C) medication carts observed. The deficient practice had the potential to affect a total of 88 residents in the facility.

Inspectors wroteBased on observations, record review, and interviews the facility failed to serve 1 (Resident #23) of 1 (Resident #23) resident investigated for food, her recommended diet as required by her diagnosis of gastroenteritis and her assessed dislikes. This had the potential to affect the 88 residents that consumed food out of the kitchen.

Inspectors wroteBased on record reviews and interviews, the facility failed to resolve a grievance within 5 working days per facility grievance policy for 1 (#3) out of 1 (#3) resident reviewed for personal property.

Inspectors wroteBased on record reviews and interview the facility failed to ensure the allegation of abuse/neglect or injury of known origin were reported immediately, but not later than 2 hours after the allegation is made, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury and reported the results of all investigations, and; report the results of all investigations to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 9 (Resident #1 - Resident #9) out of 9 (Resident #1 - Resident #9) residents reviews for timely reporting of critical incidents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#1) out of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) sampled residents. The deficient practice had the potential to effect a total census of 82.

Inspectors wroteBased on record review and interview, the facility failed to ensure the residents received all care and treatment in accordance with professional standards of practice as evidenced by nurses failing to complete neurological checks on a resident with an unwitnessed fall for 2 (Resident #1 and Resident #3) out of 3 (Resident #1, Resident #2, Resident #3) residents reviewed for accident/hazards.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Hospice agency provided services based on the agreement and facility policy to meet professional standards for 1(Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by failing to collaborate with the hospice agency to ensure the hospice nurse's visit notes were up-to-date in the resident's hospice binder.

Inspectors wroteBased on record review, interviews, and facility's policy and procedure review, the facility failed to ensure S4LPN (Licensed Practical Nurse) notified the physician and/or charge nurse when a resident had a significant change in condition for 1 (#3) resident out of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to protect the resident's right to be free from physical abuse for 1 (#2) out of 4 (#2, #4, #6, #7) residents investigated for abuse. The facility failed to protect Resident #2 from physical abuse by Resident #7. The deficient practice had to potential to affect a total census of 78.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that services were provided as outlined in the comprehensive plan of care for 1 (#3) out of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled resident as evidence by failing to: 1. foley catheter urinary output was monitored and recorded every shift, and 2. side effects of anticoagulants were monitored and recorded.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure there was enough dietary staff to provide residents' meals within 45 minutes of the facility's scheduled meal times for 84 residents who consumed meals from the kitchen.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure residents received diets and preferences as described on diet cards were followed for 5 (#R1, #R2, #R3, #R4, and #R5) of 20 (#1, #2, #3, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17 and #R18) of 20 (#1, #2, #3, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17 and #R18) residents reviewed for nutrition. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for the 84 residents who received meals from the kitchen.

Inspectors wroteResident #R6 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue (Tuesday) for monitoring for 4 weeks. There was no documentation any weights were obtained until 09/05/2024. Resident #R7 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no documentation ordered weekly weight were obtained for weeks 2, 3, 4. Resident #R8 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no documentation ordered weekly weights were obtained for week 2. Resident #R9 admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents maintained acceptable parameters of nutrition for 2 (#3 and #R18) of 20 (#1, #2, #3, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17 and #R18) residents reviewed for nutrition The facility failed to ensure: 1. Resident's #3 was assessed for weight changes and intervene to prevent severe weight loss; and 2. The registered dietician's recommendations were implemented for Resident #R18.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the resident's rights to be free from neglect by failing to ensure the availability of supplies in sufficient number the residents required necessary to provide care to residents as evidenced by: 1. Failing to provide appropriate sized incontinence briefs to 74 incontinent residents; and 2. Failing to provide a sufficient number of clean linens, when the facility was observed not having an adequate amount of clean towels and washcloths available. This had the potential to affect the census of 89.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to follow the physician's orders for 1 (#3) resident out of 5 (#1, #2, #3, #4, #5) residents sampled, as evidence by failing to follow orders for obtaining an x-ray timely causing a delay in care for the resident.

Inspectors wroteBased on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. a thick layer of debris and food residue on the deep fryer cooking oil collection area; 2. expired foods from the kitchen refrigerator, freezer, and dry storage area; and 3. sticky residue with food debris on the cart used to bring food items from one part of the kitchen to another. This deficient practice had the potential to affect the 72 residents who consumed food from the kitchen.

Inspectors wroteBased on record review, observations and interviews, the facility was not administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's administration failed to implement the facility's Enhanced Barrier Precautions (EBP) policy for residents with infection or colonization with a multi-drug resistant organisms (MDRO) or for any resident who has a chronic wound and/or indwelling medical device. The deficient practice was observed for 8 (#17, #24, #30, #35, #48, #68, #75, #232) out of 14 residents who met criteria for Enhanced Barrier Precautions.

Inspectors wroteResident #35 During an interview and observation with S6LPN (Licensed Practical Nurse) on 04/23/2024 at 1:02 p.m., she confirmed that Resident #35 had PEG (Percutaneous Endoscopic Gastrostomy) tubes. S6LPN acknowledged that a PEG tube was considered an indwelling medical device inserted into the stomach through a surgical wound in the abdomen and this could make someone with a PEG susceptible to infection. S6LPN was questioned regarding any awareness of Enhanced Barrier Precautions. S6LPN admitted she was not familiar with what it entailed or any of the requirements. S6LPN verified there was no signage on the door or near the entrance to the rooms of Resident #35 or Resident #68, announcing and explaining the need for Enhanced Barrier Precautions. S6LPN confirmed there was no PPE (Personal Protective Equipment) readily available near the entrance to Resident #35 or #68's room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' assessment accurately reflected the status of 1 (#61) out of a total of 33 sampled residents, by failing to ensure MDS (Minimum Data Set) assessment was coded correctly for antidepressant use. Findings Review of Resident # 61's Electronic Health Record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Emphysema, Diabetes Mellitus II, and Legal Blindness. Review of Resident # 61's Annual MDS assessment with an ARD (Assessment Reference Date) of 02/14/2024 revealed in Section N - High-Risk Drug Classes Antidepressant was coded 1, indicating the resident was taking an antidepressant. Review of Resident # 61's February 2024 Physician Orders revealed no orders for use of antidepressants. [...]

Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#55) of 4 (#6, #13, #55, #68) residents investigated for PASARR in a final sample of 74 residents.

Inspectors wroteBased on record review and interview, the facility failed to implement a comprehensive person-centered care plan that included monitoring for adverse reactions for antibiotic use for 1 (#10) out of 33 sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews; the facility failed to protect the resident's right to be free from abuse for 3 (#1, #2, #3) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents. The facility failed to protect: 1. Resident #1 from sexual abuse by Resident #2. 2. Resident #2 from physical abuse by Resident #5. 3. Resident #3 from physical abuse by Resident #4. This deficient practice resulted in: 1. psychosocial harm for Resident #1 on 03/02/2024 at 4:42 p.m., when Resident #2 grabbed her breasts. Resident #1 was observed startled by staff at the time of the incident. The resident's responsible party stated that she would have been panicked, very fearful, and not happy at all. 2. physical harm for Resident #2 on 03/14/2024 at 8:54 p.m., when Resident #5 struck Resident #2 on the top of his head with a cane resulting in a laceration that required sutures. 3. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide quarterly statements of personal funds for 1 (Resident #7) of 1 resident investigated for personal funds. The deficient practice had the potential to affect a census of 80 residents.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop a resident centered comprehensive care plan for 3 (#2, #4, #7) out of a finalized sample of 7 residents as evidenced by: 1. Failing to identify and plan for Resident #2's diagnosis of Sexual Dysfunction, 2. Failing to follow physician's orders to increase Resident #4's medication, 3. Failing to identify and plan for Resident #7's BIPAP (Bi-level Positive Airway Pressure) machine, 4. Failing to follow physician's orders to apply creams, change oxygen tubing, and clean oxygen concentrator filter for Resident #7. This deficient practice had the potential to affect a total census of 80 residents.

Inspectors wroteBased on observations and interviews the facility failed to properly store respiratory equipment for 1 resident (#7) out of 1 resident (#7) investigated for respiratory care.

Inspectors wroteBased on record reviews and interviews, the facility failed to obtain routine medication as ordered by the physician to meet the needs of 1 (#3) out of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents are free significant medication errors for 1 (#3) out of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to notify the State Long Term Care Ombudsman of facility-initiated transfers for 1 (Resident #1) out of 3 (#1, #2, #3) sampled residents. The deficient practice has the potential to affect a census of 61.

Inspectors wroteBased on interviews, and record reviews, the facility failed to implement a residents' plan of care by failing to provide documented evidence that monitoring of behaviors and adverse reactions was conducted for 2 (#1 and #3) out of 3 (#1, #2, #3) residents who received an antipsychotic and/or antidepressant medications.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure quality of care in accordance with professional standards of practice for 1 (#1) of 3 (#1, #2, #3) sampled residents for unwitnessed falls. This was evidenced when 72 hours of neuro-checks were not complete after an unwitnessed fall and hit their head.

Inspectors wroteBased on record reviews and interviews, the provider failed to ensure nursing personnel and/or other direct care personnel followed physician's orders for 3 (#1, #2, and #3) of 3 sampled residents. The facility census was 64. Findings Resident #1 Review of resident #1's medical records revealed she was admitted to the facility on [DATE] with diagnoses including Psychotic Disturbance, Mood Disturbance, Anxiety Disorder, Essential Hypertension, Hyperlipidemia, Essential Tremor, Major Depressive Disorder, Dysphagia, Drug Induced Subacute Dyskinesia, Non-Rheumatic Aortic Valve Stenosis, Personal History of TIA (Transient Ischemic Attack) and Cerebral Infarction without Residual Deficits, and Presence of a Cardiac Pacemaker. [...]

Inspectors wroteBased on record review and interviews, the facility failed to assess 1 (#1) out of 1 (#1) residents for self-administration of medication by the Interdisciplinary Team (IDT) to determine that this practice is clinically appropriate in a sample of 3 (#1, #2, #3) residents.

Inspectors wroteBased on policy review, record review and interviews, the facility failed to ensure nursing staff provided Basic Life Support (BLS), including notifying Emergency Medical Services (EMS) of a resident that was unresponsive with full code status according to the policy and procedure for 1 (#1) of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on policy review, record review, and interviews, the facility's staff failed to assess and monitor a resident who had a significant change of respiratory status for 1(#1) of 3 (#1, #2, #3) residents sampled.

Inspectors wroteBased on record review and interview, the facility failed to maintain documented evidence of an effective training program for all new and existing staff. This deficient practice was identified for 2 (S4RN (Registered Nurse), S5CNA (Certified Nursing Assistant)) of 5 (S4RN, S5CNA, S6CNA, S7RN) personnel records review for training requirements.