Holly Manor Center

Inspectors wroteRepeat Deficiency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 2/4/25 at 9:47 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. In the dry storage area, the surveyor observed a 16 ounce (oz) opened bottle of maple syrup labeled with a use by date of 1/1/24 and an opened 1 gallon opened container of cooking oil labeled with a use by date 1/5/24. The FSD stated both of those items should have been discarded per the use by date. 2. In the walk-in refrigerator, the surveyor observed a 1-gallon opened fat free Italian dressing without a label displaying the open and use by dates. [...]

Inspectors wroteBased on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris. On 2/4/25 at 9:47 AM, the surveyor toured in the presence of the Food Service Director (FSD) toured the kitchen and the designated garbage area and observed the following: There was garbage debris that included food wrapper, cups, gloves, paper products, and medication cups, surrounding the dumpster and surrounding areas. The FSD stated that the area should have been clean by the maintenance and dietary departments. On 2/10/25 at 12:05 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Clinical Lead (RCL) who were informed of the surveyor's findings. [...]

Inspectors wroteBased on interviews, and review of pertinent facility documents, it was determined that the facility failed to (a). provide pharmaceutical services in accordance with professional standards to ensure accurate documentation of the receipt of a controlled substance for 6 of 6 Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on three Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) reviewed and (b) to follow a physician orders (PO) for the administration of blood pressure medications for 1 or 1 resident's (Resident#60) reviewed for blood pressure management. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteBased on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities in the resident's medical record, to the facility staff, and attending physician. This deficient practice was identified for one (1) of twenty (24) residents reviewed, (Resident #60) for medication management and was evidenced by the following: On 2/5/25 at 10:19 AM, the surveyor observed Resident #60 in their room, the resident was observed seated in a chair and was watching television. The resident was alert and oriented and was wearing a knee brace on their left knee. The surveyor reviewed Resident #60's medical record. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to consistently monitor, document, and evaluate the ongoing benefits of continued use of psychoactive medications according to the facility's policy for 4 of 6 residents reviewed for unnecessary medications (Resident#4,#45, #68, and #93). The deficient practice was evidenced by the following: 1. On 2/4/25 at 10:35 AM, the surveyor observed Resident #93 lying in bed awake, screaming and yelling in their native language. A family member sat beside the resident, who could answer the surveyor's inquiry in simple English. On the same day, the surveyor interviewed the Licensed Practical Nurse (LPN#1), who stated that Resident #93 was refusing care, hitting and yelling at staff frequently. [...]

Inspectors wroteBased on observation, interview, review of medical records, and pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate infection control practices for handling and storing linens observed in the laundry room and b.) ensure the clean linen room is free from soiled clothes and devices. This deficient practice was evidenced by the following: On 2/5/25 at 12:37 PM, the surveyor and the Infection Preventionist (IP) observed the laundry room; the surveyor observed a cart full of linen. Some were in the plastic, and some were not, with no cover. The Housekeeping (HK) staff stated that all of those linens are clean and ready to be transported to the North unit, while the linen covered with plastics is from the residents who are no longer in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included refusal of care. This deficient practice was identified for one (1) of 21 residents (Resident #93) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: On 2/4/25 at 10:35 AM, the surveyor observed Resident #93 lying in bed awake, screaming and yelling in their native language. A family member sat beside the resident, who could answer the surveyor's inquiry in simple English. On the same day, the surveyor interviewed the Licensed Practical Nurse (LPN#1), who stated that Resident #93 was refusing care, hitting and yelling at staff frequently. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, dispose and secure medications in four (4) of six (6) medication carts inspected and one (1) of three (3) medication refrigerators inspected. This deficient practice was evidenced by the following: On [DATE] at 10:35 AM, the surveyor inspected the subacute medication cart in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an unopened and undated Lantus insulin pen that had a pharmacy date of [DATE] and was stored in the medication cart. The surveyor also observed an unlocked medication refrigerator inside the nursing station that contained two (2) Vancomycin IV (intravenous) bags. The were no residents in the vicinity of the nursing station. [...]

Inspectors wroteBased on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practice by the Registered Dietitian (RD) not signing a nutrition note at the time of assessment. This deficient practice was identified for 1 of 4 residents (Resident #5) reviewed for nutrition and was evidenced by the following: On 2/04/25 at 11:02 AM, the surveyor observed and interviewed Resident #5 at bedside. The resident stated they have been in the facility for about three months and were currently on an altered consistency diet for dysphagia, but they were not sure when the RD had assessed them last. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain nutrition status and prevent weight loss for one of three residents reviewed for nutrition (Resident (R) 56). Due in part to the failure to communicate R56's ongoing, significant weight loss to the interdisciplinary team, implement nutritional interventions that were recommended and closely monitor the resident's weight, R56 experienced a significant unintentional weight loss which resulted in his inability to maintain a healthy weight.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure that the kitchen was maintained in a sanitary manner. Specifically, the kitchen was found to be unclean. Work areas were in disrepair. Dishwashing was not conducted in accordance with current professional standards of sanitation, Concerns were noted with food storage, and tray line food temperatures were not within current professional safety standards. The failure to maintain required kitchen sanitation had the potential to affect 96 of 97 residents who received food stored, prepared, and served in the kitchen.

Inspectors wroteBased on interview, record review, and review of staffing sheets, the facility failed to have sufficient nursing staff to meet resident needs and/or provide care in a timely manner for four (Resident (R) 39, R 63 R76, and 303) of 27 sampled residents. The lack of sufficient staff resulted in residents who were not bathed in accordance with their preference and/or call lights which were not answered in a timely manner.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure palatable food was served to 11 (Resident (R) 88, R54, R15, R303, R19, R82, R86, R97, R37, R44, R3) of 97 total residents Specifically, the food did not look appetizing, lacked flavor and was not at an appropriate proper temperature.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure reasonable accommodation of needs for one (Resident (R) 73) of one resident reviewed for accommodation of needs.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure residents' choice of shower preference instead of bed baths was promoted for two residents (Residents (R) 63 and R39) of five residents reviewed for choices.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to complete the Centers for Medicaid and Medicare Services (CMS) Form CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for three of three residents (Resident (R) 257, R89, and R258) reviewed for advanced beneficiary notices. Failure to provide the form could result in the resident or their responsible party not being aware of the reason services were ending or of the options and cost to continue to receive services.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents received assistance to maintain continence for one resident (Resident (R) 303) of one resident reviewed for bowel and bladder continence. R303 was admitted with an indwelling urinary catheter and was continent of bowel. After discontinuing the urinary catheter, the facility did not assess the resident's urinary continence or provide measures to prevent incontinence for R303.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to identify target behaviors for monitoring of effectiveness of antipsychotic medication for one resident (Resident (R) 55) of five residents reviewed for unnecessary medications. This failure had the potential to contribute to unnecessary antipsychotic medication use for R55 who used the medication to treat the behavioral symptoms of dementia.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain controlled substances in a manner that would decrease the possibility of loss or diversion. This was found with the delivery process of controlled substances for the automated medication dispensing machine with 1 of 2 Drug Enforcement Administration (DEA) 222 forms reviewed. The deficient practice was evidenced by the following: On 2/4/21 at 2:03 PM, the surveyor reviewed two sets of DEA-222 forms for completeness and accuracy. The most recent shipment of controlled substances dated 1/25/21 did not have a signature of receipt. The form of receipt listed the following controlled substances delivered: five Fentanyl 12 mcg/hr patches, five Fentanyl 25 mcg/hr patches, five Fentanyl 50 mcg/hr patches, and 10 Oxycontin 10 mg ER tablets. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to demonstrate appropriate infection control practices when administering medication to a resident. This deficient practice as identified with 1 of 2 residents observed during medication pass, Resident # 36, and was evidenced by the following: On 2/3/21 at 9:20 AM, the surveyor observed a Licensed Practical Nurse (LPN) administer medications to Resident #36. After preparing the medications the resident was to receive the LPN used alcohol-based hand rub. The nurse picked up multiple items to carry into the resident's room, such as, a small plastic medication cup full of pills, eye drops, nasal spray, mouth spray, and an inhaled medication. The LPN went in the room, placed those items on the table, touched the door and the privacy curtain to adjust it with no gloves on. [...]