Holly Springs Rehabilitation and Healthcare Center

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to have the required staff present and in attendance for each quarterly Quality Assurance and Performance Improvement (QAPI) meetings for four (4) of 4 quarterly meetings dated 09/30/25, 12/29/25, 03/31/26 and 05/01/26.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to resolve resident grievances related to food service concerns identified during Resident Council meetings for five (5) of thirteen residents. (Resident #7, Resident #11, Resident #36, Resident #62, and Resident #74) Findings Include:Review of the facility policy titled Filing Grievances/Complaints with a revision date of 6/2024 revealed .3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. [...]

Inspectors wroteBased on observations, interviews, record review and facility policy review, the facility failed to implement care plan interventions as written for three (3) of 19 sampled residents. (Resident #2, Resident #27, and Resident #39) The scope and severity for this deficiency were cited at an E due to previous citations of F656 on the last two annual recertification surveys completed on 1/4/24 and 6/19/25 representing a pattern of deficiency.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide facial hair grooming, fingernail care, and oral hygiene for three (3) of nineteen (19) samples residents reviewed for activities of daily living (ADL) care. Residents #2, Resident #27, and Resident #39. The scope and severity for this deficiency was cited at an E due to previous citations of F677 on the last two annual recertification surveys completed on 1/4/24 and 6/19/25 representing a pattern of deficiency.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure a dignified existence by failing to apply a privacy bag to a urinary catheter drainage bag (Resident #82) and failing to provide dignified toileting assistance to a resident (Resident #22) for two (2) of 19 sampled residents. Residents #22 and Resident #82. Findings Include: Record review of facility policy titled Nursing Facility Resident Rights dated 3/6/26 revealed, .Facilities are required to protect and promote these rights for every resident. Dignity, Respect, and Freedom from Abuse: To be treated with dignity, courtesy, and respect .Quality of Care and Participation in Care: To receive care necessary to achieve the highest practicable physical, mental, and psychosocial well-being . [...]

Inspectors wroteBased on resident/resident representative (RR) and staff interviews, record review and facility policy review the facility failed to honor a resident's Advance Directive for end-of life decisions for one (1) of 28 residents advance directives reviewed. Resident #25Findings Include:Review of the facility policy titled Advance Directives, with a revision date of [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy.15. In accordance with current regulatory definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: f. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain a clean and sanitary environment by allowing a resident bathroom toilet to remain soiled for one (1) of 32 rooms on the 200 hall. room [ROOM NUMBER]Findings Include:Review of the facility policy titled 7-Step Daily Washroom Cleaning revealed under, Purpose: To teach Environmental Services employees the proper method to sanitize a washroom or bathroom . Additionally, the policy revealed under, 7-Step Daily Washroom Cleaning Procedure:. 5. Clean and Sanitize Commode - .Use [NAME] mop or toilet brush to disinfect the inside of the bowl .An observation of room [ROOM NUMBER]'s bathroom toilet on 5/11/26 at 2:15 PM revealed dark yellow stagnant urine present inside the toilet bowl and black discoloration adhered along the inner rim/water line of the toilet. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure the resident and/or resident representative were provided with written notification of transfer to the hospital for two (2) of 2 residents reviewed for hospitalization. Resident #3 and Resident #95Findings Include:Review of the facility policy titled, Transfer or Discharge Notice with a revised date of 3/3/2026 revealed, .5. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which is resident is being transferred or discharged . Record review of Resident #3's Progress Note dated 5/8/26 revealed the Resident was transported to Proper Name of Hospital for tube/drain replacement. [...]

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to provide necessary care and services to prevent worsening contractures and maintain range of motion (ROM) for two (2) of four (4) residents reviewed. (Residents #27 and Resident #39)

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to clarify a clinically questionable dialysis fluid restriction order, failed to accurately transcribe and implement the physician order, and failed to monitor fluid intake for one (1) of five (5) residents reviewed for dialysis services. Resident #22 Findings Include:Review of the facility policy titled Dialysis Management Policy revised 3/12/26 revealed under, Policy: The facility will ensure that residents requiring dialysis receive appropriate clinical oversight, coordination with dialysis providers, and monitoring to maintain health and safety. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to implement infection prevention and control practices for one (1) of two (2) sampled residents reviewed for transmission-based precautions (TBP). The facility failed to ensure proper infection control measures related to disposable meal tray use and cleaning/disinfection of a shared shower room following use by a resident on transmission-based precautions. [...]

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for one (1) of three (3) residents reviewed for accidents (Resident #1), when the facility did not increase monitoring despite repeated episodes of the resident entering other residents' rooms and consuming food while on NPO (nothing by mouth) status, resulting in multiple transfers to the emergency department for possible aspiration.

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to ensure that residents received necessary services to meet their medical needs when they allowed scheduled medical and dental appointments to be missed for (3) three of twenty-two residents with scheduled appointments. (Resident #2, #3, and #4)

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to: 1) label and store food properly and maintain the kitchen and the equipment in a clean and sanitary condition for two (2) of three (3) kitchen tours, and 2) prevent the potential for foodborne illness as evidenced by meal trays left in rooms for a prolonged time (Resident #24, #52, #68, #83) for one (1) of four (4) survey days. Findings Include: Review of facility policy titled, Food Storage: Dry Goods dated 2/2023 revealed, .All packaged and canned food items will be kept clean, dry, and properly sealed . Review of facility policy titled, Food Storage: Cold Foods dated 2/2023 revealed, .All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . [...]

Inspectors wroteResident #30 A record review of Resident #30's Care Plan revealed that the resident is resistant to care as evidenced by refusing showers, refusing to get out of bed . Interventions that included: If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed-upon time. On 6/16/25 at 11:17 AM an observation and interview revealed that Resident #30's fingernails were approximately three-fourths (3/4) of an inch long past the tip of the fingers, with a jagged appearance. Resident #30 stated, I don't like my nails this long and I want them cut. He revealed I don't know when the last time they were trimmed, but I know it's been a while. In an interview on 6/17/25 at 2:58 PM, the Director of Nurses (DON) revealed that the resident has, at times, refused to have his fingernails trimmed. [...]

Inspectors wroteResident #30 An observation and interview on 6/16/25 at 11:17 AM with Resident #30 revealed his fingernails were long and jagged. Resident #30 recalled that it had been a while since anyone had provided nail care. He then admitted that he does not like his nails this long. An interview and observation on 6/17/25 at 9:25 AM, Resident #30 revealed that no one had come to do his fingernails and stated that he wanted them cut. His fingernails remain long and jagged, measuring approximately three-fourths (3/4) inch past the tips of the fingers. During an observation and interview on 6/17/25 at 2:23 PM, RN #1 confirmed Resident #30's fingernails were long and jagged and needed to be cut. She revealed that with his fingernails being this long and jagged, he could scratch himself and create a skin tear. RN #1 asked Resident #30 if he wanted his fingernails cut, and Resident #30 replied, Yes. [...]

Inspectors wroteResident #24 An observation of Resident #24 on 6/16/25 at 10:24 AM revealed she was lying in bed, verbal but confused with two visible flies flying over her bed. Her overbed table was pulled across her bed with a remaining breakfast tray uncovered with left over food and the flies were attempting to land on the food tray. Resident #52 An observation of Resident #52 on 6/17/25 at 10:37 AM revealed he was lying in bed with his eyes closed and two flies were flying around his bed and attempting to land on the table beside his bed that had a left over breakfast tray. Resident #70 An observation of Resident #70 on 6/16/25 at 12:22 PM revealed he was lying in bed with multiple flies (3-5) flying around his room, circling over the resident and landing on his covers. [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to ensure a resident's dignity was maintained as evidenced by a resident wearing a visibly soiled shirt and pants hanging below the hips, exposing undergarments for one (1) of 41 sampled residents. Resident #44 Findings Include: Review of the facility policy titled Dignity, revised 2/2021, revealed under Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem . An observation of Resident #44 on 6/16/25 at 10:29 AM revealed he was sitting in his recliner in his room with the door open. He was wearing a soiled shirt with yellow orange smeared food and five circular stains the size of nickels and quarters, resembling spilled liquids. [...]

Inspectors wroteResident #48 Observations on 6/17/25 at 8:25 AM and 10:45 AM revealed that Resident #48 was in bed with the call light hanging down behind the bed and inaccessible to the resident. An observation and interview on 6/17/25 at 3:05 PM revealed Resident #48 lying in bed, the call light remains hanging down behind the bed and inaccessible to the resident. Resident #48 acknowledged that she was unable to reach her call light. During an observation and interview on 6/17/25 3:20 PM, Certified Nurse Aide (CNA) #4 revealed she is responsible for the resident today. She confirmed the call light was hanging down behind the bed, lying on the floor, and inaccessible to the resident. She revealed I must have forgotten to attach it to her pillow. CNA #4 revealed the call light is supposed to be attached to the resident's pillow so she can call if she needs anything. [...]

Inspectors wroteResident #20 An observation and interview on 6/16/25 at 11:33 AM, revealed Resident #20 sitting in his wheelchair. The right armrest was noted to have 95% of the vinyl missing from the top, exposing the padding, and the remaining vinyl was tattered. The left arm rest revealed tattered and torn vinyl. The wheelchair frame and spokes of the wheels were covered in a thick, gray substance. The resident revealed he wasn't sure why his wheelchair looked like this and wasn't sure when it would be cleaned. An observation and interview on 6/17/25, at 3:25 PM with the Administrator (ADM) revealed that Resident #20's wheelchair remained in need of repair and cleaning, with the frame and spokes of the wheels covered in a thick, gray substance. The Administrator confirmed the wheelchair was dirty and needed to be cleaned, and the armrests were tattered and needed to be replaced. [...]

Inspectors wroteResident #32 An observation on 6/18/25 at 9:05 AM revealed Licensed Practical Nurse (LPN) #3 entering Resident #32's room to provide medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube. Resident #32 had an EBP signage located on her door that instructed staff to wear a gown and gloves during high-contact resident care activities. LPN #3 administered the resident's medications through the PEG tube but did not wear a gown. During an interview on 6/18/25 at 9:30 AM, LPN #3 confirmed that Resident #32 was on EBP because she has a PEG tube. She further revealed that wearing the proper protective equipment is to protect both ourselves and the residents from the possible spread of infection. She confirmed that she did not wear a protective gown and revealed that she should have. [...]

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to implement a comprehensive care plan to provide for two-person assistance with a lift during a transfer in a manner to prevent an injury for one (1) of three (3) sampled residents. Resident #1. Findings Include: Review of the facility policy Care Plans, Comprehensive Person-Centered with reviewed date of November 2024 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Record review of Resident #1's Care Plan that was initiated on 07/27/23, revealed that she had an Activities of Daily Living (ADL) self-care performance deficit related to weakness and had interventions in place that included, Transfer: [...]

Inspectors wroteBased on observation, staff and resident interviews, record review and facility policy review, the facility failed to provide two-person assistance during a transfer for a dependent resident in a manner to prevent an injury for one (1) of three (3) sampled residents. Resident #1. Findings Include: Review of the facility policy titled, Safe Patient Handling and Moving Protocol with reviewed date of 06/10/2024, revealed The Quality Assurance (QA) Committee will ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident. Under the Transfer and Bed Mobility/Positioning Technique Training topic, , .It is important to remember that each resident is different; [...]

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed implement the care plan to provide two-person assistance when providing care for a dependent resident for one (1) of three (3) sampled residents. Resident #1. Findings Include: Review of the facility policy, Care Plans, Comprehensive Person-Centered with reviewed date of 01/2023, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Record review of Resident #1's Care Plan revealed that she had a self-care deficit with interventions that included, toileting/incontinent care. [...]

Inspectors wroteBased on interviews, record review and facility policy review the facility failed to provide two-person assistance with incontinent care for a dependent resident in a manner to prevent a fall for one (1) of three (3) sampled residents. Resident #1. Findings Include: Review of the facility policy titled, Fall Prevention Program with reviewed date of 06/10/2024 revealed, All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. Record review of Resident #1's Incident Report dated 07/21/24 at 14:42 revealed, Was notified by Certified Nursing Assistant (CNA Proper Name) that Resident (proper name) was on the floor. [...]

Inspectors wroteBased on record review, interviews and facility policy review the facility failed to prevent the misappropriation of narcotics for one (1) of four (4) medication carts in the facility. Medication cart B2. Based on the implementation of corrective actions the State Agency (SA) determined this to be Past Non-Compliance and the facility had achieved compliance on 5/14/24, prior to the SA entry. Findings Include: Review of the facility policy dated December 2012, titled, Controlled Substances, revealed, The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. [...]

Inspectors wroteBased on facility policy review, resident and staff interview and record review the facility failed to provide an ongoing activity program designed to meet the needs of each resident for four (4) of ten (10) residents reviewed in resident council. Resident # 14, #40, #52, and #61.

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to provide written notification of bed hold to the resident and/or resident representative upon transfer to the hospital for one (1) of three (3) residents reviewed for hospitalization. Resident #30 Findings Include: Review of the facility policy titled MS Bed Hold Policy with a revision date of 9/16/22 revealed, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of bed-hold and return policy . Record review of Resident #30's completed Physician Orders dated 8/29/23 revealed, Send to ER (Emergency Room) for evaluation d/t (due to) elevated heart rate. Record review of Resident #30's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/23 revealed under section A, a Discharge Assessment -Return Anticipated was completed. [...]

Inspectors wroteBased on record review and staff interview the facility failed to complete and transmit a Minimum Data Set (MDS) assessment in a timely manner for one (1) of 25 MDS assessments reviewed.

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review the facility failed to develop or implement a care plan for seven (7) of the 25 care plans reviewed. Residents #26, 30, 47, 51, 59, 60, 67. Findings Include: Record review of the facility policy titled Care Plans, Comprehensive Person-Centered with a revision date of 10/22 revealed under, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Resident #26 Record review of the facility policy on Trauma-Informed and Culturally Competent Care reviewed January, 2023, revealed, Purpose: [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review the facility failed to provide care to maintain hygiene as evidenced by failure to provide facial cleaning for Resident #30, nail care for Resident #47, shaving for Resident #59, and provide showers, shaving, and nail care for Resident #60 and Resident #67 for five (5) of the 21 residents reviewed.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatments and services to increase range of motion and/or to prevent further decrease in ROM as evidenced by staff not applying hand splints and an elbow brace as ordered for two (2) of 25 sampled residents. Resident #51 and #59 Findings Include: Record review of a statement on facility letterhead, undated and signed by the Administrator revealed, The facility does not have a policy that specifies who is responsible for donning/doffing splints or providing range of motion. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review and facility policy review, the facility failed to provide adequate supervision for residents who smoke as evidenced by failure to secure smoking materials for two (2) of 15 smokers residing in the facility. Resident #44 and #72 Findings Include: Review of the facility policy titled Facility Smoking Policy-Supervised Smoking with a revision date of 10/2022 revealed .THIS FACILITY IS A SUPERVISED SMOKING FACILITY All smoking in this facility is SUPERVISED and at designated times Staff will maintain/keep all smoking materials (e.g. cigarettes, pipes, matches. lighters. lighter fluid) and distribute the materials to residents at smoking times Resident #44 An observation and interview with Resident # 44 on 01/02/24 at 10:54 AM revealed her lying in bed and observed with a pack of cigarettes. [...]

Inspectors wroteBased on staff interviews, record review and facility policy review the facility failed to deliver care and services for a resident with a diagnosis of Post traumatic stress disorder (PTSD) for one (1) of 25 sampled residents. Resident #26. Findings Include: Record review of the facility policy Trauma-Informed and Culturally Competent Care with a review date of January 2023 revealed Purpose To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization On 01/03/24 9:31 AM, during an interview Resident #26 revealed that the staff were taking care of him here, but he just had been through so much that he wanted to go home. He revealed that he came home from the Army to no home due to it burning down while he was gone. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review and facility policy review, the facility failed to assess and provide the necessary adaptive equipment to a resident to promote independence for drinking for one (1) of two (2) residents reviewed for dining. Resident #30 Findings Include: Review of the facility policy titled Assistance with Meals dated 10/22 revealed under, Policy Statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Residents Who May Benefit from Assistive Devices: 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups . [...]