Hollymead

Inspectors wroteBased on interview and record review, the facility failed to appropriately discharge for 1 (Resident #1) of 7 residents reviewed for transfer/discharge. The facility failed to ensure Resident #1 was not discharged home without Home Health services to assist with ongoing care needs. This failure could place residents at risk of being discharged inappropriately causing a disruption in their care and services and potential decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in two halls (Hall 600 and Hall 700) of three halls reviewed for pests. The facility failed to ensure Hall 600 and Hall 700 were free of millipedes. This failure could place residents at risk of insect-born illness and not having a home free of pests in which to live.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the resident's physician accident involving the resident which results in injury and has the potential for requiring physician intervention, and/or a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 or 5 residents (Resident #1) reviewed for notification of physician of change of condition and falls. 1. The facility failed to ensure the physician was notified of Resident #1's fall on 04/02/2026. 2. The facility failed to ensure the physician was notified of Resident #1's pneumonia diagnosis when she was hospitalized on [DATE].3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were not cross contaminated for 1 of 5 (Resident #1) residents reviewed for infection control. The facility failed to ensure CNA A did not contaminate Resident #1's cookie when she picked up wrapped chocolate candies off the floor and put them on the plate with the unpackaged cookie. This failure could place residents at risk of consuming contaminated food items that could result in foodborne illness or foodborne intoxication.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 16 residents (Residents #67, #71, #36, #97, #401, #66) reviewed for care plans. 1. The facility failed to develop a comprehensive person-centered care plan regarding Resident #71's attention deficit disorder diagnosis. 2. The facility failed to ensure Resident #36's comprehensive care plan included a plan of care for ADL dependence including fingernail care. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 residents (Resident #2, Resident #36, Resident #27, Resident #16) of 15 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #2 had his nails cut and cleaned on 04/22/25. 2. Resident #36 had his nails trimmed on both hands on 04/22/25. 3. Resident #27 had her fingernails cleaned and trimmed on both hands on 4/22/25. 4. Resident #16 had her fingernails cleaned and trimmed on both hands on 4/22/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of three (Resident #2) reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #2's contracture to her left hand on 04/22/25. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 3 medication carts (med aid cart hall400/500) of 4 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1- LVN D responsible for Nurses Cart Hall 300, removed medications in unsecure containers from the Nurses Cart. 2- LVN L responsible for Nurses Cart Hall 100, removed medications in unsecure containers from the Nurses Cart. 3- RN A responsible for Nurses Cart Hall 200, removed medications in unsecure containers from the Nurses Cart. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food item in the facility walk-in freezer were covered. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the residents' immediate care for 2 (Resident #402 & Resident #67) of 16 residents observed for physician orders for oxygen. 1. The facility failed to provide physician orders for Resident #402 when admitted to the facility with a need for oxygen and while resident was on 4L of oxygen via nasal cannula on 11/8/24. 2. The facility failed to obtain orders for colostomy care for Resident #67 on 3/10/25 These failures could place the residents at risk of not receiving necessary physician ordered care that could result in worsening conditions or decline in health.

Inspectors wroteBased on interview, and record review the facility failed to ensure the MDS assessment accurately reflected the resident status for 2 (Resident #71 and Resident #67) of 8 residents whose records were reviewed for assessment accuracy. 1. Resident #67's colostomy status was not coded on his 03/14/25 Quarterly MDS after readmission on [DATE]. 2. Resident #71's attention deficit hyperactivity disorder diagnosis was not listed on his 03/05/25 Quarterly MDS. This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #5) of two residents observed during a transfer. The Facility failed to ensure CNA K used a gait belt when transferring Resident #5 from her bed to the wheelchair on 04/22/2025. This failure could affect the residents by placing the residents at risk for falls, discomfort, pain, and/or injury.

Inspectors wroteBased on observation, interview, 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 one of two residents (Resident #1) reviewed for catheter care. 1. The facility failed to ensure CNA B provided catheter care and appropriate perineal care for Resident #1 when she failed to separate the labia and wash downward, failed to clean under the resident's skin folds and failed to clean around the suprapubic catheter (catheter that is inserted through the abdominal wall into the bladder) on 04/23/25. 2. The facility failed to ensure RN A maintained a sterile procedure while re-inserting Resident #1's suprapubic catheter on 04/23/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 21 residents (Resident #1 and Resident #5) observed for infection control. 1. The facility failed to ensure RN A used the required PPE for Resident #1, who was on enhanced barrier precautions due to her indwelling urinary catheter, while changing the indwelling urinary catheter on 04/23/25. 2. The facility failed to ensure CNA K changed her gloves and performed hand hygiene while providing incontinence care to Resident #5 on 04/22/25. These failures could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 (Resident #1) of 2 residents reviewed for enteral nutrition. The facility failed to ensure Resident #1's correct G-tube feeding was administered as ordered by the physician on 2/19/25. This deficient practice could affect residents who receive tube feedings by not receiving the appropriate nutrition and hydration.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 (Resident #1) of 2 residents observed for infection control. The facility failed to ensure LVN A donned the appropriate PPE (personal protective equipment) required for EBP (enhanced barrier precautions) during administering G-tube (external tube inserted in the stomach to provide nutrition and hydration) for Resident #1 who was on enhanced barriers precautions on 2/19/25. These failures could place residents at risk for infection and cross contamination of pathogens and illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #1) reviewed for pain management. The facility failed to adequately assess and treat Resident #1's severe breakthrough pain. This failure could place residents at risk for unnecessary pain, discomfort and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect and dignity for 1 of 4 (Resident #1) residents reviewed for dignity in that: The facility failed to ensure staff did not stand over Resident #1 while assisting the resident with her meal in her room on 11/13/2024. This failure could affect residents who require assistance with activities of daily living and place them at risk for psychosocial harm due to a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #3) of 8 residents reviewed for ADLs. The facility failed to ensure Resident #3 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 2 Residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's nasal cannula tubing was labeled or dated. This failure could place residents at risk of respiratory infections.

Inspectors wroteThe facility failed to provide Resident #2 a divided plate to assist her with eating independently. This failure could affect residents who depended on assistive devices and infringe on the resident's dignity and feeding independence.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of one resident (Resident #4) observed for infection control. The facility failed to ensure CNA D and CNA E performed hand hygiene while providing incontinence care to Resident # 4. This failure could place the residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for medications. -The facility failed to have Resident #1's Hydromorphone (used to manage pain) available for administration, which caused the resident to miss two doses. This failure could place residents at risk of not receiving their medication treatment(s) as ordered by the physician to receive the full therapeutic benefit.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to label and date food in the walk-in freezer. 2. The facility failed to date food stored in the walk-in refrigerator that should no longer be consumed. 3. Cook B failed to wear effective hair restraint while serving food. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights, that include measurable objectives and time frames to meet Residents' mental and psychosocial needs for 1 of 4 (Resident #51) residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident # 51's use of dietary preferences and food intolerance. This failure could place resident at risk of not having a plan developed to address care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one of 5 residents (Residents #29) reviewed for dental services. The facility failed to provide a timely dental service referral for Resident #29. This failure could place residents at risk of oral infection, dental pain, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received food that accommodated their preferences for one (Resident #51) of four residents reviewed for dietary services. The facility failed to honor Resident #1's preferences which stated no pork, no fish, no eggs, and no lettuce. This failure could place residents at risk for not having their choices and food preferences accommodated, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #17, and Resident #63) of seven residents reviewed for infection control. - RN A failed to sanitize the blood pressure cuff between uses on Resident # 17 and Resident # 63. Theses failures could place residents at risk for infection and cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one (Resident #1) of five residents reviewed for ADLs. The facility failed to ensure Resident #1 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 of 4 residents (Resident #2, Resident #5, Resident #12, and Resident #31) reviewed for respiratory care. The facility failed to ensure Resident #2, Resident #5, Resident #12, and Resident #31 had oxygen concentrator filters free of sediment and debris. This failure could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for one of the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were dated and labeled in the refrigerator and dry storage rooms. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to ensure food in the food preparation area was covered. These failures could place residents at risk for cross contamination and other bacteria illnesses.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident right, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 1 residents reviewed for care plans. The facility failed to ensure Resident #12's Care Plan was comprehensively developed and implemented to meet the residents needs. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #49) reviewed for Care Plans. The facility failed to ensure Resident #49's Care Plan was reviewed quarterly. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased observation, interview and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of one residents (Residents #20) reviewed for urinary catheters. The facility failed to ensure Resident #20's urinary catheter bag was off the floor. These failures could place residents at risk of cross-contamination and infections.