Holiday Heights Healthcare

In the surveyor’s words

From the most serious findings on record at Holiday Heights Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 19, 2026

  Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure the environment was free of accident hazards for 5 (Residents #6, #12, #19, #30, and #38) of 16 residents reviewed for smoking. Specifically, on 04/08/2025, Resident #12 reported receiving a cigarette burn while smoking, and the facility determined the resident had a full thickness burn (all layers of the skin were destroyed) to the left thigh. After the burn, the facility implemented a care plan intervention for a smoking apron; however, Resident #12 was noncompliant with the intervention. […]

• No harm, potential for more than minimal, patternF759Jun 19, 2026

  Based on observation, interview, record review, facility policy review, and manufacturer instructions review, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 8 medication errors out of 25 opportunities, resulting in a medication error rate of 32%, which affected 3 (Residents #20, #2, and #4) of 12 residents reviewed during the medication administration task.Findings included: 1. An admission Record revealed the facility admitted Resident #20 on 11/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of drug- or chemical-induced diabetes mellitus (when the body cannot produce or use insulin correctly resulting in high blood sugar levels) without complications. […]

• No harm, potential for more than minimal, patternF641Jul 24, 2024

  Based on observation, record review, and interview, the facility failed to ensure MDS assessments were accurately entered for three (#3, #14 and #30) of four sampled residents reviewed for MDS accuracy. ADON #1 identified 41 residents resided in the facility. Findings: 1. Res #3's annual MDS, dated [DATE], documented the resident had a restraint. On 07/21/24 at 10:03 a.m., Res #3 was observed in their bed. A circular half rail was observed on the right side of the bed. The resident stated they had the rail for positioning, and it was their preference to have the rail. A record review documented the required consents and assessments were completed for the rail. On 07/23/24 11:39 a.m., the MDS coordinator stated there were no residents in the facility with restraints. […]

• No harm, potential for more than minimal, patternF812Jun 29, 2023

  Based on observation and interview, the facility failed to properly store food and keep the kitchen and equipment clean and in good repair. The DM identified 45 residents received services from the kitchen. Findings: On 06/27/23 at 11:27 a.m., an initial tour of the kitchen was conducted. The following observations were made: a. there was a very dirty saturated blanket on the floor beside the ice machine with puddles of water surrounding it in the dry storage room. b. there were particles of food on the shelves inside both freezers in the kitchen area. c. there were white dish towels that were observed to be wet and had orange juice spills on them under the shelving in both refrigerators in the kitchen. d. […]

• No harm, potential for more than minimal, patternF583Jan 11, 2022

  Based on observation, interview, and record review, the facility failed to ensure privacy and confidentiality for six (#4, 15, 34, 43, 147, and #247) of six sampled residents reviewed for abuse. The facility failed to ensure a staff member did not take photos of residents and send them electronically to the staff member's family. The Census and Conditions of Residents report documented 44 residents resided at the facility. Findings: Pictures of Residents (Res) #4, 15, 34, 43, and #147; and two videos of Res #247 had been submitted to OSDH by an anonymous person. CNA #1 was also observed to be included in the pictures and the videos. 1. Res #4 was pictured in her wheelchair, fully clothed, in the hallway. Half of CNA #1's face could be seen in the picture. […]