Holly Care Center

In the surveyor’s words

From the most serious findings on record at Holly Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Mar 11, 2021

  Based on observations, record review and interviews, the facility failed to implement interventions and provide appropriate treatments to prevent the development and the worsening of pressure injuries for three (#2, #3, and #8) of three residents reviewed for pressure injuries out of 12 sample residents. Record review and interview revealed the facility had multiple systemic failures in its management of pressure injuries. These included failure to properly identify, document and monitor pressure injuries, implement interventions in a timely manner and complete ordered wound treatments to prevent the development and worsening of the residents ' pressure injuries. […]

• Actual harm, isolatedF684Mar 11, 2021

  Based on observations, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#1) of three residents reviewed for skin integrity issues out of 12 sample residents. The facility failed to accurately document and monitor Resident #1's skin integrity issues and implement timely treatment and interventions to prevent the worsening of these skin issues. Record review revealed the facility failed to consistently assess and document the resident's skin condition and delayed implementing treatment for [REDACTED]. It also revealed that treatment was not being delivered to the resident as ordered by the physician. […]

• Actual harm, isolatedF697Mar 11, 2021

  Based on interviews and record review, the facility failed to manage the pain of one (#3) resident reviewed out of 12 sample residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility failed to identify an increase in the intensity and frequency of the resident's pain as her pressure ulcer worsened (cross-reference F686), and failed to provide adequate pain relief for Resident #3. The facility failed to ensure pain relief measures were provided during wound care to ensure optimal comfort during the procedure. These facility failures contributed to the resident experiencing undue severe pain. […]

• No harm, potential for more than minimal, widespreadF812Mar 30, 2023

  Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Food was stored and labeled properly Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 46-47, in part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: Before handling or putting on single use gloves for working with food, and… […]

• No harm, potential for more than minimal, widespreadF921Mar 30, 2023

  Based on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on a hose in the kitchen maintenance closet and on the hand held shower on the west hall shower, increasing the risk of contamination to the facility's main water supply. Findings include: I. Backflow prevention devices A. Professional references According to the Environmental Protection Agency's Cross-Connection Control, updated on 11/2/22, retrieved on 3/29/23 from: https://www.epa.gov/system/files/documents/2021-12/ds-toolbox-fact-sheets_ccc.pdf, it read in pertinent part, Cross-connections are actual or potential connections between a potable… […]