Holly Hall

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Apr 28, 2022

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety in that: The facility failed to ensure: -the kitchen floors were kept clean and free of food particles. -the cooking grease in the deep fryer was kept clean. - the can opener clean and free of food debris. -left over food items were properly labeled and dated. -expired foods were discarded. -the vent hood was free of grease build up. These failures could place residents at risk for food-borne illness and cross contamination. […]

• No harm, potential for more than minimal, patternF550Oct 7, 2025

  Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #37) of 4 residents and 3 of 3 confidential group residents reviewed for resident rights. The facility failed to provide showers to Resident #37 and 3 of 3 confidential group residents. This failure could affect the residents who require assistance with their ADLs from facility staff by placing them at risk for social isolation, loss of dignity, and self-worth. […]

• No harm, potential for more than minimal, patternF677Oct 7, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 1 (Resident #37) and 3 of 5 confidential residents reviewed for ADLs. The facility did not consistently provide Resident #37 and 3 of 5 confidential residents bed baths/showers on their scheduled shower days in the month of September 2025. This failure could place residents at risk of skin breakdown and reduced feelings of self-worth. Findings included: Resident #37:Record review of Resident #37's Face sheet dated 10/01/2025 indicated he was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. […]

• No harm, potential for more than minimal, patternF690Oct 7, 2025

  Based on observations, interviews, 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 1 of 3 residents (Resident #9 ) reviewed for quality of care. 1. The facility failed to assess, follow-up with treatment, update the care-plan, obtain new order due to a change in resident #9's skin condition of the groin and resident's report of pain, at which time the penis split measured 1. 8 cm length by 0.5 cm width and appeared red and raw, which was first identified on 9/22/25 and failed to ensure that Resident #9's indwelling catheter (drains urine from your bladder into a bag outside your body) had a securement device to anchor catheter.2. […]

• No harm, potential for more than minimal, patternF692Oct 7, 2025

  Based on observation, interviews and record review, the facility failed to ensure each resident had acceptable parameters of nutritional status such as usual body weight or desirable body weight range for discharged (DC #1) Resident and 8 of 8 residents reviewed for weight loss. 1. The facility failed to maintain acceptable parameters of nutritional status such as usual body weight or desirable body weight range for 1 of 1 discharged resident (DC) #1 and 8 of 8 (Resident #7, Resident #9, Resident #10, Resident #16, Resident #23, Resident #29, Resident #37 and Resident #42) residents, reviewed for weight loss. 2. The facility failed to ensure 3 of 3 scales used for weight were calibrated accurately. 3. […]