Holly Heights Care and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 11, 2025

  Based on record review and interviews, the facility failed to ensure one (#1) of three residents at risk for elopement out of three sample residents received adequate supervision and were kept free from elopement. Specifically, the facility failed to provide Resident #1 with the supervision necessary to prevent elopement. The facility's failure created a situation for the likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1 was admitted on [DATE] with a diagnosis of Wernicke's encephalopathy (a brain disorder), repeated falls, unspecified dementia, somnolence (a state of being drowsy or sleepy) and alcohol dependence. […]

• Actual harm, isolatedF689Jun 15, 2023

  Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents received adequate supervision and services to prevent an accident/hazard. Resident #1, who had a diagnosis of multiple sclerosis (nerve damage resulting in weakness), type 2 diabetes mellitus, muscle weakness and history of falling was initially admitted to the facility on [DATE]. The facility failed to implement fall interventions and updating the care plan following a fall on 1/28/23. […]

• Actual harm, isolatedF692Sep 14, 2022

  Based on interviews, record review, and facility policy review, the facility failed to ensure residents were weighed weekly as ordered by the physician for three (Resident #36, Resident #47, and Resident #90) of three sampled residents reviewed for nutrition. The failed practice resulted in a delay in identifying and intervening to address a severe weight loss of 9.28% of Resident #90's total body weight over a period of three months and three weeks. Findings included: Review of an undated facility policy titled, Policy for Weighing Resident revealed, Individuals will be weighted [sic] upon admission or readmission to establish a baseline weight. […]

• No harm, potential for more than minimal, widespreadF925Jan 21, 2026

  Based on observations, record review and interviews, the facility failed to maintain an effective pest control program so the facility was free from pests and rodents on two of three units.Specifically, the facility failed to keep the resident's rooms free from mice.Findings include:I. Facility policy and procedureThe Pest Control policy revised April 2021, was provided by the nursing home administrator (NHA) on 1/21/26 at 1:42 p.m. via email. It read in pertinent part, It is the policy of this facility to provide an environment free of pests. The facility will have a pest contract that provides frequent treatment of the environment for pests. It will allow for additional visits when a problem is detected. Monitoring of the environment will be done by the facility's staff. […]

• No harm, potential for more than minimal, widespreadF761Jan 9, 2024

  Based on observation and interview, the facility failed to ensure all drugs and biologicals were properly stored and labeled in three out of three units. Specifically, the facility failed to: -Ensure expired medications were timely removed from the medication storage refrigerator; -Ensure Tuberculin purified protein derivative (PPD) was dated after opening; and, -Ensure refrigerated a schedule IV controlled medication was securely double locked and affixed in the refrigerator. Findings include: I. Professional reference Sanofi Pasteur (2020). Package insert. Tuberculin Purified Protein Derivative (Mantoux): Tubersol. Food and Drug Administration (FDA). […]