Holly Hill Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 3, 2021

  Based on facility investigation documentation and medical records, observations and interviews, it was determined that the facility failed to have an effective system in place to prevent residents with cognitive impairment, who had a guardian designated as the appointed decision maker, from leaving the facility without appropriate supervision. Additionally, the facility failed to notify the resident's guardian of their desire to sign out against medical advice (AMA) resulted in the resident, who was deemed unsafe to be discharged , signing out AMA. This action placed this resident and other residents in the facility at risk for serious harm. […]

• Actual harm, isolatedF600Aug 1, 2025

  Based on review of a facility reported incident with investigation, medical record review, and interviews, it was determined the facility staff failed to protect a cognitively impaired resident from physical abuse from facility staff. This was evident for 2 (#6, and #11) of 3 residents reviewed for abuse during a complaint survey. This resulted in actual harm to resident #6. The findings include: 1. A review on 7/30/25 at 9 AM, investigation revealed that on 9/7/24 Resident #6 alleged that GNA #10, physically abused them by slapping open hands on the face. The GNA was suspended, and a full investigation was launched. Further review of the facility investigation revealed that another Resident #8, was a witness to the incident. […]

• No harm, potential for more than minimal, widespreadF801Mar 5, 2024

  Based on the interview with facility staff, it was determined that the facility failed to have a full time (Full-time means working 35 or more hours a week) clinically qualified Food Service Director. This was evident for 1 of 1 Food service Director reviewed for required credentialing. The findings include: On 02/28/24 at 01:07 PM, during an interview with Registered Dietician (RD) Staff #13, it was revealed that she/he worked 16 hrs a week and did not get involved with the kitchen, but monitored monthly food tasting and temperatures only. On 02/29/24 at 12:01 PM, the Dietary Director (staff #17) was interviewed and reported that he/she worked for five years in healthcare-related areas, and had a certificate for Baltimore food service manager valid until Sep 2026. […]

• No harm, potential for more than minimal, widespreadF812Mar 5, 2024

  Based on observation and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents at the facility. The findings include: On 02/22/24 at 12:52 PM, surveyor observed food serving trays with chipped and cracked edges. On 02/22/24 at 01:20 PM, surveyor reviewed chipped and cracked trays that were observed in use with the Food service Director (staff#17). On 02/29/24 at 12:08 PM, an observation of the trayline revealed several food trays with chips and cracks. […]

• No harm, potential for more than minimal, widespreadF880Mar 5, 2024

  Based on observation and interviews, it was determined that the facility failed to ensure that all laundry was processed and handled in a manner that prevents cross contamination and the spread of infections by failing to keep the door closed that separated the clean from the soiled area of the laundry room. This was evident for 1 of 1 laundry rooms and had the potential to affect all residents. The findings include: On 3/5/24 at 3:38 PM, while accompanied by the Nursing Home Administrator (NHA), a tour of the facility's laundry area revealed the laundry area consisted of a soiled laundry room, a clean laundry room and a room holding clean clothing , which the NHA indicated held clothes and linens belonging to residents which had not been labeled with a resident's name. […]