Holly Hill House

In the surveyor’s words

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

• Actual harm, isolatedF656Mar 24, 2026

  Based on record review, observations, and interviews, the facility failed to ensure staff implemented a resident's established, individualized plan of care for 1 (Resident #1) of 3 sampled residents who required two person assistance with bed mobility.This deficient practice resulted in an actual harm for Resident #1 on 03/11/2026 at 1:45 p.m., when S4CNA failed to follow the resident's plan of care for using two person staff assistance. S4CNA provided bed mobility during ADL (activities of daily living) care for Resident #1 without assistance from another staff member resulting in the resident falling from her bed onto the floor sustaining an injury to her right lower extremity requiring hospitalization. […]

• Actual harm, isolatedF600Apr 9, 2024

  Based on observations, interviews, and record reviews; the facility failed to protect the resident's right to be free from abuse for 3 (#1, #2, #3) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents. The facility failed to protect: 1. Resident #1 from sexual abuse by Resident #2. 2. Resident #2 from physical abuse by Resident #5. 3. Resident #3 from physical abuse by Resident #4. This deficient practice resulted in: 1. psychosocial harm for Resident #1 on 03/02/2024 at 4:42 p.m., when Resident #2 grabbed her breasts. Resident #1 was observed startled by staff at the time of the incident. The resident's responsible party stated that she would have been panicked, very fearful, and not happy at all. 2. […]

• No harm, potential for more than minimal, widespreadF727Apr 15, 2025

  Based on record review and interviews, the facility failed to ensure an RN (Registered Nurse) provided services for at least 8 consecutive hours a day. Findings: Review of the facility's PBJ (Payroll Based Journal) RN Coverage Report for 01/01/2025 to 03/28/2025 revealed no RN hours for 01/01/2025, 01/04/2025, and 01/05/2025. Review of RN clock in hours for 01/01/2025 to 03/28/2025 revealed there were no RN hours for 01/01/2025, 01/04/2025, and 01/05/2025. On 04/14/2025 at 12:30 p.m., an interview was conducted with S1ADM (Administrator). S1ADM acknowledged the PBJ RN Coverage report for 01/01/2025 to 03/28/2025 revealed on 01/01/2025, 01/04/2025, and 01/05/2025 there was not 8 hours of RN coverage on those dates. […]

• No harm, potential for more than minimal, widespreadF865Apr 15, 2025

  Based on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner. The facility failed to maintain documentation of evidence of its ongoing facility QAPI program. This deficient practice has the potential to affect 88 residents residing in the facility. Findings: Review of a facility policy on 04/15/2025 at 3:00 PM titled, QAPI Policy with a revised date of 01/2024, revealed the following in part, the QAPI program takes a systematic, comprehensive and data-driven approach to maintaining and improve safety and quality while involving all caregivers in practical and creative problem solving. […]

• No harm, potential for more than minimal, widespreadF802Sep 5, 2024

  Based on interviews, observations and record review, the facility failed to ensure there was enough dietary staff to provide residents' meals within 45 minutes of the facility's scheduled meal times for 84 residents who consumed meals from the kitchen. Findings: A review of the facility's policy on 09/05/2024, titled, Dining Service Meal Times, with no reviewed date, read in part, procedure: .3. Dining service times are planned in accordance with resident preferences and staffing available at scheduled meal times. 4. Meals and snacks will be served at the following times: Breakfast 7:30 a.m., Lunch 12:00 p.m., Afternoon snack 2:00 p.m., Supper 5:30 p.m., HS (nightly) snack 6:00 p.m. On 09/03/2024 at 8:35 a.m., an interview was conducted with S9CNA. […]