Holly Manor Center

In the surveyor’s words

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

• Actual harm, isolatedF692Jan 27, 2023

  Based on observation, interview, and record review, the facility failed to provide care and services to maintain nutrition status and prevent weight loss for one of three residents reviewed for nutrition (Resident (R) 56). Due in part to the failure to communicate R56's ongoing, significant weight loss to the interdisciplinary team, implement nutritional interventions that were recommended and closely monitor the resident's weight, R56 experienced a significant unintentional weight loss which resulted in his inability to maintain a healthy weight. […]

• No harm, potential for more than minimal, widespreadF584Jun 12, 2026

  Based on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms and common areas. The deficient practice was observed on 2of 2 units during the facility tour. The deficient practice was evidenced by the following: On 6/3/26 at 10:45 AM, while on initial tour of the facility, the surveyor observed the following: Stained ceiling tiles in 56-west Scuff marks on the wall in room [ROOM NUMBER]-West On 6/8/26 at 11:17 AM, while interviewing a resident, the surveyor observed stained ceiling tiles in room [ROOM NUMBER]-South At 11:22 AM, while in the dining room the surveyor observed a multiple ceiling tiles the were curving upward at their edges. […]

• No harm, potential for more than minimal, widespreadF804Jun 12, 2026

  Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure meals were served at a palatable temperature on 1 of 3 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 6/9/26 at 11:41 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the Regional Food Service Director (RFSD).At 12:08 PM, the surveyor and RFSD observed the food truck arrive on the North 1st floor unit. The surveyor observed the first lunch tray being served at 12:08 PM. At that time a test tray of a regular diet and pureed consistency was identified by the surveyor and FSD, this tray was left in the food truck. […]

• No harm, potential for more than minimal, widespreadF806Jun 12, 2026

  Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences and menus were consistently provided for 2 of 4 residents (Resident #38 and #100) reviewed for dietary preferences. This deficient practice was evidenced as follows: 1. On 6/3/26 at 10:45 AM, the surveyor observed Resident #100 in their room sitting in a wheelchair (w/c). Resident #100 indicated they do not speak English and called a family member for a phone interview. The family member revealed Resident #100 had been in the facility about 8 days and the resident did not like the food. […]

• No harm, potential for more than minimal, widespreadF812Jun 12, 2026

  Repeat Deficiency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/3/26 at 9:28 AM, the presence of the Food Service Director (FSD), the surveyor observed the following: 1. On top of the ice machine, the surveyor observed a dust-like build up. The FSD stated they were covering for the regular FSD and were not sure of the cleaning schedule.2. In the 2-door standing refrigerator, the surveyor observed a container of sliced apples with a use by date of 6/2/26. The FSD stated the evening staff should have discarded the apples last night. […]