Holly Manor Rehab and Nursing

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 17, 2022

  Based on staff interview, facility document review and clinical record review, the facility staff failed to provide adequate supervision to prevent injury for one of 33 residents in the survey sample, Resident #61, resulting in harm of past non-compliance. The findings include: The facility staff failed to supervise and assist Resident #61 (R61) with breakfast on 11/2/22. The resident spilled oatmeal on themselves and was diagnosed with a second degree burn on the forearm that required treatment with silver sulfadiazine cream (1). […]

• No harm, potential for more than minimal, widespreadF814Aug 30, 2024

  Based on observation, staff interview, and facility document review, the facility staff failed to maintain the garbage areas in a sanitary manner for one of one trash compactor and two of ten trash bins. The findings include: The facility staff failed to ensure the door/lids on the trash compactor and two trash bins were kept closed when not in use. On 8/26/24 at 4:00 p.m., an observation of the trash compactor was conducted. The side door of the compactor was open and multiple bags of trash were observed in the compactor. On 8/27/24 at 1:52 p.m., an observation of the outside trash bins was conducted. […]

• No harm, potential for more than minimal, widespreadF880Aug 30, 2024

  Based on observation, staff interview, and facility document review, the facility staff failed to maintain a complete infection control program and implement infection control practices for one of 50 residents in the survey sample, Resident #33. The findings include: 1. The facility staff failed to evidence infection surveillance for January 2023 through December 2023. A review of the facility infection control program for January 2023 through December 2023 failed to reveal a system of surveillance. There was only a binder containing multiple Antibiotic Timeout forms for multiple residents. On 8/28/24 at 9:16 a.m., an interview was conducted with RN (registered nurse) #4 (the infection control nurse who was not employed at the facility during 2023). […]

• No harm, potential for more than minimal, widespreadF801Nov 17, 2022

  Based on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to continuously employ a registered dietitian (RD) or qualified nutritional professional. The findings include: The facility staff failed to employ a registered dietitian or qualified nutritional professional from 4/30/22 until 6/15/22. A complaint submitted to the state agency on 6/29/22 alleged there was no registered dietitian employed by the facility since 5/1/22. A review of facility documents/timesheets revealed a RD began employment on 6/15/22. On 11/16/22 at 5:52 p.m., an interview was conducted with ASM (administrative staff member) #4, the interim administrator. […]

• No harm, potential for more than minimal, widespreadF865Nov 17, 2022

  Based on staff interview and facility document review, the facility staff failed to implement a QAPI (Quality Assurance and Performance Improvement) program potentially affecting all residents in the survey sample. The findings include: The facility staff failed to provide evidence of a QAPI program prior to August 2022. On 11/17/22 at 10:24 a.m., ASM (administrative staff member) #2, the director of nursing (hired on 7/25/22), stated she could not provide evidence of any QAPI program/documentation prior to August 2022. […]