Holly Springs Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 24, 2025

  Based on observation, staff interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for one (1) of three (3) residents reviewed for accidents (Resident #1), when the facility did not increase monitoring despite repeated episodes of the resident entering other residents' rooms and consuming food while on NPO (nothing by mouth) status, resulting in multiple transfers to the emergency department for possible aspiration. Findings include:Review of a reported complaint related to Resident #1 revealed the resident has a Percutaneous Endoscopic Gastrostomy (PEG) tube and the facility is not monitoring him closely enough and he is getting food from various places throughout the facility.Review of a statement provided by the facility administration… […]

• Actual harm, isolatedF656Jan 27, 2025

  Based on staff interviews, record review and facility policy review, the facility failed to implement a comprehensive care plan to provide for two-person assistance with a lift during a transfer in a manner to prevent an injury for one (1) of three (3) sampled residents. Resident #1. Findings Include: Review of the facility policy Care Plans, Comprehensive Person-Centered with reviewed date of November 2024 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. […]

• Actual harm, isolatedF689Jan 27, 2025

  Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to provide two-person assistance during a transfer for a dependent resident in a manner to prevent an injury for one (1) of three (3) sampled residents. Resident #1. Findings Include: Review of the facility policy titled, Safe Patient Handling and Moving Protocol with reviewed date of 06/10/2024, revealed The Quality Assurance (QA) Committee will ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident. […]

• No harm, potential for more than minimal, widespreadF868May 14, 2026

  Based on record review, staff interview, and facility policy review, the facility failed to have the required staff present and in attendance for each quarterly Quality Assurance and Performance Improvement (QAPI) meetings for four (4) of 4 quarterly meetings dated 09/30/25, 12/29/25, 03/31/26 and 05/01/26. Findings include:Review of facility document titled QAPI Program undated revealed, .Leadership of the QAPI committee will include the Medical Director and or Nurse Practitioner (NP), Administrator, and Director of Nurses.QAPI meetings will be held monthly. […]

• No harm, potential for more than minimal, widespreadF812Jun 19, 2025

  Based on observations, staff interviews, record review, and facility policy review, the facility failed to: 1) label and store food properly and maintain the kitchen and the equipment in a clean and sanitary condition for two (2) of three (3) kitchen tours, and 2) prevent the potential for foodborne illness as evidenced by meal trays left in rooms for a prolonged time (Resident #24, #52, #68, #83) for one (1) of four (4) survey days. Findings Include: Review of facility policy titled, Food Storage: Dry Goods dated 2/2023 revealed, .All packaged and canned food items will be kept clean, dry, and properly sealed . […]