Hollymead

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Nov 5, 2021

  Based on observation, interview, and record review the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Residents #166, #4, and #165) of five residents reviewed for pressure ulcers. The facility failed to ensure: 1. nursing staff obtained physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. […]

• Actual harm, isolatedF697Jan 2, 2025

  Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #1) reviewed for pain management. The facility failed to adequately assess and treat Resident #1's severe breakthrough pain. This failure could place residents at risk for unnecessary pain, discomfort and a decreased quality of life. Findings include: Record review of Resident #1's electronic face sheet, dated 12/31/24 reflected a [AGE] year-old female, who admitted to the facility on [DATE]. […]

• Actual harm, isolatedF690Apr 8, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services for one (Resident #1) of five residents reviewed for urinary catheters. The facility failed to drain Resident #1's suprapubic urine catheter bag, 18 out of the 76 prescribed and scheduled opportunities; which contributed to the increase in bladder spasms and pain. Review of Resident #1's MDS, undated, provided by the facility 04/08/2022, reflected she was a [AGE] year-old female admitted to the facility 03/09/2022. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was moderately cognitively intact, with a BIMS score of 12. […]

• Actual harm, isolatedF697Apr 8, 2022

  Based on observation, record review, and interview, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, and the residents' goals and preferences, for one (Resident #1) of three residents reviewed for pain management. The facility failed to drain Resident #1's suprapubic urine catheter bag, 18 out of the 76 prescribed and scheduled opportunities; which contributed to the increase in bladder spasms and pain. Review of Resident #1's MDS, undated, provided by the facility 04/08/2022, reflected she was a [AGE] year-old female admitted to the facility 03/09/2022. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was moderately cognitively intact, with a BIMS score of 12. […]

• No harm, potential for more than minimal, patternF925Jun 6, 2026

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in two halls (Hall 600 and Hall 700) of three halls reviewed for pests. The facility failed to ensure Hall 600 and Hall 700 were free of millipedes.This failure could place residents at risk of insect-born illness and not having a home free of pests in which to live. Findings included:Review of Resident #1's admission Record reflected Resident #1 was a [AGE] year old female resident admitted to the facility on [DATE], residing on the 700 Hall, with diagnoses in part including cerebral infarction (a type of stroke caused by blocked blood flow to the brain), essential hypertension (high blood pressure not due to another medical… […]