Suites at Holly Creek Care Center, The

In the surveyor’s words

From the most serious findings on record at Suites at Holly Creek Care Center, The, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 21, 2024

  Based on observations, record review and interviews, the facility failed to ensure one (#6) of one resident reviewed for pressure injuries out of 20 sample residents received care consistent with professional standards of practice to prevent and heal pressure injuries. Resident #6 was admitted on [DATE] for long term care. At the time of admission, the resident was identified for being at risk for developing pressure injuries. Upon admission, the resident had a surgical incision on her right leg and her skin was otherwise intact. Resident #6 attended dialysis three times a week. On 8/2/24, a primary care physician documented Resident #6 developed a blister on her left heel that had thick white drainage which may have represented some early infection. […]

• Actual harm, isolatedF689Jul 31, 2023

  Based on record review, observations, and interviews, the facility failed to ensure the resident environment was as free of accident hazards (risks) as possible for three of seven residents (#22, #13 and #2) investigated for accidents and four of seven residents (#20, #16, #3 and #12) investigated for falls out of 22 sample residents. Specifically: Record review, observations, and interviews revealed the facility failed to identify, consider and address potential risks in the staff's transport of residents in wheelchairs and in the staff's transfer of residents with severe cognitive and functional limitations, in order to reduce the risks as much as possible. […]

• No harm, potential for more than minimal, patternF880Nov 21, 2024

  Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP); and, -Ensure staff followed appropriate infection control practices while cleaning resident rooms. Findings include: I. Failure to ensure staff donned appropriate PPE when providing care to a resident on EBP A. […]

• No harm, potential for more than minimal, patternF550May 25, 2022

  Based on record review and interviews, the facility failed to ensure residents had the right to a dignified existence. Specifically, the facility failed to ensure residents experienced a dignified living experience by answering the call lights timely for two (Resident #9 and Resident #13) of 16 out 20 residents and addressed continued call light complaints voiced during resident council for several months. Findings include: I. Facility policy A call light policy was requested during survey 5/23/22 to 5/25/22; however the executive director (ED) reported the facility did not utilize a call light policy. The Resident Rights policy, dated August 2021 was received by ED on 5/25/22 at 8:10 a.m. […]

• No harm, potential for more than minimal, isolatedF689Nov 21, 2024

  Based on observations, record review and interviews, the facility failed to ensure two (#4 and #10) of two of 20 sample residents remained free from accidents hazards. Specifically, the facility failed to ensure Resident #4 and Resident #10 had a physician's order, a consent and a completed safety assessment before the implementation of a floor to ceiling transfer pole by the resident's bed. Findings include: I. Facility policy and procedure The Bed Mobility Devices policy, approved October 2024, was provided by the nursing home administrator (NHA) on 11/20/24 at 10:30 a.m. The policy revealed bed mobility devices had the potential to cause actual harm or entrapment to residents. […]