Holly Hall

Inspection findings

1. Oct 7, 2025 Health · 15 findings
   • Not serious Scope/severity E

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0770 Administration Deficiencies

     Provide timely, quality laboratory services/tests to meet the needs of residents.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0779 Administration Deficiencies

     Keep signed and dated reports of x-rays and other diagnostic services in the residents record.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity B

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Oct 8, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Oct 1, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Oct 1, 2025 · CMS fire safety

2. Oct 3, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Nov 5, 2024 · CMS health inspection

3. Aug 29, 2024 Fire Safety · 1 finding
   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Oct 7, 2024 · CMS fire safety

4. Jun 29, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0678 Quality of Life and Care Deficiencies

     Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

     Corrected Aug 14, 2024 · CMS health inspection

5. Apr 3, 2024 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Apr 24, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Apr 24, 2024 · CMS health inspection

6. Jun 8, 2023 Health · 8 findings
   • Not serious Scope/severity E

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0640 Resident Assessment and Care Planning Deficiencies

     Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 28, 2023 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jul 21, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• CLOUSE, AUTUMN — corporate director, NOT APPLICABLE, since 07/15/2019
• DREW, PETER — corporate officer, NOT APPLICABLE, since 08/01/2022
• DREW, PETER — operational/managerial control, NOT APPLICABLE, since 08/01/2022
• HOLLY HALL — operational/managerial control, NOT APPLICABLE, since 07/01/2018