All citations for Holly Manor Rehab and Nursing

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Holly Manor Rehab and Nursing

Last standard health inspection on record

August 30, 2024

This is more than 2 years ago. Newer inspection results may not be on record yet, so the results below may not describe the home today. Ask the home for its most recent inspection report.

Showing 1 to 25 of 47 citations

  1. Harm to a resident

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    Past non-compliance: already corrected by the time of the inspection (November 11, 2022).

  2. No harm, with potential for more than minimal harm

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

    Widespread (many residents). CMS level F.

    Health citation F-0801, Nutrition and Dietary Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  3. No harm, with potential for more than minimal harm

    Have a plan that describes the process for conducting QAPI and QAA activities.

    Widespread (many residents). CMS level F.

    Health citation F-0865, Administration Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  4. No harm, with potential for more than minimal harm

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    Widespread (many residents). CMS level F.

    Health citation F-0867, Administration Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  5. No harm, with potential for more than minimal harm

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

    Widespread (many residents). CMS level F.

    Health citation F-0868, Administration Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  6. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Widespread (many residents). CMS level F.

    Health citation F-0880, Infection Control Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2022).

  7. No harm, with potential for more than minimal harm

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

    Widespread (many residents). CMS level F.

    Health citation F-0882, Infection Control Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  8. No harm, with potential for more than minimal harm

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0585, Resident Rights Deficiencies. Inspection of June 5, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 26, 2025).

  9. No harm, with potential for more than minimal harm

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0605, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of June 5, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 26, 2025).

  10. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of June 5, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 26, 2025).

  11. No harm, with potential for more than minimal harm

    Ensure services provided by the nursing facility meet professional standards of quality.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of June 5, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 26, 2025).

  12. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of June 5, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 26, 2025).

  13. No harm, with potential for more than minimal harm

    Provide safe, appropriate pain management for a resident who requires such services.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0697, Quality of Life and Care Deficiencies. Inspection of June 5, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 26, 2025).

  14. No harm, with potential for more than minimal harm

    Ensure that residents are free from significant medication errors.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of June 5, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 26, 2025).

  15. No harm, with potential for more than minimal harm

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0804, Nutrition and Dietary Deficiencies. Inspection of June 5, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 26, 2025).

  16. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of June 5, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (August 26, 2025).

  17. No harm, with potential for more than minimal harm

    Reasonably accommodate the needs and preferences of each resident.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0558, Resident Rights Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  18. No harm, with potential for more than minimal harm

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0585, Resident Rights Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  19. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  20. No harm, with potential for more than minimal harm

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0698, Quality of Life and Care Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  21. No harm, with potential for more than minimal harm

    Observe each nurse aide's job performance and give regular training.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0730, Nursing and Physician Services Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  22. No harm, with potential for more than minimal harm

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0757, Pharmacy Service Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  23. No harm, with potential for more than minimal harm

    Ensure that residents are free from significant medication errors.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  24. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

  25. No harm, with potential for more than minimal harm

    Employ staff that are licensed, certified, or registered in accordance with state laws.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0839, Administration Deficiencies. Inspection of November 17, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 25, 2022).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.