Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holly Care Center during CMS and state inspections, most recent first.
The facility failed to ensure proper infection control practices in housekeeping, nursing, and storage. A housekeeper did not use gloves or perform hand hygiene when handling soiled items. A nurse improperly handled a soiled dressing during wound care and did not wash hands adequately. Medications were stored in a bathroom, and body soap was left on shower room floors, posing infection risks.
The facility failed to develop comprehensive care plans for two residents, one with diabetes and renal disease lacking plans for dialysis, insulin, and anticoagulant use, and another with hypertension without a care plan. Despite physician orders, these plans were only created during a survey, contrary to facility policy.
A resident with moderate cognitive impairments and multiple health conditions lost her upper denture over a year ago, but the facility failed to replace it in a timely manner. Despite the facility's policy for timely ancillary services, the resident's care plan did not reflect the missing denture, and staff were unaware of the issue. The resident's insurance would not cover the cost, and she could not afford it privately, leading to a delay in addressing her needs.
Infection Control Deficiencies in Housekeeping, Nursing, and Storage Practices
Penalty
Summary
The facility failed to ensure that housekeeping staff adhered to proper infection control practices while cleaning resident rooms. Observations revealed that a housekeeper did not wear gloves when handling soiled mop pads and trash, and did not perform hand hygiene after these tasks. The facility's policy required the use of heavy-duty gloves and hand hygiene after glove removal, which was not followed. Interviews with the housekeeping supervisor and the infection preventionist confirmed that the housekeeper should have worn gloves and used hand sanitizer to prevent the spread of infection. The nursing staff also failed to follow appropriate infection control practices during wound care. A registered nurse was observed placing a soiled dressing on a clean disposable cloth near an uncovered wound and washing hands for only 10 seconds instead of the required 20 seconds. The facility's wound care policy required immediate disposal of soiled dressings and thorough handwashing. The infection preventionist confirmed that the nurse should have discarded the soiled dressing immediately and washed hands for at least 20 to 30 seconds. Additionally, the facility did not store clean items, such as medications and body soap, in a sanitary manner. Emergency medication kits were found stored in a bathroom within the medication storage room, which was sometimes used by nurses. This was against the facility's policy for medication storage. Furthermore, opened containers of body soap were found on the floor in shower rooms. The infection preventionist acknowledged that storing medications in the bathroom and body soap on the floor posed infection control risks.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, which resulted in deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #25, who had diagnoses including type 2 diabetes mellitus, end-stage renal disease, and multiple rib fractures, did not have care plans for dialysis, insulin use, or anticoagulant medication. Despite having physician orders for these treatments, the resident's electronic medical record lacked corresponding care plans until they were developed during the survey. Similarly, Resident #23, who had severe cognitive impairments and was diagnosed with essential hypertension, hemiplegia, vascular dementia, anxiety, and depression, did not have a care plan for hypertension. The resident was receiving medications for hypertension as per physician orders, but the care plan was only developed during the survey. The absence of these care plans was acknowledged by the nursing home administrator, director of nursing, and quality mentor, who agreed that care plans should have been in place according to the facility's policy. The facility's policy required that comprehensive care plans be developed within seven days after the completion of the comprehensive minimum data set assessment, incorporating measurable objectives and timeframes. The director of nursing indicated that the interdisciplinary team was responsible for developing these care plans, which should have been done during the seven-day assessment period. The lack of care plans for these critical areas was a clear deviation from the facility's policy and procedures, as confirmed by staff interviews.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a resident who required the replacement of her upper denture. The resident, who is under 65 years old and has diagnoses including intracranial shunt, bipolar disorder, severe obesity, and chronic pain, was admitted to the facility with moderate cognitive impairments. Despite being independent in most daily activities, the resident reported losing her upper denture in a transportation vehicle over a year ago and informed the facility of the loss. However, the facility did not take timely action to replace the denture, which affected the resident's ability to eat certain foods. The facility's Ancillary Services policy mandates timely provision of services such as dental care, but the resident's care plan did not reflect the missing denture. A dental consultation in March 2024 indicated that the resident's insurance would not cover the cost of new dentures for seven years, and the resident could not afford them privately. Despite this, there was no further documentation in the resident's electronic medical record showing efforts to assist the resident in replacing the dentures. Interviews with staff revealed a lack of awareness about the resident's missing denture. The DON acknowledged the facility's responsibility to ensure timely denture replacement and expected the social services director to coordinate with the business office and nursing home administrator to arrange funding. However, the current social services director was unaware of alternative means to obtain new dentures for residents, leading to a delay in addressing the resident's needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Holly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lamar Estates Nursing Center | 27.3 mi | ★★★★★ | 8 | 1 |
| Greeley County Hospital Ltcu | 34.6 mi | ★★★★★ | 19 | 0 |
| Stanton County Health Care Facility Ltcu | 39.3 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.