Average — CMS composite of the measures below.
A standard survey is most likely before around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holly Hill Healthcare Center during CMS and state inspections, most recent first.
A resident developed a bruise under the eye after an AM care incident, but the facility gave conflicting accounts of how it happened and did not notify the family member about the event. The chart included a nurse note and an NP note describing different causes and findings, yet there was no ongoing documentation of the bruise’s status, size, color changes, progression, or cause. The DON confirmed the assessment and follow-up documentation were not appropriate.
Call bells were not kept within reach for 5 residents during the survey. An LPN observed call bells under a bed, wrapped around an outlet, or hanging in baskets behind beds while residents were lying in bed, and one resident stated the call bell is usually not within reach. The NHA stated the expectation that residents should be able to access the call bell and have it placed next to them when in bed.
A resident was observed fully exposed in a room with the curtain open and the door wide open, allowing staff, residents, and visitors in the hallway to see the resident undressed. In separate observations, a GNA and an Activities Leader entered a shared resident room without knocking, despite both stating that staff were expected to knock before entering resident rooms.
Failure to provide quarterly resident funds statements to a resident’s representative. A resident with dementia and severe cognitive impairment had a designated representative, but the representative stated they never received the quarterly statement. The BOM confirmed the resident was not their own representative and that no statement had been mailed to the representative, even though the quarterly funds record had Administrator and BOM signatures.
A resident was found with a Geri chair placed beside the bed in a way that restricted getting out of bed. An RN confirmed the chair should not have been there and identified it as a restraint concern.
A resident enrolled in hospice, but the facility did not complete a significant change MDS within the required timeframe. The record showed a quarterly MDS before hospice enrollment and a Death in Facility MDS after the resident’s death, with no significant change assessment documented in between. The NHA said the full-time MDS coordinator was on extended leave and regional MDS staff were covering the facility, and the MDS Regional Coordinator confirmed the missing assessment.
A resident who was unable to move or feel anything below the neck, including the arms and legs, did not have a baseline care plan addressing this condition within 48 hours of admission. Review of the 48-hour care plan showed no plan for the resident’s condition, and the RD of Clinicals, DON, and Administrator stated that the condition should have been included in the baseline care plan.
A resident had an active order for bilateral elbow and hand splints to be worn during the day for 5 to 7 hours as tolerated, but staff repeatedly observed the resident without the splints in place while the splints remained at the bedside. Even so, the order was documented as complete. An LPN stated orders should only be signed off if completed, and if refused, refusal should be documented.
Inaccurate documentation of ordered splint use: A resident with left arm and hand contractures had an order for a carrot splint for contracture management, but repeated observations found the splint was not being worn. The TAR documented the splint as administered on multiple days even though the resident stated they had not worn it for months, the splint was found in a drawer, and an RN confirmed there was no refusal documentation to match the charted administrations.
A resident fell out of bed while receiving incontinence care, and only one staff member was present. The resident’s care plan required 2 or more helpers for toileting hygiene, but the fall documentation did not show a second staff member was there during the incident.
A resident with a tracheostomy did not have an ambu bag at bedside despite a physician order requiring it every shift. Surveyors observed the resident’s room with oxygen equipment and a trach tube, but no ambu bag was present. An RN could not locate one in the room and said the ambu bag was on the crash cart outside the room, while another RN stated the order required one at bedside.
Failure to obtain informed consent and document alternatives before bedrail use. A resident with paralysis below the neck was observed with two 1/4 bed rails in place, and the resident reported that staff rolled him/her toward the rail during incontinence care, the rail gave out, and the resident fell out of bed. The DON and regional clinical leader stated consent was not obtained because the facility did not view the devices as bedrails, and the therapy manager said therapy did not recommend bedrails for this resident.
An LPN failed to maintain infection control practices while administering eye drops to a resident. The LPN left the room with the eye drop bottle without hand hygiene, then returned wearing one glove, did not perform hand hygiene on entry, put on a second glove in the room, and administered the eye drops without hand hygiene between room entry and medication administration.
Unsafe and poorly maintained resident rooms and laundry areas were observed during survey. Deficiencies included detached wall and bathroom components, damaged blinds, exposed light bulbs, a privacy curtain off its tracks, missing tile, a running toilet, a furnace with loose and missing pieces, damaged furniture, and a laundry sink and table with rust, debris, and other damage. Staff reported maintenance concerns could be submitted by text, in person, or through TELS.
Inadequate Monitoring and Documentation of Resident Bruise
Penalty
Summary
The facility failed to ensure that Resident #5 received necessary monitoring and documentation after a bruise was identified under the resident’s eye. During the complaint investigation, the resident’s family member reported seeing a purple bruise under the eye on 2/12/26 and stated that the family was not notified about the incident. The facility gave two different explanations for how the bruise occurred. In the medical record, a nurse documented that the resident bumped his/her head on the headboard during AM care and had a raised knot with no bruising or discoloration, while the Nurse Practitioner documented that the resident hit his/her face on the foot board during transfer to the room for AM care and had swelling with a large bruise under the right lower eyelid. After these entries, there was no further documentation describing the bruise’s status, including its size, color changes, progression, or cause. The DON stated that a non-pressure skin issue must be documented in the medical chart with the status of the bruise, and the DON validated that there was no appropriate assessment or ongoing documentation for Resident #5’s bruise.
Call Bells Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that call bells were kept within reach for residents to use, affecting 5 of 36 residents reviewed during the annual survey investigation. On 10/1/2025, Resident #26’s call bell was observed hanging on the wall left of the bed and wrapped around the call bell plug outlet, not within reach, and it was seen in the same position later that morning. Resident #9’s call bell was observed underneath the bed and not within reach while the resident was lying in bed. Resident #3’s call bell was observed hanging in a basket behind the bed and not within reach; when asked, the resident stated the call bell is usually not within reach. Resident #43 and Resident #46 also had call bells hanging in baskets behind their beds and not within reach while lying in bed. During a tour with the surveyor, LPN #3 observed the call bells not within reach for Residents #26, #9, #3, #43, and #46 and then placed the call bells next to the residents, stating it was the facility’s expectation that call bells are always within reach.
Failure to Protect Resident Privacy and Knock Before Entering Rooms
Penalty
Summary
The facility failed to treat a resident with dignity when Resident #35 was observed fully exposed in a room with the privacy curtain not pulled and the room door wide open, allowing staff, residents, and visitors in the hallway to see the resident undressed. During interview, an RN stated that Resident #35 had a history of behaviors such as removing clothing and that the expectation was for the privacy curtain to be pulled and the door to be closed to prevent exposure. The facility also failed to maintain resident rights by not ensuring staff knocked before entering resident rooms. During observations, a GNA entered the room shared by Resident #1 and Resident #6 without knocking, and later an Activities Leader entered the same room without knocking. Both staff members stated that the expectation was to knock before entering resident rooms, with one saying she did not know why she failed to do so and the other saying she forgot. The Administrator later confirmed that staff were expected to knock on every resident's door prior to entering.
Failure to Provide Quarterly Resident Funds Statements
Penalty
Summary
The facility failed to provide quarterly resident funds statements to the resident’s representative for one resident with personal funds managed by the nursing home. The resident had dementia and severe cognitive impairment, with a BIMS score of 5 out of 10, and the admissions face sheet identified a resident representative. During interview, the representative stated they had never received a quarterly resident funds statement. The Business Office Manager stated that when a resident is not their own representative, a copy of the quarterly funds statement should be mailed to the representative, and confirmed that this resident was not their own representative and that no quarterly statement had ever been mailed to the designated representative. Review of the quarterly resident fund statement for the period reviewed showed signatures by the Administrator and the BOM, but there was no evidence that the statement had been reviewed by the resident or sent to the responsible party.
Physical Restraint Concern
Penalty
Summary
The facility failed to ensure Resident #23 was free from the use of a physical restraint. During the initial tour, a Geri chair was observed placed beside the resident’s bed in a way that restricted the resident from getting out of bed. During an interview, an RN confirmed that the chair should not have been there and acknowledged it as a restraint concern.
Failure to Complete Significant Change MDS After Hospice Enrollment
Penalty
Summary
The facility failed to complete a significant change MDS assessment within 14 days of a resident’s enrollment in hospice services. Resident #70 was admitted to hospice at the facility on 6/9/2025 and later died on 8/23/2025. Review of the resident’s MDS record showed a quarterly assessment with an ARD of 5/26/2025, followed by a Death in Facility MDS on 8/23/2025, with no significant change assessment documented between those assessments. During interview, the NHA stated that the facility’s full-time MDS coordinator was on extended leave and regional MDS staff were covering the facility. The MDS Regional Coordinator confirmed that Resident #70 did not have a significant change MDS after enrolling in hospice services and stated that the expectation was for residents entering hospice to have a significant change MDS within 14 days of enrollment.
Baseline Care Plan Not Developed for Resident With Paralysis
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #1, who was unable to move or feel anything below the neck, including the arms and legs. Review of the resident’s 48-hour care plan on 10/03/2025 did not show a plan of care for this condition. A later review of the hospital discharge summary dated [DATE] showed that the resident had this condition upon admission to the facility. During interviews on 10/07/2025 and 10/14/2025, the Regional Director of Clinicals, DON, and Administrator stated that the resident’s plan of care for this condition should have been included in the 48-hour care plan.
Improper Documentation of Splint Care Orders
Penalty
Summary
The facility failed to maintain professional standards of practice related to signing off resident care orders for one resident’s bilateral elbow and hand splints. The resident stated on interview that staff were supposed to put the arm splints on every day but did not. The medical record showed an active order for the resident to wear bilateral elbow and hand splints during the daytime for 5 to 7 hours every day as tolerated. Observations on multiple occasions showed the resident in the room without the splints in place, with the splints sitting next to the bedside. Despite these observations, the order was documented as complete in the record. An LPN stated that staff were expected to sign off orders only if they were done, and if a resident refused, it could be documented as refused. The concern was reviewed with the Regional Director of Clinical Services and the Administrator, who stated that staff should not sign off orders as completed unless they were done.
Inaccurate documentation of ordered splint use
Penalty
Summary
The facility failed to ensure that a resident with an order for an orthopedic device was wearing the device as prescribed and that device administration was accurately documented. Resident #3 had contractures of the left arm and hand and an order, initiated on 10/23/2024, for a left elbow and hand carrot splint to be applied up to 4-6 hours a day as tolerated, with removal for skin inspection and ADL care, every day shift for contracture management. During multiple observations on 10/1/2025, 10/6/2025, 10/8/2025, and 10/10/2025, the resident was lying in bed and no brace or splint was observed in place on the left arm or hand. When asked, the resident stated no to wearing an orthopedic device in the last few months and later shook their head no when asked if the splint had been applied that day. The treatment administration record for October 2025 documented that the brace and splint had been administered on October 1 through October 10, 2025. The same record also showed behavior monitoring entries stating the resident was not exhibiting behaviors, with no documentation that the resident refused to wear the elbow and carrot splint. RN #7 confirmed the TAR showed the splint as applied, observed that the resident was not wearing it, and located the splint in the resident’s top drawer. RN #7 stated the resident had a history of refusing the splint and had not worn it in about a year, but could not show documentation of refusal in the medical chart on the days it was recorded as administered. The Regional Clinical Director stated the splint should not be documented as administered if the resident did not wear it, and that refusals should be documented under behavioral monitoring.
Failure to Follow Care Plan for Two-Person Assistance During Incontinence Care
Penalty
Summary
The facility failed to ensure staff implemented interventions consistent with a resident’s care plan to prevent a fall. Resident #1 reported falling out of bed while a staff member was providing incontinence care and stated that only one staff member was present at the time. Record review showed a progress note documenting that the resident fell on [DATE] at 3:15 PM, and the fall documentation identified Geriatric Nursing Assistant Staff #18 as being with the resident during the fall without indicating that a second staff member was present. The resident’s care plan, reviewed on 10/03/2025, included an intervention for activities of daily living self-care performance stating that 2 or more helpers were required for toileting hygiene, initiated on 2/6/25. During review with the Administrator and Regional Director of Clinical Services, they indicated that two staff members should have been with the resident during care.
Missing Ambu Bag at Bedside for Resident With Tracheostomy
Penalty
Summary
Failure to provide necessary respiratory care services occurred when the facility did not maintain an ambu bag at the bedside for a resident with a tracheostomy despite a physician order dated 1/30/2024 directing that an ambu bag be kept at bedside every shift. During observation, the resident’s room contained an oxygen concentrator with sterile saline bottle for humidification, oxygen tubing, and a trach mask, and the resident was observed with a tracheostomy tube, but no ambu bag was present in the room. On a later observation, survey staff again did not find an ambu bag in the room. An RN was unable to locate one in the room and stated that an ambu bag was on the crash cart outside the room and down the hall, while another RN stated that if the order says ambu bag at bedside, there should be one in the room.
Failure to Obtain Consent and Document Alternatives Before Bedrail Use
Penalty
Summary
The facility failed to obtain informed consent and document alternatives attempted before initiating bedrails for Resident #1. On 10/02/2025, an observation showed two 1/4 bed rails raised on either side of the top end of the bed. During an interview at that time, Resident #1 stated that staff had rolled the resident toward the bed rail, it gave out during incontinence care, and the resident fell out of bed. The resident also stated having a condition that left him/her unable to move or feel anything below the neck. Review of an incident note dated 9/21/2025 showed that the bed rail gave way when the resident fell out of bed. During interviews on 10/09/2025, the Administrator and Regional Director of Clinical Services stated that bedrails were used when a resident could grab the bedrail and could not roll on their own, that therapy completed the assessment, and that alternatives had been attempted, but they also stated that consent was not obtained because the facility did not view the devices as bedrails. On 10/10/2025, the Therapy Manager stated therapy did not recommend bedrails for Resident #1 and would not recommend bedrails for a resident with Resident #1's condition.
Failure to Maintain Hand Hygiene During Eye Drop Administration
Penalty
Summary
The facility failed to ensure infection control practices were maintained during medication administration for one resident observed receiving eye drops. During the observation, an LPN entered the resident’s room and prepared to administer eye drops, then walked out of the room with the eye drop bottle without performing hand hygiene. The LPN later returned to the resident’s room wearing one glove, did not perform hand hygiene upon entering, and then put on a second glove in the room without having performed hand hygiene since entering. The LPN then administered eye drops into both of the resident’s eyes. The concern was reviewed with the Administrator and Regional Director of Clinical Services, who stated that staff are expected to perform hand hygiene when entering and exiting a resident’s room.
Unsafe and Poorly Maintained Resident and Laundry Areas
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for residents and staff, as shown by multiple observations during the annual survey. In one room, a wall foot board was completely detached and leaning against the wall, a rubber lining below the shower was detached from the floor and in the bathroom pathway, the window blinds were bent or cracked, and a corner protector in the bathroom was detached from the wall at the bottom. In another room, the bathroom door panel was split at the bottom by the hinges, a square tile behind the toilet was missing and exposed the inside of the wall, and the toilet was running for several minutes while the surveyor observed the room. Additional observations found the light bulbs above one bed were exposed, one side of the window blinds was completely detached and lying on the window sill, the privacy curtain between the beds was off the ceiling tracks in multiple sections, and the furnace had missing and loose top square pieces exposing internal parts. The night stand was missing a top drawer, the dresser had a broken handle and multiple scratches and chips, and the laundry room had a sink filled with soiled items, rust, and white particles. The laundry room also had a drain without a cover, a damaged wall corner cover with exposed metal, and a folding table that was rusted and dusty. Staff interviews confirmed that maintenance concerns could be reported through text, in person, or through an online system, and the maintenance director reviewed the concerns with surveyors.
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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.
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Nursing homes near Towson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Multi Medical Center Llc | 0.2 mi | ★★★★★ | 13 | 0 |
| Towson Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 22 | 0 |
| Autumn Lake Healthcare At Long Green | 1.4 mi | ★★★★★ | 33 | 0 |
| Greater Baltimore Medical Center Sub Acute Unit | 1.5 mi | — | 0 | 0 |
| Autumn Lake Healthcare At Homewood | 1.5 mi | ★★★★★ | 28 | 0 |
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