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 Manor Center during CMS and state inspections, most recent first.
The facility failed to maintain proper kitchen sanitation practices, resulting in a repeat deficiency. Expired food items were found in the dry storage and chef preparation areas, and a lack of labeling was noted in the walk-in refrigerator. Additionally, a blackish dust-like substance was observed on the refrigerator's fan grate. The facility's policies on food storage and equipment maintenance were not followed, as confirmed by the FSD and LNHA.
The facility failed to maintain a sanitary environment by not keeping the dumpster and surrounding area free of garbage and debris. During a tour, the surveyor observed garbage debris, including food wrappers, cups, gloves, paper products, and medication cups, around the dumpster. The Food Service Director acknowledged that the area should have been cleaned by the maintenance and dietary departments. The Licensed Nursing Home Administrator confirmed that the garbage area should be kept free of debris, as per the facility's trash removal policy.
The facility failed to document the receipt of Schedule II controlled substances on DEA 222 Forms and did not follow physician orders for a resident's blood pressure medication. The forms lacked necessary details, and the resident's blood pressure was not recorded before administering Cozaar, despite instructions to hold the medication if systolic blood pressure was below 110. These deficiencies were confirmed by the DON and an LPN during the survey.
A facility failed to ensure the Consultant Pharmacist identified and reported irregularities in medication management for a resident. The CP did not notice that a nurse was not documenting the resident's blood pressure when administering Cozaar, which was prescribed with a parameter to hold if the systolic BP was below 110. This oversight occurred multiple times over several months, despite the facility's policy requiring the CP to communicate potential or actual problems related to medication therapy.
The facility failed to monitor, document, and evaluate the use of psychoactive medications for four residents. Observations and record reviews revealed a lack of documentation for target behaviors and side effects, incomplete AIMS assessments, and care plans missing specific interventions. Staff interviews confirmed inadequate monitoring practices, contrary to the facility's policy requiring non-pharmacological approaches and psychotropic medication evaluations.
The facility failed to follow infection control practices for linen handling and storage. Clean linens were observed uncovered in the laundry room, and pillows were stacked to the ceiling in the linen room, posing a fire hazard. The IP could not confirm the cleanliness of various items found on the floor, contrary to the facility's linen handling policy.
A facility failed to implement a comprehensive care plan for a resident who frequently refused care and was combative. Despite the resident's medical history of cerebral infarction and mood disorders, the care plan did not address their refusal of care. Staff interviews confirmed the resident's behavior, and the facility's policy required documentation of such refusals, which was not present.
The facility failed to properly label, dispose, and secure medications in multiple medication carts and a refrigerator. An LPN acknowledged an undated Lantus insulin pen was improperly stored, and a refrigerator was unlocked with Vancomycin IV bags. Further inspections revealed undated insulin pens, opened Xalatan eye drops without dates, expired medications, and undated blood glucose test strips. Staff acknowledged these deficiencies.
A facility failed to maintain accurate medical records when an RD did not sign a nutrition note for a resident on an altered consistency diet for dysphagia. The note, dated over a month prior, remained in draft status, and the RD confirmed it was not signed upon completion. The LNHA acknowledged that all clinical documentation should be signed at the time of service, as per facility policy.
Improper Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, leading to a repeat deficiency. During a kitchen tour, the surveyor, accompanied by the Food Service Director (FSD), observed several issues. In the dry storage area, an opened bottle of maple syrup and a container of cooking oil were found with use-by dates that had already passed. In the walk-in refrigerator, an opened container of fat-free Italian dressing lacked a label with open and use-by dates, and a blackish dust-like substance was observed on the fan grate. Additionally, on the chef preparation table, an opened container of red wine vinegar was found with a use-by date that had expired. The facility's policies on food storage and equipment maintenance were reviewed, revealing that all foods should be labeled, dated, and stored properly, and equipment should be routinely cleaned and maintained. The FSD acknowledged that the items should have been discarded according to their use-by dates, and the fan grate required immediate cleaning. The Licensed Nursing Home Administrator (LNHA) confirmed that all items in the kitchen should be discarded by their use-by dates. Despite these policies, the facility failed to adhere to them, resulting in the observed deficiencies.
Failure to Maintain Sanitary Garbage Area
Penalty
Summary
The facility failed to maintain a sanitary environment by not keeping the dumpster and surrounding area free of garbage and debris. During a tour conducted by the surveyor in the presence of the Food Service Director (FSD), it was observed that the designated garbage area had garbage debris, including food wrappers, cups, gloves, paper products, and medication cups, scattered around the dumpster. The FSD acknowledged that the area should have been cleaned by the maintenance and dietary departments. The Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Clinical Lead (RCL) were informed of these findings, and the LNHA confirmed that the garbage area should be kept free of debris. The facility's policy on trash removal, which was provided to the surveyor, stated that the trash container is scheduled to be cleaned on a regular cleaning cycle or when visibly soiled. However, no further information was provided by the facility staff during the exit conference.
Deficiencies in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, as evidenced by the incomplete documentation on DEA 222 Forms for Schedule II controlled substances. The forms, which are used to order controlled substances, were not filled out in Part 5 by the purchaser, which should include the quantity and date received. This deficiency was noted for six orders of controlled substances, including Fentanyl patches, Oxycodone tablets, and Morphine Sulfate, where the necessary documentation was missing despite the presence of supplier packing slips. Additionally, the facility did not adhere to physician orders for the administration of blood pressure medication for a resident with hypertension, congestive heart failure, and hyperlipidemia. The resident's medical record indicated a prescription for Cozaar, with instructions to hold the medication if the systolic blood pressure was below 110. However, the electronic Medication Administration Record (eMAR) showed that the medication was administered multiple times without documenting the resident's blood pressure, making it impossible to verify compliance with the physician's order. The surveyor's review, in the presence of the Director of Nursing and a Licensed Practical Nurse, confirmed these deficiencies. The LPN acknowledged the omission of blood pressure documentation, which was necessary to ensure the safe administration of the medication. The facility's policies on controlled drug management and medication administration were not followed, as evidenced by the lack of proper documentation and monitoring of vital signs prior to medication administration.
Consultant Pharmacist Fails to Identify Medication Administration Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities in medication management for a resident. Specifically, the CP did not identify that the facility nurse was not documenting the resident's blood pressure (BP) when administering Cozaar, a medication prescribed with a parameter to hold if the systolic BP was below 110. This oversight was noted for one resident, who was admitted with diagnoses including hypertension, congestive heart failure, and hyperlipidemia. The resident's medical records showed that Cozaar was administered multiple times across December 2024, January 2025, and February 2025 without the required BP documentation. The deficiency was identified during a survey when the surveyor reviewed the resident's electronic Medication Administration Record (eMAR) and found numerous instances where the medication was administered without BP documentation. The Licensed Practical Nurse (LPN) acknowledged the omission and stated that it was the CP's responsibility to identify such issues during monthly medication reviews. Despite the facility's policy requiring the CP to communicate potential or actual problems related to medication therapy, the CP failed to report this irregularity. The Director of Nursing (DON) confirmed the CP's responsibility in this matter, and no additional information was provided by the facility's administrative staff during the surveyor's inquiry.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to consistently monitor, document, and evaluate the ongoing benefits of continued use of psychoactive medications for four residents. This deficiency was identified through observations, interviews, and record reviews. For Resident #93, the facility did not document the target behaviors of screaming, hitting, and refusing care, nor did it monitor side effects and target behaviors with the use of psychotropic medications. The resident's care plan lacked specific target behaviors and non-pharmacological interventions, and there was no Abnormal Involuntary Movement Scale (AIMS) assessment conducted as per the facility's policy. Resident #68 was observed to be receiving antipsychotic medication without documentation of target behaviors and potential side effects. The resident's care plan did not include specific target behaviors or non-pharmacological interventions. An AIMS assessment was incomplete, and there was no routine monitoring of psychotropic medication use as required by the facility's policy. Similarly, Resident #4's records showed a lack of documentation for target behaviors and side effects, and the care plan did not reflect specific interventions for psychotropic medication use. Although some AIMS assessments were conducted, they were not done quarterly as required. For Resident #45, the facility did not document target behaviors and potential side effects after an increase in risperidone dosage. The care plan did not include specific target behaviors or non-pharmacological interventions. An AIMS assessment was incomplete, and there was no routine monitoring of psychotropic medication use. Interviews with staff revealed that side effects were only documented if observed, and there was no documentation of targeted behavior monitoring. The facility's policy required the use of non-pharmacological approaches and completion of psychotropic medication evaluations, which were not consistently followed.
Infection Control Deficiency in Linen Handling
Penalty
Summary
The facility failed to adhere to proper infection control practices in the handling and storage of linens. During an inspection, a surveyor and the Infection Preventionist (IP) observed a cart full of linens in the laundry room, some of which were not covered with plastic. The housekeeping staff indicated that these linens were clean and ready for transport, but could not explain why some were uncovered. Additionally, in the linen room, pillows were stacked almost to the ceiling, posing a fire hazard, and some were uncovered. There were also heel boots on top of the pillows, and a pile of clothes, luggage, and a floor mat on the floor, with the IP unable to confirm if these items were clean. The facility's policy on linen handling, which requires clean linens to be covered and stored separately from soiled items, was not followed.
Failure to Implement Comprehensive Care Plan for Resident Refusing Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was refusing care. The deficiency was identified during a survey when a resident was observed screaming and yelling in their native language, with a family member present. Interviews with staff, including an LPN and a CNA, revealed that the resident frequently refused care, was combative, and only responded to a family member. The resident's medical records indicated a history of cerebral infarction, mood disorders, and moderate cognitive impairment, with regular administration of antipsychotic and antidepressant medications. Despite these behaviors and medical conditions, the care plan did not address the resident's refusal of care. The surveyor's review of the resident's records showed that the care plan focused on the risk of complications from psychotropic drugs but failed to include interventions for the resident's refusal of care. The facility's policy on person-centered care plans required documentation of services not provided due to the patient's exercise of rights, including the right to refuse treatment. Interviews with the Unit Manager/RN confirmed the absence of a care plan addressing the resident's refusal of care. The deficiency was discussed with the facility's administration, but no additional information was provided to address the concern.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to properly label, dispose, and secure medications in four out of six medication carts and one out of three medication refrigerators inspected. During the inspection of the subacute medication cart, an unopened and undated Lantus insulin pen with a pharmacy date was found stored improperly. Additionally, an unlocked medication refrigerator contained two Vancomycin IV bags. The Licensed Practical Nurse present acknowledged the insulin pen should have been dated and the refrigerator should have been locked. Further inspections revealed additional issues with medication management. In the South medication cart #1, two unopened and undated Lantus insulin pens and two opened bottles of Xalatan eye drops without an opened date were found. The Registered Nurse acknowledged the insulin pens should have been refrigerated and the eye drops dated. In the South medication cart #2, an expired Xalatan eye drop was found, and the LPN confirmed it should have been removed. Lastly, the North medication cart #2 contained an opened bottle of blood glucose test strips without an opened date, which the RN acknowledged should have been dated.
Failure to Sign Nutrition Note by RD
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards, as evidenced by the Registered Dietitian (RD) not signing a nutrition note at the time of assessment for a resident. This deficiency was identified during a survey when the surveyor observed and interviewed a resident who had been in the facility for about three months and was on an altered consistency diet for dysphagia. The resident was unsure when the RD had last assessed them. A review of the resident's electronic medical record revealed a nutrition consult note dated over a month prior, which was still labeled as a draft and had not been signed by the RD. During the investigation, the RD confirmed that they had written the nutrition consult note but had not signed it upon completion, resulting in the note remaining in draft status. The Licensed Nursing Home Administrator (LNHA) acknowledged that all clinical documentation should be signed at the time of service. The facility's policy on Medical Nutrition Therapy, revised in 2017, states that the RD is responsible for completing a comprehensive assessment annually or as indicated by the resident's clinical condition. Despite this policy, the lack of a signed nutrition note indicated a failure to adhere to these standards, as no other staff member had alerted the RD to the oversight until the surveyor's investigation.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mendham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morris View Healthcare Center | 3.7 mi | ★★★★★ | 20 | 1 |
| Merry Heart Nursing Home | 5.2 mi | ★★★★★ | 0 | 0 |
| Careone At Madison Avenue | 5.4 mi | ★★★★★ | 1 | 0 |
| Morristown Post Acute Rehab And Nursing Center | 5.5 mi | ★★★★★ | 0 | 0 |
| Dwelling Place At St Clares | 5.7 mi | ★★★★★ | 0 | 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.