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Public Record

Holly Manor Center

Nursing HomeMendham, NJCMS 315143
36 citations on record

From CMS

Facility profile

CMS overall rating
3 / 5

*CMS Five-Star

Certified beds
124

*CMS

Avg. residents per day
84.6

*CMS

Inspection record

On record from CMS

Citations on record
36

*CMS

Inspections on file
6

*CMS

Last inspection
2025-02-11

*CMS

Citations

36 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0656Generalpotential for harm

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

  • 0755Generalpotential for harm

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

  • 0756Generalpotential for harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0758Generalpotential for harm

    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.

  • 0761Generalpotential for harm

    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.

  • 0812Generalpotential for harm

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

  • 0814Generalpotential for harm

    Dispose of garbage and refuse properly.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0923Generalpotential for harm

    Have proper medical gas storage and administration areas.

  • 0921Generalpotential for harm

    Ensure that testing and maintenance of electrical equipment is performed.

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0521Generalpotential for harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0355Generalpotential for harm

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

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0291Generalpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0211Generalpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0604Generalpotential for harm

    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  • 0622Generalpotential for harm

    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0812Generalpotential for harm

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

  • 0804Generalpotential for harm

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

  • 0758Generalpotential for harm

    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.

  • 0725Generalpotential for harm

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0692Seriousactual harm

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

  • 0690Generalpotential for harm

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

  • 0582Generalpotential for harm

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0561Generalpotential for harm

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0558Generalpotential for harm

    Reasonably accommodate the needs and preferences of each resident.

  • 0211Generalpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0341Generalpotential for harm

    Install a fire alarm system that can be heard throughout the facility.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0374Generalpotential for harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0755Generalpotential for harm

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

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

FAQ

Questions and answers

What is Holly Manor Center?
Holly Manor Center is a Medicare- and Medicaid-certified nursing home in Mendham, NJ, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 315143.
What is the CMS rating for Holly Manor Center?
Holly Manor Center has a CMS overall rating of 3 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Holly Manor Center have?
Holly Manor Center is certified for 124 beds. It serves an average of 84.6 residents per day.
How many citations does Holly Manor Center have?
Holly Manor Center has 36 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Holly Manor Center last inspected?
Holly Manor Center was last inspected on February 11, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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