Holly Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control practices when cleaning resident rooms; -Ensure nursing staff followed appropriate infection control practices when providing wound care; and, -Ensure clean items, such as medications and body soap, were stored in a sanitary manner. Findings include: I. Failure to ensure housekeeping staff followed appropriate infection control practices when cleaning resident rooms A. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy, revised August 2013, was provided by the quality mentor (QM) on 8/27/24 at 2:43 p.m. It read in pertinent part, Use heavy duty gloves and other personal protective equipment (PPE) as indicated for housekeeping tasks. Perform hand hygiene after removing gloves. B. Observations On 8/27/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to develop and implement a comprehensive centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for two (#23 and #25) of six residents out of 16 sample residents. Specifically, the facility to: -Ensure a care plan and interventions were developed for Resident #23's use of a hypertensive medication; and, -Ensure a care plan and interventions were developed for Resident #25's use of insulin, an anticoagulant medication and for dialysis treatments. Findings include: I. Facility policy and procedure The Comprehensive Care Plans policy, revised on 2/28/24, was provided by the quality mentor (QM) on 8/28/24 at 12:27 p.m. The policy revealed this facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives, timeframes to meet a resident's medical, nursing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#3) of two residents reviewed for ancillary services out of 16 sample residents received routine dental care and 24-hour emergency dental care. Specifically, the facility failed to ensure Resident #3 was provided dental services for timely replacement of her upper denture. Findings include: I. Facility policy and procedure The Ancillary Services policy, revised February 2024, was provided by the director of nursing (DON) on 8/28/24 at 2:20 p.m. It read in pertinent part, Any resident needing or requesting ancillary services such as dental, vision, audiology and podiatry will have their needs met timely. Social services/Designee will be responsible for ensuring residents needing ancillary services receive needed/requested services in a timely manner. II. Resident #3 A. Resident status Resident #3, age less than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Food was stored and labeled properly Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 46-47, in part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on a hose in the kitchen maintenance closet and on the hand held shower on the west hall shower, increasing the risk of contamination to the facility's main water supply. Findings include: I. Backflow prevention devices A. Professional references According to the Environmental Protection Agency's Cross-Connection Control, updated on 11/2/22, retrieved on 3/29/23 from: https://www.epa.gov/system/files/documents/2021-12/ds-toolbox-fact-sheets_ccc.pdf, it read in pertinent part, Cross-connections are actual or potential connections between a potable water supply and non-potable water plumbing. Backflow is the unintended reversal of water flow through a cross-connection, which can result in a potentially serious public health hazard. A cross-connection control and backflow prevention program helps prevent contaminants from entering a drinking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 14 of 25 resident rooms in two hallways. Specifically, the facility failed to ensure walls, halls, ceilings, floors, and doors were repaired, painted and properly maintained. Findings include: I. Initial observations Observations of the resident living environment was conducted on 3/29/23 at 8:47 a.m. revealed: room [ROOM NUMBER]A: There were four nickel sized holes underneath the resident's shelf next to his bed. The wall next to the resident's bed had an area 24 inches by 24 inches which had not been painted. The outlet box did not have a cover on it with the cable wire exposed. The lament in front of the sink had an area approximately eight inches long by two inches wide which was lifted. room [ROOM NUMBER]B: The resident's call light was wrapped around the grab bar in the restroom which made it inaccessible. room [ROOM NUMBER]B: There was a large chip of sheet rock…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for two (#1 and #26) of three residents reviewed for accidents/hazards out of 15 sample residents. Specifically, the facility: -Failed to ensure a medication in Resident #1's room had a current order and was not kept at bedside; -Failed to ensure Resident #26 had fall interventions in place; and, -Failed to ensure an oxygen concentrator was plugged into an appropriate electrical supply. Findings include: I. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physicians orders (CPO), diagnoses included intracranial injury (brain injury), bipolar disorder, and acute kidney failure. The 3/6/23 minimum data set (MDS) assessment did not assess the brief interview for mental status. No behaviors were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure nursing staff had completed competencies in the past 12 months prior to providing skilled services as described in the plan of care for two out of two registered nurses (RN) and one out of one licensed practical nurses (LPN) reviewed for competencies. Findings include: I. Resident census and conditions According to the resident census and conditions provided by the nursing home administrator (NHA) on 3/27/23, the facility had: -Two residents with an indwelling catheter; and, -One resident with a pressure ulcer. II. Record review RN #1, RN #2, and LPN #2 did not have competencies completed for identified conditions in the facility specifically catheter care and wound care. III. Interviews The director of nursing (DON) was interviewed on 3/29/23 at 1:18 p.m. She said nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for two (#23 and #15) of three residents reviewed for oxygen therapy out of 16 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Residents #23 and #15. Findings include: I. Professional reference According to [NAME]/[NAME], Fundamentals of Nursing, ninth edition, Elsevier, Canada, 2017, p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Facility policy The Medication Administration policy, revised 11/26/19, provided by the director of nursing (DON) on 12/14/21 at 9:49 a.m. included, Medications are administered in accordance with written orders of the attending physician or physician extender. III. Resident #23 A. Resident status Resident #23, age [AGE], was admitted on [DATE] and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure as needed (PRN) orders for psychotropic drugs were evaluated by a physician within 14 days for use and duration for one (#8) of five residents reviewed for unnecessary medication use out of 16 sample residents. Specifically, the facility: -Failed to re-evaluate the use of PRN psychotropic medication by a physician within 14 days; and, -Failed to have individualized person centered interventions to utilize prior to the administration of PRN psychotropic medication. I. Facility policy The Psychopharmacological policy, revised 1/10/19, was provided by the director of nursing (DON) on 12/14/21 at 3:35 p.m. included, The licensed nurse or Social Services Director will initiate behavior monitoring within the first twenty-four hours of admission. Behavior monitoring is mandatory for residents who take psychotropic medications. The plan of care must include behavior interventions and medication monitoring/dosage reduction if appropriate.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.