Holden Rehabilitation & Nursing Center

Based on observations, interviews, and record review, the facility failed to determine if the practice for self-administration of medications was clinically appropriate for one Resident (#119) out of a total sample of 20 residents. Specifically, the facility failed to assess Resident #119's ability to self-administer medications before the Resident was allowed to have three bottles of Aspercreme (topical anesthetic medication), one prescription Ventolin (fast-acting bronchodilator medication) inhaler, one unit dose dropper of Systane Ophthalmic Solution (eye lubricant and irrigation medicine), and one bottle of prescription Latanoprost (medication used to treat high intraocular pressure) eye drops in his/her possession for the purpose of self-administration which increased the Resident's risk for improper medication administration. Findings include:Review of the facility's Self-Administration of Medications Policy, undated, indicated the following: -Purpose- To establish a standardized process for evaluating, authorizing, monitoring, and documenting resident self-administration of…

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, interviews, and record review, the facility failed to adhere to professional standards of practice relative to arranging for follow-up dermatology services, for one Resident (#12) out of a total sample of 20 residents.Specifically, the facility failed to arrange a follow-up dermatology appointment recommended by the Dermatologist for Resident #12, when the Resident had been assessed by the Dermatologist and treated for a skin condition of the upper lip, increasing the Resident's risk for unresolved upper lip/skin conditions. Findings include:Resident #12 was admitted to the facility in May 2022 with diagnoses including mild cognitive Impairment, Dementia, and need for assistance with personal care. Review of the Minimum Data Set (MDS) Assessment, dated 4/23/26, indicated Resident #12: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 total possible points. -has clear speech. -understands and was understood. Review of Resident #12's Dermatology Visit Note, dated 3/2/26, indicated: -A focused…

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, interviews, and record reviews, the facility failed to provide care and services consistent with professional standards of practice for an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) for one Resident (#13) of five applicable residents for urinary catheters, out of a total sample of 20 residents.Specifically, for Resident #13, the facility failed to accurately monitor the Resident's urinary output and secure the Resident's suprapubic catheter (small incision in the lower abdomen to drain urine directly from the bladder, bypassing the urethra) with a leg strap as ordered by the Physician, increasing the Resident's risk for indwelling urinary catheter complications. Findings include: Review of the Centers for Disease Control (CDC) guidelines for the Prevention of Catheter Associate Urinary Tract Infections (CAUTI). Retrieved from: https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html, revised 3/25/24, indicated the following: -Need for accurate measurements of urinary…

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, interviews, and record review, the facility failed to adhere to Transmission Based Precautions (TBPs) and Standard Precautions for two Residents (#79 and #24), out of a total sample of 20 residents, increasing the risk for transmission of infection. Specifically, the facility failed to ensure its staff adhered to Contact Plus Precautions and Standard Precautions when: -Resident #79 was symptomatic and being treated for Clostridioides difficile (C. diff: highly contagious bacterium that infects the colon causing severe diarrhea and painful intestinal inflammation) and placed on Contact Plus Precautions. -Resident #24 did not have a C. diff infection and was not placed on TBPs. -Nurse #3 entered Resident #79's room without donning a gown and gloves, used bare hands to adjust the Resident's legs, exited Resident #79's room without performing any hand hygiene, then proceeded to Resident #24's room, entered his/her room without performing any hand hygiene, and used bare hands to adjust Resident…

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 record review, observation, and interview, the facility failed to provide an environment free from physical restraints for one Resident (#42) out of a total sample of 22 residents. Specifically, the facility failed to ensure that Resident #42 was free from physical restraints when CNA #1 used a locked wheelchair at the foot of the Resident's bed to prevent him/her from getting out of bed. Findings include: Review of the facility policy titled Physical Restraint Policy, revised 2/26/21, included but was not limited to the following: Operative Definitions: -PHYSICAL RESTRAINT- Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot easily move which restricts freedom of movement normal access to one's own body. >Physical restraints include but are not limited to: leg restraints ., lap buddy/seat belts. Also included are chairs which prevent rising. -Convenience - Any action taken by the facility to control resident…

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 interviews and records reviewed, the facility failed to notify the state mental health authority for resident review after a significant change in the mental health condition of one Resident (#16) out of a total sample of 22 residents. Specifically, the facility failed to notify the State PASRR (Preadmission Screening and Resident Review - federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) Office of the need for a Resident Review when Resident #16 was newly diagnosed with Auditory Hallucinations and treatment using antipsychotic medications was implemented. Findings include: Resident #16 was admitted to the facility in May 2022 with diagnoses including Major Depressive Disorder and Mild Cognitive Impairment. Review of Resident #16's Level I PASRR dated 5/22/22, indicated the Resident had a negative screen for Serious Mental Illness (SMI). Review of Resident #16's Nursing Progress Note, dated 4/4/24, indicated the following: -Increased paranoia noted in…

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 observation, interview, and record review, the facility failed to provide care and services as required for an indwelling urinary/Foley catheter for one Resident (#36) out of a total sample of 22 residents. Specifically, for Resident #36, the facility failed to ensure that a blocked indwelling urinary catheter was replaced with the correct sized catheter balloon as ordered by the Physician. Findings include: Review of the facility policy for Catheter Care, Urinary, updated 12/12/24, indicated: >Preparation -Review the resident's care plan to assess for any special needs of the resident. -Assemble the equipment and supplies as needed. >Reporting -Report other information in accordance with facility policy and professional standards of practice. Resident #36 was admitted to the facility in September 2023 with diagnoses including Multiple Sclerosis, Quadriplegia and Neurogenic Bladder. Review of the Resident's care plan for a Foley Catheter, last revised 9/24/24, indicated: -Change Foley catheter as needed…

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 interview, and record review, the facility failed to provide Behavioral Health Care and services to attain or maintain the highest practicable mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one Resident (#16) out of a total sample of 22 residents. Specifically, for Resident #16, the facility failed to: -obtain psychotherapeutic counseling based on recommendations of a Psychotherapy Evaluation, and consent for the therapy by the Resident. -obtain a Psychiatric evaluation timely for the Resident when the Nurse Practitioner ordered a Psychiatric Evaluation to assess the Resident for auditory hallucinations. Findings include: Review of the facility's policy titled Behavioral Health Services, undated, indicated the following: -The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable . mental and psychosocial well-being in accordance with the . plan of care. -Behavioral health services are provided to residents as needed as part of the…

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, record review, and interview, the facility failed to ensure that one Resident (#161) out of a total sample of 14 residents was free from significant medication errors. Specifically, the facility failed to administer Hydromorphone (Opioid: medication used to treat severe pain) Hydrochloride (HCl: common salt used in some medications to make them more water soluble) on an as needed (PRN) basis, according to the facility standards of practice and the prescribing Practitioner's orders. Findings include: Review of the facility's policy, titled Administering Medications, dated 2001 and revised April 2019, indicated the following: - Medications are administered in accordance with Prescriber orders . - If a dosage is believed to be inappropriate ., the person preparing or administering the medication will contact the Prescriber, . to discuss the concerns. Resident #161 was admitted to the facility in December 2023 with diagnoses including Malignant Neoplasm (cancerous tumor which invades normal tissue) of the soft palate (flexible fleshy tissue toward the back of the…

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 observation, interview, record and policy review, the facility failed to store drugs and biologicals in accordance with professional standards and facility policy for three Residents (#19, #66, and #35) out of a total sample of 24 residents and on two out of four medication carts. Specifically, the facility failed to adhere to medication storage requirements when: 1. Medications were observed stored on Resident #19's night stand. 2. Medications were observed stored inside a disposable plastic cup on Resident #66's rolling bedside table. 3. Medications were observed on a medication cart on the Laurel Unit with no Nurse present at the cart. 4. Medications were observed stored in a medicine cup on Resident #35's breakfast tray. 5. One open, 10 milliliter (ml) vial of Lidocaine (medication used to numb an area on the body) 1% and one bag of popcorn were observed stored in the medication carts on two units. Findings include: Review of the facility policy titled Administering Medications, revised April 2019,…

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, interview, and policy review, the facility failed to ensure that staff stored, labeled, and dated food used for resident consumption, in accordance with professional standards for food safety within the facility's main kitchen. Findings include: Review of the facility policy titled, Food Storage, dated 2021, indicated the following: -Date marking should be visible on all high-risk food to indicate the date by which a ready to eat, Time/Temperature Control for Safety (TSC) food should be consumed, sold, or discarded. During a tour of the kitchen on 12/15/23 from 9:26 A.M. through 9:52 A.M., the surveyor observed the following: In the walk-in refrigerator: -two packages of cheese that were opened, (undated) and moldy -a cranberry sauce container, with a use by date of 11/29/23 -one opened and undated bag of hamburger patties -one opened and undated bag of fried eggs During an interview on 12/15/23 at 9:51 A.M., Dietary Staff #1 said that the food items should be labeled and dated when opened. She further said that food items should not be used after the use by…

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, interview, record and policy review, the facility failed to adhere to infection control standards and implement the facility policy relative to Contact Precautions (actions implemented in addition to standard precautions based upon means of transmission in order to prevent or control infections), for one Resident (#87), in a total sample of 24 residents. Specifically, the facility staff failed to ensure that Contact Precautions were maintained during a wound dressing change for a Resident with Vancomycin Resistant Enterococcus (VRE- an infection with bacteria that are resistant to the antibiotic vancomycin). Findings include: Review of the facility policy titled, Vancomycin Resistant Enterococcus (VRE) Policy, undated, indicated: -The facility would place residents with diagnosed VRE on Contact Precautions in addition to Standards Precautions to protect against the transmission of VRE infection to other residents and to personnel. -Wash hands after removing gloves. Use antiseptic soap. Review of the facility policy titled, Hand Washing/Hand Hygiene revised…

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.