Holbrook Healthcare Center

Inspectors wroteBased on observation, record review, staff interview and resident review, the facility failed to provide liquids in the correct consistency to meet the resident's individual needs. This was true for three (3) of seven (7) residents that were ordered nectar and honey thickened liquids. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #7, #82, and #31. Facility Census: 107.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to provide a homelike dining experience for residents served in the main dining room and to ensure resident areas were clean and odor free. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident Identifiers: #90 and #5. Facility Census: 107.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure food was stored in accordance with professional standards for food services. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 107.

Inspectors wroteBased on record review, staff interview and record review the facility failed to ensure it had a complete and accurate medical record. This failed practice was found true for (6) six of 36 residents reviewed for medical record accuracy during the Long- Term Care Survey Process. Resident identifiers #43, #6, #7, #10, #4, and #77. Facility Census 107.

Inspectors wroteBased upon record review and staff interview, the facility failed to inform the Resident or the Resident's representative of the risks and benefits for a prescribed psychotropic medication. This was found to be true for one (1) of six (6) residents reviewed during the annual survey process. Resident identifier: #77. Facility census: 107.

Inspectors wroteBased on record review, staff interview, and family interview the facility failed to inform the Medical power of Attorney (MPOA) of appointments for Resident #55, and failed to notify the physician and responsible party of a change in condition for Resident #7. This failed practice was found true for (2) two of (2) two residents reviewed for notification of change during the Long-Term Care Survey Process. Resident identifiers #55, and #7. Facility Census 107.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required notifications to a resident transfered to the hospital. This deficient practice affected one (1) of three (3) residents reviewed for the care area of hospitalization. Resident Identifier: #104. Facility Census: 107.

Inspectors wroteBased upon record review and staff interview, the facility failed to maintain accuracy of the Minimum Data Set (MDS) Resident Assessment and Care Screening for a diagnosis of major depressive disorder. This was found to be true for one (1) of six (6) residents reviewed during the annual survey process. Resident identifier: #77. Facility census: 107.

Inspectors wroteBased upon record review, resident interview and staff interview, the facility failed to develop a personalized care plan for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). This was found to be true for one (1) of thirty-six (36) residents reviewed during the annual survey process. Resident identifier: #4. Facility census: 107.

Inspectors wroteBased on family interview, staff interview, record review, and observation the facility failed to provide Activities of Daily Living (ADL) care to dependent residents. This failed practice was found true for (1) one of (8) eight residents reviewed for ADL care during the Long-Term Care Survey Process. Resident identifier: #55. Facility Census: 107.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure residents did not develop preventable pressure ulcers. The facility also failed to ensure residents with pressure ulcers received assessment in accordance with professional standards of practice. This deficient practice had the potential to affect two (2) of four (4) residents reviewed for the care area of pressure ulcers. Resident Identifiers: #110. Facility census: 107.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide tube feeding care and services within established acceptable standards of care. TThis deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of tube feeding. Resident Identifier: #2. Facility census: 107.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications were stored properly. This was a random opportunity for discovery. Facility census: 107.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure laboratory testing was performed according to the physician orders. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident identifier: #10. Facility census: 107.

Inspectors wroteBased upon record review, resident interview, and staff interview, the facility failed to honor the food preferences of a resident. This was found to be true for one (1) of eleven (11) residents reviewed during the annual survey process. Resident identifier: # 45. Facility census: 107.

Inspectors wroteNumber of residents sampled: 36Number of residents cited: 1The facility failed to ensure residents had ordered adaptive equipment. Resident #5Based on observation, resident interview, medical record review, the facility failed to ensure Resident #5 had ordered adaptive eating utensils. This failed was true for one (1) of 36 sample residents. Resident identifier: #5. Facility census:

Inspectors wroteBased on observation and staff interview, a Nurse Aide (NA) failed to don on a gown when performing catheter care for Resident #44 who was on Enhanced Barrier Precautions. This was true for one of one sampled residents. Resident identifier: #44. Facility census: 107.

Inspectors wroteBased on record review and staff interview, the facility failed to follow principles of antibiotic stewardship. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for antibiotic use. Resident Identifier: #66. Facility Census: 107.

Inspectors wroteBased on staff interview and record review, the facility failed to implement their written Abuse and Neglect policy as it related to reporting allegations of abuse and failed to follow procedures to investigate any such allegations. Their lack of action to investigate the abuse allegation placed Resident #1 at continued risk of staff abuse for six (6) days prior to Surveyor intervention. Review of facility records found that there were 30 other residents who had a BIMS (Brief Interview for Mental Status) score between 0-7, suggesting severe cognitive impairment. They also were at risk of staff abuse. Resident identifiers: #1, #3, #6, #10, #13, #14, #17, #26, #34, #36, #37, #38, #44, #49, #50, #53, #55, #57, #60, #66, #67, #68, #75, #87, #89, #95, #97, #99, #103, #104, #111. Facility Census: 107.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a thorough investigation of a staff member's allegation of resident abuse, maintain documentation that alleged violation was thoroughly investigated, and report the results to Adult Protective Services and the State Survey Agency, within five (5) working days of the incident in accordance with State law. The facility's failure to complete a thorough investigation of a staff member's allegation of resident abuse left residents who were deemed to be severely cognitively impaired at risk of further abuse. In addition, the facility failed to ensure the victim was protected from further abuse which put the residents at risk for additional serious harm and or death.

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to protect a resident's right to be free from abuse that resulted in mental anguish for Resident #1. This was a random opportunity for a discovery made during a complaint investigation. Resident identifier: #1. Facility census: 107. Using the reasonable person concept, the facility's failure to protect a resident's right to be free from abuse resulted in mental anguish for Resident #1 and had the potential to cause serious harm and or death. This was true for Resident #1. Facility Census: 107.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that an alleged violation involving resident abuse was reported, not later than 2 hours of the event / allegation being brought to the facility's attention, to appropriate state agencies as required. Resident identifier: #1. Facility census: 107.

Inspectors wroteBased on observation, resident interview and staff interview the facility failed to care for an indwelling Foley catheter to meet the professional standards of practice. This was a random opportunity for discovery and had the potential to affect a limited number of residents who reside at the facility. Resident identified: #4, #24, and #18. Facility census 109.

Inspectors wroteBased on policy review, observation, staff interview, medical record review, the facility failed to ensure shared communication, coordination and collaboration between the dialysis center and the facility. This was true for two (2) of two (2) residents reviewed under the dialysis pathway during a complaint survey. Resident identifiers: #56 and #102. Facility census: 107.

Inspectors wroteBased on staff interview, observations and record review the facility failed to properly hold and serve cold foods at a temperature of 41 degrees Fahrenheit (F) or below. This failed practice had the potential to affect more than a limited number of residents. Facility census:

Inspectors wroteBased on resident interview, observations and staff interview the facility failed to provide notification of changes to the menu for residents who ate breakfast in their rooms. These residents were not notified of the change in the breakfast menu or when there were food substitutions. This had the potential to affect all residents receiving nutrition from the kitchen.

Inspectors wroteBased on observation and staff interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The floor to the walk-in cooler was dirty, the shelving units for the baking pans and bowls had a buildup of dust, and a very soiled industrial metal box used to catch rodents was located under the clean hand washing sink and in proximity of the preparation and serving tray line. This had the potential to affect any resident receiving nourishment from the kitchen. Facility census:

Inspectors wroteBased on observation, resident interviews, and staff interview, the facility failed to provide reasonable accommodations of needs to the residents in room [ROOM NUMBER] and #407. The commode was not functional and flushable. This is a random opportunity for discovery. Facility census: 107.

Inspectors wroteBased on record review and staff interview the facility failed to notify the representative/family when one (1) of three (3) residents reviewed for the care area of hospitalization experienced significant medical changes. Resident identifier: #104. Facility census 107.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (1) of 26 resident rooms observed during the long-term care survey process. room [ROOM NUMBER]. Resident Identifier: #52. Facility Census: 107.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer/Discharge when a resident was discharged from the facility. This was true for two (2) of three (3) residents reviewed for hospitalizations in the long-term care survey process. Resident identifiers: #104 and #16. Facility census: 107.

Inspectors wroteBased on medical record review and staff interview, the facility failed to transmit a discharge minimum data set (MDS) assessment within 14 days of completion. This was true for one (1) of one (1) resident reviewed for discharge assessments. Resident identifier: #33. Facility census: 107.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected a pre-admission mental health diagnosis for one (1) of two (2) residents reviewed for the category of PASARR (Pre-admission Screening and Resident Review). Resident #50 was diagnosed with bipolar disorder. The lack of pre-screening resulted in the resident's condition not being evaluated through the Level II PASARR process. Resident identifier #50. Census 107.

Inspectors wroteBased on observation, medical record review and staff interview the facility failed to provide necessary respiratory care and services. This was true for two (2) of three (3) residents reviewed for respiratory services during the investigation phase of the survey process. Resident Identifiers: Resident #98 and Resident #105. Facility Census: 107. Findings Included: a) Resident #98 During the initial tour of the facility on 08/07/23 at 11:27 AM, observation found Resident # 98 laying in bed receiving oxygen (02) via nasal cannula. The oxygen flow rate was at three (3) liter/minute (l/m) via nasal cannula. During a record review on 08/07/23 at 3:30 PM Resident #98 medical records revealed a physician order dated 05/22/23 Oxygen at two (2) L/M via nasal Cannula every shift for hypoxemia. [...]

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to ensure professional standards and practice to maintain accurate and complete medical records. The facility failed to follow a physician order for a palm protector. This was a random opportunity for discovery. Resident Identifier: Resident #55. Facility Census: 107. Findings Included: a) Resident #55 During a record review on 08/07/23 at 2:00 PM, Resident #55's medical records revealed a physician order dated 02/21/23, Palm protector to be placed in left hand for 23 out of 24 hours/day and removed for bathing and therapy to prevent skin breakdown and contractures. During an observation on 08/07/23 at 2:30 PM, Resident #55 was not observed wearing the palm protector while laying in bed. During an observation on 08/08/23 at 8:36 AM, Resident #55 was not wearing the palm protector in her left hand. [...]

Inspectors wroteBased on policy review, record review, and staff interviews, the facility failed to ensure the quality assessment and assurance (QAA) committee meetings was composed of the required committee members. This was a random opportunity for discovery. Facility Census: 108 Findings Included: a) Quality Assurance Performance Improvement (QAPI) attendance A review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan with a revision date of 10/01/22 found the following: .II. Element 2: Governance and Leadership .d. Process Tools: i. QAPI committee sign in and agenda and the QAPI communication tool . During a record review, on 08/09/23 at 8:27 AM, the QAPI Meeting attendance form was void with the actual signatures of the persons attending the meeting. The facility documentation titled QAPI meeting Agenda and Minutes read as follows. Attendees of the meeting: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to comply with the requirements for the POST (Physician Orders for Scope of Treatment) form completion. The facility failed to timely get the MPOA (Medical Power Of Attorney) to sign the POST from after a verbal signature, the facility failed to complete the POST form and the facility had the MPOA sign the POST form when a Resident had capacity. This was true for 4 (four) of the 25 residents reviewed during the long term care process survey process. Resident identifiers: #35 , #46, #57, and #15. Facility census 109. Findings Included: a) Resident #35 A review of Resident #35's medical record revealed a Physician's Determination of Capacity form dated 06/08/21. The form was completed as follows: Demonstrates Capacity to make decisions. This form is signed by the facility physician. [...]

Inspectors wroteBased on policy review, observation, record review, and staff interview, the facility failed to have signage on the door and a doffing station available at the door in a resident's room designated as a transmission-based precaution (TBP). The facility also failed to ensure staff donned appropriate personal protective equipment (PPE) prior to entering a TBP room and failed to keep a resident on isolation precautions from socializing outside the room. These failed practices had the potential to affect every resident currently residing in the facility. Resident Identifiers: #28, #405 and #406. Facility census: 109.

Inspectors wroteBased on observation and staff interview, the facility failed to treat each resident with respect and dignity as evidenced by failing to cover a urinary catheter bag with a privacy cover. This was a random opportunity for discovery. Resident identifier: #39. Facility census: 109. Findings Included: a) Resident #39 On 04/04/22 at 12:15 PM, Resident #39 was observed sitting in a chair in the hallway. Resident #39's urinary catheter bag was attached to the side of the chair without a privacy bag covering the urinary catheter bag. On 04/04/22 at 12:16 PM, Nurse Aide (NA) #104 confirmed Resident #39's urinary catheter bag was not covered with a privacy bag. NA #104 stated I will go and get one now. On 04/05/22 at 10:38 AM, the Administrator acknowledged urinary catheter bags should be covered with privacy bags at all times. .

Inspectors wroteBased on resident interview, staff interview, and policy review, the facility failed to ensure that all alleged violations involving abuse and neglect were reported to appropriate state agencies as required. This had the potential to affect a limited number of residents. This was a random opportunity for discovery identified during an annual survey and involved one (1) of four (4) halls in the facility. Resident identifier: #41. Facility census: 109.

Inspectors wroteBased on policy review, resident interview, and staff interviews, the facility failed to complete a thorough investigation of an allegation of abuse and neglect, maintain documentation that alleged violations were thoroughly investigated, and report the results to the State Survey Agency, within five (5) working days of the incidents in accordance with State law. This was a random opportunity for discovery identified during an annual survey and involved one (1) of four (4) halls in the facility. Resident identifier: #41. Facility census: 109.

Inspectors wroteBased on resident interview, observation, and staff interview, the facility failed to provide food to accommodates resident preferences. This was a random opportunity for discovery. Resident identifier: #61. Facility census: 109.