Holden Manor Health & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with dignity when one resident (Resident #1) alleged that Certified Nursing Assistant (CNA) A put his/her hands on the resident and pushed him/her in the shoulders, causing the resident to be scared and angry. The facility census was 34 residents. The Administrator and the Regional Nurse Consultant were notified on 1/22/26 of the past noncompliance which began on 1/11/26. The facility immediately completed an all-staff education for Abuse and Neglect and customer service. The deficiency was corrected on 1/19/26. [...]

Inspectors wroteBased on observation and interview, the facility failed to remove a buildup of dust and food debris from under the reach-in refrigerator; failed to label items that were not easily identifiable in the containers those items were in; failed to ensure employees washed hands after handling non-food items then going back to handling food items; failed to prevent the buildup of debris in the window unit air conditioner; failed to check the temperature of food items before placing those items on the steam table; failed to ensure the pot holder was free from damage that could allow fibers to contaminate food; failed to ensure dietary employees handled containers used or serving residents, without contaminating those containers; failed to use a three-step (wash, rinse and sanitize) process to wash the food processor container between foods; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform adequate hand hygiene during medication pass for three supplemental residents (Resident's #11, #27, and #10) out of nine supplemental residents and failed to create and implement a Tubercolosis (TB, a potentially serious infectious bacterial lung disease) program when staff failed to complete two-step Mantoux skin tests (a test to show potential TB infection) for two sampled residents (Resident #141 and #241). The facility census was 46 residents. Review of the facility's policy titled Handwashing/Hand Hygiene dated August 2019 showed: -The facility considered hand hygiene the primary means to prevent the spread of infections. -All personnel should be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain evidence (via receipts or signatures) for monetary transactions in the resident trust fund accounts for two sampled residents (Resident #2 and #3) out of four sampled residents; and failed to maintain a proper accounting of the end of month petty cash (the amount of cash that is accessible for residents with resident trust that residents can request funds from) amounts from July 2023 through April 2024. This practice potentially affected 22 residents with resident trust. The facility census was 46 residents. 1. Review of Resident #2's resident trust fund transactions list dated 4/1/24 through 7/31/24 showed: - A transaction dated 5/6/24 for $40.41 without a receipt or signature for that transaction. - A transaction dated 6/14/24 for $18.97, without a receipt for that transaction. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the ambient (pervasive quality of the surrounding environment) temperature of Resident #291's room, and resident rooms [ROOM NUMBERS], within the required Centers for Medicaid and Medicare Services (CMS) regulatory requirement of 71-81 ºF (degrees Fahrenheit) failed to monitor temperatures of those rooms when those rooms felt warm, failed to ensure all staff knew where the locations of the thermometers and failed to ensure that two of the facility thermometers were properly operating. The facility also failed to maintain the restroom floor in resident room [ROOM NUMBER] free from a pungent urine odor; failed to maintain the floors in resident rooms [ROOM NUMBER] free from a buildup of debris; failed to maintain the filter of the climate control unit in resident room [ROOM NUMBER] free of dust and mildew; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications brought in by one sampled resident's (Resident #33) family member was labeled and stored correctly in the Certified Medication Technician (CMT) cart out of 14 sampled residents; failed to ensure other medications in the CMT cart were stored and labeled appropriately and failed to dispose of expired medical supplies found in the medication room which had the potential to affect all residents in the facility. The facility census was 46 residents. Review of the facility's policy titled Labeling of Medication Containers dated [DATE] showed: -Medication labels were to be legible at all times. -Labels for individual resident medications included all necessary information, such as: --The resident's name. --The prescribing physician's name. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure recipes were available for dietary staff to use while making pureed (food that is blended, chopped, mashed, or strained until it becomes a soft and smooth consistency) waffles, chicken tenders and pureed mixed vegetables; and the facility failed to ensure the recipes for the pureed versions of those items were detailed enough to include the amounts of liquids and/or thickener that were needed to make the recipe properly. This practice potentially affected five residents with pureed diets. The facility census was 46 residents. 1. Observation on 7/29/24 at 8:17 A.M., showed Dietary [NAME] (DC) A made pureed waffles without having the recipe book open. During an interview on 7/29/24 at 8:41 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the pureed french fries were palatable and failed to ensure the dinner rolls were cooked properly for the lunch meal on 8/2/24. The facility census was 46 residents. 1. Review of Resident #15's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 12/20/23, showed the resident was cognitively intact. Review of Resident #31's quarterly MDS dated [DATE], showed the resident was cognitively intact. Review of the Resident Council minutes dated 12/5/23 showed: -Resident #15 said the food was not good. -Resident #31 said the food was bad. Review of the Resident Council Minutes dated 1/2/24 showed Resident #15 said the food was still not good. 2. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the pureed (food that is blended, chopped, mashed, or strained until it becomes a soft and smooth consistency) chicken tenders and french fries were pureed to smooth consistency. This practice potentially affected 5 residents with pureed diets. The facility census was 46 residents. 1. Review of the pureed recipe for chicken tenders dated 9/5/17, showed: -Remove desired number of servings and add nutritive liquid (milk, broth, etc.). -Blend until desired consistency. Add approved thickener to achieve desired consistency if needed. The recipe did not state how much liquid or thickener to add per the number of servings that needed to be pureed. Observation on 7/29/24 at 10:59 A.M., showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's policy regarding the proper storage was followed, when food was stored in the resident use refrigerator. This practice potentially affected at least 4 residents who had food stored in the resident use refrigerator. The facility census was 46 residents. Review of the policy entitled Foods Brought by Family/Visitors dated 10/17, showed: -Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. -Nursing staff will provide family/visitors who wish to bring foods to the facility with a copy of this policy. Residents will also be provided a copy in a language and format he/she can understand. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal pneumonia vaccines (a vaccine to protect against pneumococcal disease caused by the bacteria Streptococcus pneumoniae) were offered, administered, or documented for three sampled residents (Residents #10, #141, #241) out of five residents sampled for vaccination provision. The facility census was 46 residents. Review of an undated facility policy titled Pneumococcal Vaccines showed: -All residents would be offered pneumococcal vaccines to aid in preventing pneumococcal infections. -Upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine and, if eligible, receive the vaccine within 30 days of admission. -Assessments of the residents' vaccination status would occur within five days of admission. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the kitchen area and resident rooms [ROOM NUMBERS], free of ants. This practice affected the kitchen and affected 4 residents who resided in those rooms. The facility census was 46 residents. Review of the policy entitled Foods Brought by Family/Visitors dated 10/17, showed: -Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. -Non perishable foods will be stored in resalable containers with tight fitting lids. Intact fresh fruit may be stored without a lid. 1. Observations on 7/29/24 at 11:06 A.M., showed the presence of ants at the 3-compartment sink location. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain an authorization signature from one sampled resident (Resident #291) to allow the facility to open and maintain a resident trust account out of four sampled residents sampled for resident trust accounts. The facility census was 46 residents. 1. Review of Resident #291's trust account on 8/2/24 showed: -The resident was admitted to the facility on [DATE]. -The resident had a balance of $0.0 in his/her account -The absence of an authorization form that was signed by the resident. During an interview on 8/2/24 at 10:21 A.M. the Regional Business Office Manager (BOM) said he/she gave the form to the new facility BOM, but the new facility BOM did not have the resident sign the authorization form. During a telephone interview on 8/8/24 at 2:42 P.M., the previous BOM said: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the funds of one discharged resident (Resident #93) was forwarded to the resident within 5 days of the resident moving to a new facility; and failed to ensure that Third Party Liability (TPL- a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account) forms were completed and sent to Missouri (MO) Healthnet (a state agency which administers the provision and payment of services for Missouri's Medicaid program) within 30 days of death for two discharged residents (Resident #91 and #92). The facility census was 46 residents. 1. Review of Resident #93's medical record, showed: -He/she was discharged from the facility to a hospital on 1/25/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a timely advanced directive for one sampled resident (Resident #291) when he/she elected to be a Do Not Resuscitate (DNR, an election to have Cardio-Pulmonary Resuscitation [CPR] withheld in the event of cardiac arrest) out of 14 sampled residents. The facility census was 46 residents. Review of the undated facility policy titled Advanced Directives showed the facility was to: -Inform and offer the resident a choice to elect to be a DNR on admission. -Assist the resident in obtaining an advanced directive. -Ensure coordination with the physician to enact the advanced directive. -Update the plan of care and place orders in the medical record. 1. Review of the resident's medical record showed: -An admission to the facility on [DATE]. -An out of hospital DNR form signed by the resident on [DATE] with no other signatures. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete Minimum Data Set assessments (MDS-a federally mandated comprehensive assessment) in a timely manner (within 14 calendar days after admission) for two sampled residents (Resident #291 and Resident #292); and failed to complete an accurate MDS assessment for one sampled resident (Resident #1) out of 14 sampled residents. The facility census was 46 residents. Review of an undated facility policy titled MDS Completion and Submission Timeframes showed the facility was to complete and submit MDS assessments within federal requirements but lacked mention of the specific guidelines. No other policies for MDS assessments were received. [...]

Inspectors wroteBased on interview and record review, the facility failed to create person-centered comprehensive care plans to guide facility staff in resident care of new admissions for two sampled residents (Residents #291 and #292) out of 14 sampled residents. The facility census was 46 residents. Review of an undated facility policy titled Comprehensive Person-Centered Care Plans showed the facility was to: -Complete a person-centered care plan for all residents. -Complete the care plan within seven days of a comprehensive Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff for care planning) admission assessment. --The policy lacked direction for staff on when to complete the comprehensive care plan without completion of the comprehensive assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bathing was completed per choice for one sampled resident (Resident #2) and failed to ensure the resident's care plan showed the resident's care needs and abilities regarding Activities of Daily Living (ADL-bathing, dressing, toileting, eating and mobility) out of 14 sampled residents. The facility census was 46 residents. Review of the facility's ADL policy and procedure dated March 2018, showed: -Residents would be provided with care, treatment and services to ensure their ADLs do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADLS are unavoidable. -Appropriate care and services would be provided for resident's who were unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary services to address one sampled the resident's behavioral symptoms in order to manage known behaviors, failed to ensure the resident's behaviors were monitored and documented by staff as they occurred and failed to ensure actions and interventions were implemented upon the first aggressive behavior and subsequently followed up on to ensure resident behaviors toward his/her roommate did not continue for sampled resident (Resident #141) out of 14 sampled residents. The facility census was 46 residents. Review of the facility's Behavioral Assessment, Intervention and Monitoring policy and procedure dated March 2019, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' monthly Medication Regimen Review (MRR-thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) were completed by the pharmacy to ensure irregularities were identified so they could be acted upon for one sampled resident (Resident #1) out of 14 sampled residents. The facility census was 46 residents. Review of the facility's policy titled MRRs dated May 2019 showed: -The goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete recommended Gradual Dose Reduction (GDR- involves the stepwise tapering of a dose of medication to determine if symptoms, conditions, or risks can be managed by a lower dose or the medication can be discontinued altogether) and/or (MRR-thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for psychotropic medications (drugs which affect psychic function, behavior, or experience) for three sampled residents (Resident #1, #18 and #33) out of 14 sampled residents. The facility census was 46 residents. Review of the facility's policy titled MRRs dated May 2019 showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to store dishes in a manner to prevent contamination; to ensure two ceiling vents were free from a buildup of dust; to label four containers with the contents of what was in those containers; to maintain the gasket (a piece of rubber or some other material that is used to make a tight seal between two parts that are joined together) one of the reach-in refrigerators; to maintain the blade portion of a spatula in an easily condition; and to maintain the stovetop free of a heavy buildup of food debris and grease. This practice potentially affected all residents. The facility census was 41 residents. 1. Observations on 1/9/23 from 9:22 A.M. through 12:55 P.M., showed: -Two ceiling vents over dishwasher with a heavy buildup of dust inside those vents. -Five pitchers were stored on top of a refrigerator with the container side facing up. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its Water Management Plan outlined plans for implementing testing protocols and plans for corrective actions that the facility would implement as a result of changes in municipal or facility water quality; and to ensure proper hand hygiene was performed during a medication pass. The facility census was 41 residents. 1. Record review of the guidance outlined in the Centers for Disease Control and Prevention (CDC) Legionella Environmental Assessment Form, dated June 2015, showed: -On page three, obtain a written copy of the program policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a signature from (or maintain a paper receipt) for one discharged sampled resident (Resident #90) when he/she withdrew money at the time of his/her discharge and to prevent the existence of a negative balance for one sampled resident (Resident #31) for 41 days. This practice affected two residents out of six residents selected for the resident fund review. The facility census was 41 residents. 1. Record review of Resident #90's Face Sheet showed he/she was discharged to another facility on 7/20/22 with his/her return not anticipated. Record review of the Resident's Trust Fund Statement dated 7/1/22 through 9/30/22 showed a check was disbursed to the resident on 7/19/222 for $65.02. During an interview on 1/10/23 at 10:23 A.M., the Business Office Manager (BOM) said he/she: [...]

Inspectors wroteBased on interview and record review, the facility failed to protect two severely cognitively impaired residents (Resident #26 and #34) from physical and sexual abuse, when Resident #34 hit Resident #26 on or about 12/14/22 causing pain and a raised area on his/her head, and to assess severely cognitively impaired residents for the capacity and ability to consent to consensual sexual expression, when Resident #34 was found kissing and fondling Resident #26 on 10/31/22 and when Resident #34 was found unclothed in Resident #26's bed attempting to have sexual intercourse on 1/6/23. The facility census was 41 residents. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised on April 2021 showed: -Residents have the right to be free from abuse, neglect, and exploitation. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate and/or report the findings of an investigation of resident to resident physical and sexual abuse between two severely cognitively impaired residents after one supplemental resident (Resident #34) hit another sampled resident (Resident #26) with a bag of coins leaving a knot on his/her head on 12/14/22, and after staff found Resident #34 kissing and touching Resident #26 in an inappropriate sexual manner on 10/31/22 and staff found Resident #26 unclothed from the waist down on top of Resident #34 unclothed from the waist down in bed attempting to have sexual intercourse on 1/6/23, out of 14 sampled residents and nine supplemental residents. The facility census was 41 residents. Record review of the facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised on April 2021 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate a resident to resident physical and sexual abuse between two severely cognitively impaired residents after one supplemental sampled resident (Resident #34) hit one sampled resident (Resident #26) on 12/14/22 causing a knot on his/her head, and after staff found Resident #34 kissing and touching Resident #26 in an inappropriate sexual manner on 10/31/22 and after staff found Resident #26 unclothed from the waist down on top of Resident #34 unclothed from the waist down in bed attempting to have sexual intercourse on 1/6/23, out of 14 sampled residents and nine supplemental residents. The facility census was 41 residents. Record review of the facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised on April 2021 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accuracy of a baseline care plan for one sampled resident (Resident #240) out of 14 sampled residents. The facility census was 41 residents. Record review of the facility's policy, dated December 2016, titled Care Plans-Baseline showed: -The Interdisciplinary Team (IDT) was to review the physician's orders, including medication and treatments, in developing the baseline care plan. -The IDT was to gather information from the resident and their representative that included any services or treatments necessary. 1. Record review of Resident #240's face sheet showed he/she was admitted with the following diagnoses: -Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan addressed oxygen usage for one sampled resident (Resident #5) out of 14 sampled residents. The facility census was 41 residents. Record review of the facility's policy, dated April 2009, titled Goals and Objectives, Care Plans showed: -Staff were to include specific resident problems. -Staff were to enter goals and objectives on the resident's care plans so that all disciplines had access to such information. 1. Record review of Resident #5's face sheet showed he/she was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders for Hospice services (end of life care) were documented on the Physician's Order Sheet (POS) for two sampled residents (Resident #12 and #35) and to ensure the care plan showed the coordination of services and interventions between Hospice and the facility for one sampled resident (Resident #12) out of 14 sampled residents. The facility census was 41 residents. Record review of the facility Hospice and Palliative Care policy and procedure dated July 2017, showed the facility had an agreement with Hospice to ensure that residents who wish to participate in a Hospice program may do so. Procedures showed: -It is the responsibility of the Hospice to manage the resident's care as it relates to terminal illness and determining the Hospice plan of care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reassess smoking safety for one sampled resident (Resident #5) out of 14 sampled residents. The facility census was 41 residents. Record review of the facility's policy, dated July 2017, titled Smoking Policy-Residents showed a resident's ability to smoke safely would be reevaluated quarterly, upon a significant change, and as determined by staff. 1. Record review of Resident #5's face sheet showed he/she was admitted with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -Muscle spasm (muscle involuntary and forcibly contracts uncontrollably and can't relax). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders were accurate, complete, and followed for three sampled residents (Resident #5, Resident #240 and Resident #22) who utilized oxygen and a bilevel positive airway pressure machine (BiPAP, uses two settings with one for inhaling and one for exhaling), and to properly store oxygen equipment when not in use for two sampled residents (Resident #240, Resident #22) out of 14 sampled residents. The facility census was 41 residents. Record review of the facility's policy, dated November 2014, titled Medication Orders showed staff were to record orders for oxygen with the rate of flow, route, and rationale. Record review of the facility's policy, dated April 2019, titled Administering Medications showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide ongoing reassessment for behavioral management, to ensure the residents were free from potential inappropriate sexual and physically aggressive behaviors when implementing and re-evaluating interventions, to document the outcomes of preventive measure for effectiveness, and to prevent further occurrences of inappropriate physically aggressive and sexually inappropriate behaviors for two severely cognitively impaired residents, one sampled resident (Resident #26) and one supplemental resident (Resident #34) who were found by facility staff engaged in sexual activity on 10/31/22, 11/12/22 and 1/6/23, and an aggressive or inappropriate behavioral incident on 12/14/22, resulting in Resident #34 hitting Resident #26 on top of head with a bag of change causing Resident #26 to have a painful raised area on his/her head, out [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food containers in the resident use refrigerator, were labeled with the resident 's name and the date it was received and to prevent the storage of staff's food in the resident use refrigerator. This practice potentially affected at least five residents who allowed their food to be stored in the refrigerator. The facility census was 41 residents. Record review of the facility's policy entitled Foods Brought by Family/Visitors, dated 10/2017, showed: - Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable form facility prepared food. - Non-perishable foods will be stored in resealable containers with tight fitting lids. Intact fresh fruit may be stored without a lid. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a policy regarding hospice (end of life care) visits and to allow hospice visits for two sampled residents (Residents #24 and #3) out of two residents sampled for hospice services. The facility identified four residents on hospice. The facility census was 30 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to utilize the required format of the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (Centers for Medicare and Medicaid Services form (CMS)-10055) and Notice of Medicare Provider Non-Coverage (NOMNC) (form CMS-10123) for two sampled residents (Residents #83 and #84) out of two sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled) services. The facility identified two residents who required beneficiary notices over the past six months. The facility census was 30 residents. No policy was received from the facility. Record review of the form and the instructions for the SNF ABN CMS form 10055 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to check the Certified Nursing Assistant (CNA) Registry to ensure individuals did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect) and check the Employee Disqualification List (EDL) (a marker given to individuals who have committed crimes against residents in long term care settings) for two sampled employees (Employee #4 and #5) out of eight sampled employees hired since the last annual survey. The facility census was 30 residents. Record review of facility undated policy titled, Abuse Prevention Program, showed: -Facility policy requires employee background checks as a part of their abuse prevention program. -Employees are required to have backgriund checks prior to employment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update the residents' care plans for two sampled residents (Resident #24's and #19) out of 12 sampled residents. The census was 30 residents. The facility did not provide a policy regarding updating care plans. 1. Record review of Resident #24's nurse's note dated 8/26/20 showed: -At approximately 6:20 A.M., the resident spilled hot chocolate on his/her right hand and both thighs. -The resident's right hand was swollen and appeared to have first degree burn (affects only the outer layer of skin and appears red with no blisters). -Both thighs were red. Record review of the resident's care plan for admission date of 3/4/20 showed an update on 8/26/20 that showed the resident spilled hot chocolate on his/her thighs but the update did not include any interventions. [...]