Holden Rehabilitation & Nursing Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, and record review, the facility failed to accurately code three Minimum Data Set (MDS) Assessments relative to medications administered to the Resident during the Assessment observation periods for one Resident (#16), out of a total sample of 22 residents. Specifically, the facility failed to accurately code three consecutive MDS Assessments for the administration of an antiplatelet medication when Aspirin was ordered by the Physician for the Resident and the Resident received Aspirin during the observation periods for each MDS Assessment.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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).