Holiday Hill Inc

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 3 (Resident #6, Resident #49, and Resident #50) of 14 residents reviewed for unnecessary medications. The facility failed to ensure Resident #6's PRN Lorazepam (medicine used to treat the symptoms of anxiety) and PRN Risperidone (medicine used to treat mental health disorders) were discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #49's PRN Lorazepam (medicine used to treat the symptoms of anxiety) were discontinued after 14 days or a documented rational for the continued provision of the medication. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 14 (Resident #4 and Resident #10) residents reviewed for infection control practices. The facility failed to ensure LVN A performed hand hygiene and changed gloves at the appropriate times while providing G-tube dressing change for Resident #4. The facility failed to ensure LVN A performed hand hygiene and changed gloves at the appropriate times while providing G-tube feeding for Resident #4. The facility failed to ensure CNA B performed proper incontinent care and proper use of peri-wipes while providing incontinent care for Resident #10. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, for 1 of 1 facility, the results of the most recent survey of the facility including any plans of correction without identifying information about complainants or residents reviewed for resident rights. The facility failed to ensure the three preceding years of any surveys, certifications, and complaint investigations with plans of correction were posted for residents, family members, and visitors to review without identifying information about complainants or residents. This failure could place residents at risk of not reviewing the findings from State surveys and investigations conducted in the facility without asking to review the reports.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #23) whose assessments were reviewed, in that: The facility failed to ensure Resident #23's Quarterly MDS assessment was coded correctly related to the administration of insulin. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observations, interviews, and record review the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure foods were heated to a temperature of 165 degrees F and held at least 15 seconds when food temperature was below 140 degrees F. 2. The facility failed to ensure temperature logs were completed for all meal services. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 8 residents (Resident #1, Resident #32, and Resident #57) reviewed for comprehensive care plans. The facility failed to ensure Resident #1 had a care plan to address an indwelling urinary catheter, a continuous blood glucose monitoring device (a sensor worn by the resident that continuously provides real-time blood sugar, or glucose, levels), and weight loss. The facility failed to ensure Resident #32 had a care plan to address a physician's order for a fall mat. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to conduct regular inspections of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 2 of 2 (Residents #4 and #9) residents reviewed for bed rails. The facility did not conduct regular inspections of bed rails, including Residents #4 and #9's beds. This failure could place residents who have bed rails at risk for injury related to poor maintenance of the bed rails.

Inspectors wroteBased on observations, interviews, and record review the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 2 of 2 residents (Resident #4 and Resident #9) reviewed for bed rails. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails for Resident #4 and Resident #9. These failures could place residents at risk for injury and restricted movement.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 2 residents reviewed for quality of care. The facility failed to ensure the nurses initialed and dated wound dressings when wound care was performed on Resident #1 This failure could result in residents with wounds not having their treatments performed as ordered, wounds becoming infected, and decreased wound healing.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property by failing to conduct a criminal history/EMR/NAR verification on employees prior to employment and/or annually for 13 of 14 (ADMN, DON, SW, AD, DM, DE, RN-A, RN-B, LVN-C, LVN-D, CNA-E, CNA-F, CNA-G) employees reviewed for employability. Facility staff did not have criminal history check and/or an EMR/NAR check prior to offering employment to the facility and/or annually for employees. These findings placed residents at risk of receiving care by someone that was unemployable.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for one of one facility. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 10 days of the second quarter of year 2023. This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 3 (Resident #18, Resident #41, and Resident #2) of 8 residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #18's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 2. The facility failed to ensure Resident #41's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 3. The facility failed to ensure Resident #2's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerator. The facility failed to ensure all food was not kept past expiration date. These failures could place residents that eat from the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that the quality assessment and assurance committee developed and implemented appropriate plans of actions to correct identified quality deficiencies for the failing to conduct criminal history/EMR/NAR verifications on employees prior to employment and/or annually for 13 of 14 (ADMN, DON, SW, AD, DM, DE, RN-A, RN-B, LVN-C, LVN-D, CNA-E, CNA-F, CNA-G) employees reviewed for employability reviewed in that: The Facility HR failed to correct and monitor a quality deficiency identified on the previous survey, regarding employee criminal history, and EMR/NAR checks had been performed since previous past noncompliance. These findings placed residents at risk of receiving care by someone that was unemployable due to abuse/neglect charges in the past. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 6 of 12 meetings reviewed for QAPI. The facility did not ensure the MD, or a representative attended QAPI meetings in January 2023, February 2023, March 2023, April 2023, May 2023, June 2023 and July 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident, for 1 of 1 lunch meal reviewed. The facility failed to follow the recipe when preparing the puree bread. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake.