Holiday Operator, LLC Dba Holiday Rehabilitation a

Inspectors wroteBased on clinical record review, and staff and resident interview, the facility failed ensure that Resident ID #2's environment remained free of accident hazards, as possible, relative to the resident's assessed transfer needs and facility policy. Specifically, the facility failed to implement the Physical Therapist's recommendation for the use of a mechanical lift following the resident's identified decline in strength and mobility on 5/11/2026 and failed to ensure staff utilized a gait belt during manual transfers. As a result, Resident ID #2 was subjected to unsafe transfer practices including, being lifted under the arm and elbow area, which resulted in swelling, extensive bruising, and increased pain to the resident's left upper extremity. Requiring medical evaluation, diagnostic testing, pain medication, and ongoing monitoring. [...]

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that a resident with an injury of unknown origin was thoroughly investigated for 1 of 1 resident reviewed for bruising, Resident ID #2.

Inspectors wroteBased on clinical record review and resident and staff interviews, the facility failed to provide dental services for 1 of 2 residents reviewed with dentures, Resident ID #1. Additionally, the facility failed to have a policy that addressed instances when a resident's dentures are lost or damaged.

Inspectors wroteBased on surveyor observation, record review, and staff interview, the facility failed to ensure that a resident receives timely and appropriate pain and symptom management consistent with professional standards of practice, for end-of life-care including the prompt administration of physician-ordered medications for pain and anxiety, for 1 of 2 residents reviewed who were receiving hospice services, Resident ID #1. This failure resulted in the resident experiencing unmanaged pain, terminal agitation, and psychosocial distress during his/her final hours of life.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that an allegation involving an accident resulting in serious injury, which occurred prior to a resident's death, was reported to the appropriate authorities, including the State Survey Agency, as required by State law, for 1 of 1 resident reviewed Resident ID #1.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure each resident's care plan is revised by the interdisciplinary team, for 1 of 2 residents reviewed relative to falls, Resident ID #2.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that residents receive treatment and services in accordance with professional standards of practice and physician orders, relative to the transcription and implementation of physician-approved hospice medication orders, for 1 of 2 residents reviewed, Resident ID #1.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure residents receive care and services in accordance with professional standards of practice related to post-fall assessments, neurological monitoring, care plan revision, and adherence to advance directives, for 1 of 1 resident who sustained a fall with head injury, Resident ID #1.

Inspectors wroteBased on clinical record review and staff interview, it has been determined that the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 1 of 2 residents reviewed who are receiving hospice services, Resident ID #1.

Inspectors wroteBased on clinical record review, resident and staff interview, the facility failed to keep a resident free of significant medication errors for one of two residents reviewed, Resident ID #3.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that a resident with an injury of unknown origin was thoroughly investigated for 1 of 1 resident reviewed for bruising, Resident ID #3.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that residents receive care, consistent with professional standards of practice relative to physician's orders, for 1 of 1 resident who requires two staff members at all times during care, Resident ID #3 and for 1 of 1 resident who requires a cardiology consult, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 4 of 8 residents reviewed with an air mattress, Resident ID #s 86, 91, 111, and 135, 1 of 3 residents reviewed for oxygen administration, Resident ID #70, and for 1 of 1 resident reviewed with an order for daily weights, Resident ID #93.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices relative to 3 of 8 residents reviewed with an mattress, Resident ID #s 86, 91, and 135, 1 of 3 residents reviewed for oxygen administration, Resident ID #70, and for 1 of 1 resident reviewed for the use of an incentive spirometer (a handheld medical device used to help patients improve the functioning of their lungs, by training patients to take slow and deep breaths), Resident ID #66.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 3 of 5 residents reviewed for antibiotic use, Resident ID #s 69, 85, and 135.

Inspectors wroteBased on surveyor observations, record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with edema (swelling due to excess fluid trapped in the body's tissues), Resident ID #51.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment (PPE) for 1 of 1 resident observed for wound care and transfers, Resident ID #21.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident was offered or received the indicated pneumococcal vaccination or did not receive the vaccination due to medical contraindications or a refusal for 2 of 5 residents reviewed, Resident ID #s 88 and 111. Additionally, the facility failed to have updated policies regarding pneumococcal immunizations.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to maintain a safe, functional, and comfortable environment relative to 1 of 3 kitchenettes and the main kitchen.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that residents receive foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) relative to peripheral vascular disease for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident relative to skin assessments for 6 of 6 licensed nursing staff reviewed, Staff IDs A, C, D, E, F and G.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented relative to skin assessments for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on record review, and staff and resident interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed for the utilization of a Freestyle Libre sensor (a continuous glucose monitoring system that is designed to replace finger sticks and lessen the need for test strips for persons with diabetes), Resident ID #2.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 1 of 3 residents reviewed for insulin, Resident ID #2.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to keep a resident free from physical abuse for 1 of 3 residents reviewed for staff to resident abuse, Resident ID #1.

Inspectors wroteBased on record review, and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following a physician's order for 1 of 1 resident reviewed with 15-minute checks for behaviors, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent elopements, for 1 of 1 residents reviewed for a successful elopement, Resident ID #52.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for Narcan (a medication used for the emergency treatment of known or suspected opioid overdose) use, Resident ID #131.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 1 of 1 resident's reviewed for Methicillin-resistant Staphylococcus aureus (MRSA, an infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics) and for 1 of 1 resident's reviewed for Extended spectrum beta-lactamases (ESBL, an infection that is resistant to specific types of antibiotics), Resident ID #s 3 and 89. Additionally, the facility failed to have a completed water management plan.