Holladay Healthcare Center

Inspectors wroteBased on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine temperatures were not meeting the required temperature for sanitation.

Inspectors wroteBased on interview and record review, the facility did not assess a resident using the quarterly review instrument no less frequently than once every 3 months. Specifically, 4 of 37 sampled residents, quarterly Minimum Data Set (MDS) assessments were completed greater than 3 months apart. Resident identifiers: 9, 10, 39 and 63.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and served at a safe and appetizing temperature. Specifically, for 8 out of 37 sampled resident, residents complained of food quality, a test tray not attractive or palatable and resident council minutes revealed complaints of food quality. Resident identifiers: 23, 33, 37, 50, 60, 124, 126 and 286.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish 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. Specifically, hand hygiene was not performed between residents who were being assisted with eating or performed when delivering lunch trays between multiple resident rooms. Resident identifiers: 25, 34, 35 and 43.

Inspectors wroteBased on interview and record review the facility did not complete a comprehensive assessment every 12 months. Specifically, 1 of 37 sample residents, an annual Minimum Data Set (MDS) was completed over 13 months after the previous annual assessment. Resident identifier: 18.

Inspectors wroteBased on interview and record review, it was found that the facility failed to ensure that a resident received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, 1 of 37 sampled residents, did not have an intervention for podus boots implemented to prevent pressure ulcers. Resident identifier: 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents and had an environment that was as free from accident hazards as was possible. Specifically, tools were left in the bathroom of a cognitively impaired resident. In addition, a staff member was observed to carry oxygen tanks down the hallway that were unsecured. Resident identifier: 47.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that each resident who needed respiratory care was provided such care consistent with professional standards of practice. Specifically, 1 of 37 sampled residents, did not have a physician's order for oxygen and no orders to change the tubing and humidifier. Resident identifier: 43.

Inspectors wroteBased on interview and record review, the facility did not ensure that any individual working in the facility as a nurse aide for more that 4 months, on a full-time basis, was competent to provide nursing and nursing related services; and completed a training and competency program, or a competency evaluation program approved by the State. Specifically, a Nurse Aide (NA) was employed at the facility on a full-time basis, for approximately 8 months with out completion of training and competency evaluation program.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was defined as any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, for 1 out of 37 sampled residents, a resident's metoprolol was administered outside of the physician's ordered parameters. Resident identifier: 50.

Inspectors wroteBased on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the expiration date when applicable. Specifically, for 1 out of 37 sampled residents, an opened insulin injector pen was labeled with an open date past the 28 days and was in the medication cart available for use. Resident identifiers: 26.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #23) of 18 sampled residents was assessed for self-administration of medication.

Inspectors wrote2. A review of Resident #54's admission Record indicated the facility admitted the resident on 03/13/2023 with a diagnosis that included obstructive sleep apnea. A review of Resident #54's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/2023, revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident used a non-invasive mechanical ventilator (BiPAP [bilevel positive airway pressure]/CPAP [continuous positive airway pressure]). A review of Resident #54's Order Summary Report revealed an order dated 03/14/2023, to apply CPAP every shift per home settings for sleep apnea. [...]

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure there was documented evidence staff administered medications to 3 (Residents #7, #14, and #75) of 18 sampled residents as ordered by the physician. Specifically, during Licensed Practical Nurse (LPN) #7's shift from 06/15/2023 to 06/16/2023, the nurse blacked out and the facility was unable to determine what medications had been administered to residents as there was no documentation of the administration of medications. The facility further failed to transcribe orders to reflect the route of medication administration for 1 (Resident #243) of 18 sampled residents.

Inspectors wroteBased on interviews, record review, and facility policy and document review, the facility failed to report allegations of physical and sexual abuse timely to the state survey agency for 4 (Residents #34, #292, #77, and #242) of 5 residents reviewed for abuse and/or neglect.

Inspectors wroteBased on interviews, record review, document reviews, and facility policy review, the facility failed to thoroughly investigate allegations of physical and sexual abuse for 3 (Residents #34, #77, and #242) of 5 residents reviewed for abuse. The facility further failed to protect 2 (Resident #34 and Resident #77) of 5 sampled residents reviewed for abuse from further potential abuse while the investigation was in progress.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to maintain an accurate account of controlled medication for 1 (Resident #14) of 18 sampled residents. Specifically, on 06/16/2023, 13 oxycodone 5 milligrams (mg) tablets ordered for Resident #14 were unaccounted for.

Inspectors wroteBased on interviews, record review, document review, and facility policy review, the facility failed to ensure 1 (Resident #14) of 18 sampled residents was free from a significant medication error. Specifically, Resident #14 had a physician's order for fentanyl (a synthetic opioid pain medication) 12 micrograms (mcg) transdermal patch; however, on 06/19/2023, the resident was found to have a 75 mcg (more than six times the ordered dose) fentanyl patch on.

Inspectors wroteBased on observation and interview it was determined, for 4 of 40 sampled residents, that the facility did not provide each resident with food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained that the food was not palatable and the test tray was not attractive and palatable. Resident identifiers: 25, 40, 49, and 67.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, transmission-based precautions (TBP) and Personal Protective Equipment (PPE) guidelines were not followed. Resident identifier 26, 55, and 229.

Inspectors wroteBased on observation and interview it was determined, for 3 of 40 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. Specifically, facility staff were observed standing while feeding residents on the memory care unit. Resident identifiers: 10, 45, and 55.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 40 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after an allegation was made, if the events that cause the allegation involve abuse or resulted in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services). Specifically, an allegation of abuse was not reported to Adult Protective Services (APS). Resident identifier:

Inspectors wroteBased on interview and record review it was determined, for 2 out of 40 sampled residents, that the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to residents who were unable to carry out activities of daily living (ADLs). Specifically, two dependent residents did not receive showers or bathing assistance in a timely manner. Resident identifiers 36 and 44.

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that residents who received psychotropic drugs were not given them unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, the resident had an order for an antipsychotic medication (Seroquel) to treat Alzheimer's Disease. Resident identifier 73.

Inspectors wroteBased on observation and interview it was determined, for 1 of 40 residents, that the facility did not ensure that all feeding assistants had completed a State-approved training course before feeding residents. Specifically, observations were made of a Concierge staff providing feeding assistance to a resident. Resident identifier: