Holland Lake Rehabilitation and Wellness Center

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 7 residents (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for care plans. 1. The facility failed to ensure the staff implemented the comprehensive care plan goals and interventions for Resident #1. 2. The facility failed to ensure the comprehensive care plan for Resident #2, Resident #3, Resident #4 and Resident #5 described the resident's goals for admission and desired outcomes. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 7 resident's (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure staff followed physician orders in administering Resident #1's medication. This failure could place residents at risk of physical harm and inadequate care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service. The facility failed to ensure that the dietary staff performed proper hand hygiene when entering the kitchen area and between tasks. The facility failed to ensure that kitchen equipment and nutrition service areas (nourishment rooms) were maintained in clean and in sanitary conditions. The facility failed to properly label open food items in the kitchen and nutrition areas. These failures placed residents at risk for foodborne illness and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to 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 disease and infection for two (Resident #1 and, Resident #2) of three residents reviewed for infection control in that:-LVN A failed to perform hand hygiene and changed her gloves at the appropriate times while providing urostomy care for Resident #1.-CNA B failed to perform hand hygiene and change his gloves at the appropriate times while providing incontinence care for Resident #2. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 6 resident (Residents #11, #13, #14) reviewed for respiratory care. 1. The facility failed to ensure Resident #11, #13, #14's nebulizer/Mask and tubing were kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases.

Inspectors wroteBased on observations, and interview and record review the facility failed to ensure that drugs and biologicals were secured and stored in locked compartments, and permit only authorized personnel to have access to the keys for 1 of 2 treatment and medication carts (Hall 200 treatment cart ) observed for medication storage, The treatment cart on hall 200 was left unlocked in the hallway by room # 216. This failure placed the residents at risk for medications being misappropriated or for potential harm and adverse reactions from access to medications not prescribed for them.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents have the right to formulate an advance directive for 1 of 24 residents (Resident #279) reviewed for advanced directives. The facility failed to maintain medical records on each resident that are complete, and accurately documented for Resident #279. This failure could affect residents by not having their preferences honored concerning advanced directives .

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. The lids to the bulk storage containers were soiled with food particles. 2. Opened gravy mix and breaded chicken patties were not stored in sealed bags. 3. The vent-a-hood was soiled with grease and the interior surface of the deep fryer unit was soiled with fried food crumbs. 4. Sanitized cooking utensils and pans were stored on hooks suspended in the air from a frame located near the ceiling air duct vents and the sanitized surfaces were not protected from contaminants in the air. 5. Knives were stored on a magnetic strip rack and in a metal box holder mounted on a wall with the sanitized knife blades exposed to the air and potential contaminants. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the health status for 4 of 26 residents (Residents #7, #35, #45, and #63) whose MDS assessments were reviewed, in that: 1. Resident #7 had contractures in two fingers of her right hand. Her MDS documented no limitations in ROM. 2. Resident #35 had contractures in the fingers of both hands. His MDS assessments documented no limitations in range of motion in his upper extremities. 3. Resident #45 had contractures in both of her legs. Her MDS assessments documented no limitations in range of motion in her lower extremities. 4. Resident #63 had contractures in two fingers of his left hand. His MDS assessments documented no limitations in range of motion in his upper extremities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate care to maintain the highest practical physical and psychosocial well-being for 5 of 26 residents (Residents #7, #21, #33, #63, and #68) reviewed for ADL care, in that: 1. The facility failed to ensure Resident #7's right hand fingernails were trimmed and filed. 2. The facility failed to ensure Resident #21's fingernails on both hands were cleaned and her toenails on both feet were filed or trimmed. 3. The facility failed to ensure Resident #33 had his fingernails on both hands trimmed and filed. 4. The facility failed to ensure Resident #63's left hand fingernails were trimmed and filed. 5. The facility failed to ensure Resident #68 had her toenails on both feet cut and filed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who entered the facility without limited range of motion did not experience a reduction in range of motion; residents with limited range of motion received appropriate treatment and services to increase range of motion or prevent further decrease in range of motion; and residents received appropriate services, equipment, and assistance to maintain or improve mobility for 3 of 15 residents (Residents #34, #45, and #63) who were reviewed for care and assistive devices to maintain mobility and avoid further contractures. 1. Resident #35 had contracted fingers in both hands and did not use assistive devices to prevent further contractures. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were updated timely after completion of comprehensive assessments for 1 of 6 (Resident #38) reviewed for care plan timing and revision, in that: Resident #38's comprehensive care plan was not updated within seven days after completion of his comprehensive MDS Assessment on 6/28/2023. The facility's failure placed residents at risk of not having their needs met due to lack of direction related to care area triggers.

Inspectors wroteBased on observation, interview, 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 one of two residents (Resident #1) reviewed for infection control practices, in that: CNA A failed to perform proper hand before resident contact and after glove changes while providing incontinence care to Resident #10. This failure could place residents at risk for the spread of infection.