Holly Heights Care and Rehabilitation

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an effective pest control program so the facility was free from pests and rodents on two of three units. Specifically, the facility failed to keep the resident's rooms free from mice.

Inspectors wroteBased on record review and interviews the facility failed to inform residents about hospice care before notifying a hospice agency for four (#3, #8, #9 and #7) of seven residents out of 10 sample residents. Specifically, the facility failed to inform Resident #3, Resident #8, Resident #9 and Resident #7 in advance of proposed treatment options by a physician or other healthcare professional prior to sharing their information with a hospice company.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in three of four shower rooms. Specifically, the facility failed to ensure shower rooms and tubs were clean and free from debris in order for residents to have a sanitary environment to bathe.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received substantial nourishing snacks per their preferences. Specifically, the facility failed to:-Ensure residents received snacks upon request; and, -Ensure nourishing snacks were available for diabetic residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in the main kitchen. Specifically, the facility failed to:-Utilize a pest control method that was sanitary; and,-Ensure perishable foods were labeled and dated.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically the facility failed to:-Ensure necessary kitchen equipment was maintained in safe, working condition by repairing leaks to sinks timely; and,-Ensure handrails were in safe, operational, and functional conditions.

Inspectors wroteBased on record review and interviews, the facility failed to ensure money from personal funds account was managed accurately one (#110) of five residents reviewed for personal funds accounts out of 41 sample residents. Specifically, the facility failed to reimburse Resident #110's estate within 30 days from the resident's personal funds account after his death.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that one (#34) of five residents out of 41 sample residents were free from chemical restraint and were receiving the least restrictive approach for their needs. Specifically, the facility failed to:-Provide adequate documentation, including physician documented risks versus benefits, to justify the addition of new psychotropic medications, the increase in dosage of psychotropic medications and/or the continued use of psychotropic medications;-Ensure behavior monitoring physician's orders reflected the specific behaviors Resident #34 was to be monitored for for the use of psychotropic medications; and,-Ensure consents were obtained prior to the administration of psychotropic medications for Resident #34.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure two (#1 and #47) of five residents out of 41 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to:-Ensure Resident #1's physician was notified of a skin alteration for anticoagulation monitoring; and,-Ensure weekly skin assessments were completed for Resident #47 prior to him developing moisture associated skin damage (MASD).

Inspectors wroteBased on observations record review and interviews, the facility failed to ensure the environment were free of accidents and hazards for one (#68) of two residents reviewed out of 41 sample residents. Specifically, the facility failed to: -Ensure Resident #68 was assessed to determine if he was safe to smoke independently; and,-Ensure Resident #68 was not smoking within ten feet of the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#48) of three residents who required respiratory care received care consistent with professional standards or practice out of 41 sample residents. Specifically, the facility failed to ensure Resident #48's bilevel positive airway pressure (BiPAP) machine was cleaned and sanitized.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing for one (#53) of five residents out of 41 sample residents. Specifically, the facility failed to:-Ensure individualized care approaches were provided and monitored with ongoing assessment for Resident #53 in order to meet the emotional and psychosocial needs of the resident; and,-Ensure Resident #53, who had expressed suicidal ideations, a history of attempts, and a history of trauma, was monitored for signs and symptoms of suicidal ideation.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help the development and transmission of communicable diseases and infections on one of four units. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care for Resident #5, who was on enhanced barrier precautions (EBP).

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents at risk for elopement out of three sample residents received adequate supervision and were kept free from elopement. Specifically, the facility failed to provide Resident #1 with the supervision necessary to prevent elopement. The facility's failure created a situation for the likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1 was admitted on [DATE] with a diagnosis of Wernicke's encephalopathy (a brain disorder), repeated falls, unspecified dementia, somnolence (a state of being drowsy or sleepy) and alcohol dependence. Upon admission, Resident #1 was assessed to be a high risk for elopement due to exit seeking behaviors and verbalizing the desire to leave the facility. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#4) of three residents reviewed out of five sample residents. Specifically, the facility failed to ensure Resident #4 , who was dependent on staff for bathing, received his scheduled showers.

Inspectors wroteBased on interviews and record review, the facility failed to provide person-centered, individualized recreational activities to meet the needs and interests, and promote physical, medical and psychosocial well-being for three (#3, #6, #8) three residents reviewed for activities out of eight sample residents. Specifically, the facility failed to provide one on one activity program visits to meet the individualized recreational needs of Resident #3, Resident #6 and Resident #8, who were identified by facility assessment and the resident's comprehensive care plans to need one on one activity visits.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were properly stored and labeled in three out of three units. Specifically, the facility failed to: -Ensure expired medications were timely removed from the medication storage refrigerator; -Ensure Tuberculin purified protein derivative (PPD) was dated after opening; and, -Ensure refrigerated a schedule IV controlled medication was securely double locked and affixed in the refrigerator.

Inspectors wroteBased on observations and interviews, the facility failed to ensure garbage and refuse were properly disposed of and the dumpster lids were closed to prevent harborage of pests and insects for four of four dumpsters. Specifically, the facility failed to: -Empty the dumpsters in a timely manner; -Remove trash piled trash on the ground outside the gated dumpster area; and, -Close dumpster lids.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for one (#63) of nine out of 36 sample residents. Specifically, the facility failed to ensure: -Resident #63 was provided eating assistance, who required assistance with eating; and, -Resident #63 was repositioned and offered incontinence care timely.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#36 and #46) of four residents reviewed for respiratory care out of 36 sample residents were provided respiratory care consistent with professional standards of practice. Specifically, the facility failed to: -Provide Resident #46 oxygen per physician orders due to an empty portable tank resulting in the resident's low blood oxygen saturation level (SPO2); and, -Obtain physician orders for the use of oxygen for Resident #36.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one of seven nursing staff reviewed for license verification had the appropriate State licensure requirements to provide nursing care and services upon hire. Specifically, the facility failed to ensure certified nurse aide (CNA) #2 provided resident care and nursing related services was certified in the State registration system who was hired and worked 1/25/23 to 3/25/23.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure residents were weighed weekly as ordered by the physician for three (Resident #36, Resident #47, and Resident #90) of three sampled residents reviewed for nutrition. The failed practice resulted in a delay in identifying and intervening to address a severe weight loss of 9.28% of Resident #90's total body weight over a period of three months and three weeks.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure physician-ordered medications were available for administration for 1 (Resident #87) of 4 sampled residents reviewed for medication administration.