Holt Senior Care and Rehab Center

Inspectors wroteBased on observation, interview and record review the facility failed to implement care planned interventions to prevent falls in 1 of 3 sampled residents (Resident #69) assessed for falls, resulting in repeated falls during staff assisted transfers and the potential for continued falls and/or serious injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate coding of a Minimum Data Set (MDS) assessment for one (R80) of 19 reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure comprehensive care plans were accurate and implemented for two out of 19 residents (Resident #8 & 69). Resident #8 (R8): Review of R8's electronic medical record (EMR) revealed R8 was admitted to the facility on [DATE] with a code status of full code by default. Review of a Code Status Form dated [DATE], revealed R8 was a full code by default and was signed by the Physician and two witnesses. Review of a Code Status Form dated [DATE], revealed R8 was a full code by default and was signed by the Physician and two witnesses. Review of a Code Status Form dated [DATE], revealed R8 was a full code by default and was signed by two witnesses, but no Physician. Review of a Code Status Form dated [DATE], revealed R8 was a DNR (do not resuscitate) and was signed by the Physician and two witnesses. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain complete and accurate medical records for one (R2) of 19 reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an antibiotic was administered as ordered for one (R4) of five reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely transport portable oxygen tank, resulting in the increased likelihood of severe injury, potentially affecting all 92 residents in the facility, staff and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate personal protective equipment (PPE) was utilized for contact precaution and ensure hand hygiene was performed for four (Resident #22, 26, 52, and 57) of reviewed for contact precautions.

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA) timely for one (Resident #91) of 20 reviewed for Minimum Data Set (MDS).

Inspectors wroteBased on interview and record review, the facility failed to transmit Minimum Data Set (MDS) assessments to Centers for Medicare & Medicaid Services (CMS) timely for two (Resident #49 and #89) of 20 reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate coding on a Minimum Data Set (MDS) assessment for one (Resident #96) of 20 reviewed.

Inspectors wroteBased on interview and record review the facility failed to confirm that the Pre-admission Screening And Resident Review (PASARR Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a level II Omnibus Budget Reconciliation Act (OBRA) evaluation prior to their admission to the facility for 1 residents (#83) of 2 reviewed. Review of the clinical record reflected Resident # 83 (R83) was admitted to the facility on [DATE] with diagnoses that include morbid obesity and bi-polar disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Status Score of 15 out of 15 (cognitively intact). The mood section of the same MDS reflected R83 felt down, depressed or hopeless several days a week. [...]

Inspectors wroteThis citation pertains to intake MI00146126: Based on observation, interview and record review the facility failed to meet the needs of residents with regard to the timeliness of providing laboratory services and reporting laboratory results for one residents(R104) of three residents reviewed for medications, resulting in delayed treatment and intervention related to lab results, and impaired coordination of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate two out of four residents (Resident #81 and 86) with briefs that fit them, resulting in red marks and painful skin irritation. Findings Included: Resident #81 (R81): Review of R81's electronic medical record revealed R81 was recently admitted to the facility on [DATE]. R81 had a diagnosis of, MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIES. Review of a BRIEF INTERVIEW OF MENTAL STATUS assessment dated [DATE], revealed R81 scored a 15 out of 15, which indicated R81 had no impairment in her cognition. In an interview on 12/18/2023 at 9:45 AM, R81 stated that her briefs were too small. R81 said she had asked staff (could not recall names of staff) several times for the larger size brief, but said staff told her corporate had to approve her to have a larger size brief. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent pressure ulcers in 1 of 2 residents reviewed for pressure ulcers (Resident #251), resulting in pain, wound treatments, and the potential for additional skin breakdown and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supplements and fortified foods to prevent weight loss in one of one residents reviewed for weight loss (Resident #91), resulting in a severe weight loss of 7.8 pounds. Resident #91(R91) admission History and Physical dated 11/09/23 and Dietary Profile dated 11/10/23 revealed R91 had a history of heart disease, kidney disease, arthritis, bone loss, moderate protein-calorie malnutrition and history of gastric bypass 28 years prior. R91 had been admitted to the facility following a hospitalization for pneumonia and respiratory failure. R91 was alert and oriented to person and place only. R91 received supplements twice a day during her hospitalization and took a protein supplement when at home. R91 did not have any swelling of her extremities. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow pharmacy policy and acceptable practice for maintaining controlled medication for two out of five medication carts resulting in the potential for controlled medication diversion. Findings Included: During observation of the Cedar One medication cart on 12/20/2023 at 09:12 a.m. it was observed that the facility Controlled Accountability Record for this medication cart was last signed by only the out going nurse at 06:30 a.m. on the date of 12/20/2023. The signature box for the on coming nurse was blank. In an interview on 12/20/2023 at 09:37 a.m. Licensed Practical Nurse (LPN) M explained that she was the on coming nurse that took control of the Cedar One Medication cart on 12/20/2023 at 06:30 a.m. [...]