Holzer Senior Care Center

Inspectors wroteBased on observation, record review, review of wound notes, facility policy review review and interview, the facility failed to assess, develop, and implement a comprehensive and individualized prevention program to prevent the development of avoidable pressure ulcers and ensure interventions were in place as ordered to prevent new or worsening pressure injuries for Resident #8 and #34. Actual Harm occurred on 04/17/25 when it was discovered that Resident #8, who was determined to be at risk for skin breakdown with no pressure ulcers upon admission, was assessed as cognitively impaired, incontinent, and required moderate (staff) assistance with bed mobility, developed an unstageable (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure Pre-admission Assessment/Resident Reviews (PASRRs) were completed accurately to reflect diagnoses of serious mental illness. This affected four (#7, #12, #13, and #28) of four residents reviewed for PASRRs. The facility census was 40.

Inspectors wroteBased on record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure comprehensive care plans were in place to address mental illness disorders and care plans were implemented in the areas of fall prevention, incontinence care, and pressure ulcer prevention. This affected four (Resident #12, #13, #21, and #34) of 17 residents reviewed for care planning.

Inspectors wroteBased on observation, interview and review of the Tuberculin or purified protein derivative (PPD) solution manufacturer guidelines revealed the multi dose vial was dated as opened on 03/19/25 and should be discarded in 30 days after opened. This had the potential to effect all new admissions to the facility from 03/19/25 through 05/07/25. The facility census was 40.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to follow diagnostic criteria prior to the administration of antibiotics and failed to follow blood pressure medication parameters. This affected four (#16, #31, #34, and #194) of four residents reviewed for antibiotic stewardship. The facility census was 40.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to follow diagnostic criteria prior to the administration of antibiotics. This affected four (#16, #31, #193 and #194) of four residents reviewed for antibiotic stewardship. The facility census was 40.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents being offered a COVID vaccination received education regardless of if the vaccine was administered or not. This affected four (#7, #12, #22 and #25) of five residents reviewed for vaccination administration. The facility census was 40.

Inspectors wroteBased on record review and interview the facility failed to notify the state agency of a significant change to the Pre admission Screening and Resident Review (PASSAR) for Resident #13. This effected one (Resident #13) of four residents reviewed for PASSAR. The facility census is 40. Review of the medical record for Resident #13 revealed an admission date of 06/12/23 with diagnoses including diabetes mellitus type two, atrial fibrillation and dementia with other behavioral disturbances. A new diagnosis of delusional disorder was added on 09/18/23. Review of the physician orders dated 05/25 revealed Resident #13 was ordered donepezil hydrochloride (a medication used to treat dementia) 10 milligrams by mouth one time daily for dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had intact cognition with no behaviors documented. [...]

Inspectors wroteBased on observation, interview, review of the manufacturer's guidelines and per the standards of practice the facility failed to ensure Resident #31's insulin was administered per the standard of practice and manufacturer's guidelines. This effected one ( Resident #31) of two residents reviewed for insulin administration. The facility census was 40.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure residents who were dependent on staff for personal care received the assistance needed with incontinence care and the removal of unwanted facial hair as per their plan of care. This affected two (Resident #1 and #21) of two residents reviewed for activities of daily living (ADL's). The facility census was 40.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a resident was properly positioned when up in a specialized wheelchair and another resident received appropriate intervention when they went without a bowel movement for six days. This affected one (Resident #28) of two residents reviewed for positioning and one (Resident #8) of two residents reviewed for nutrition. The facility census was 40.

Inspectors wroteBased on record review, observation, and interview, and facility policy review, the facility failed to ensure a resident, who had a history and was at risk for falls, had their fall prevention interventions implemented as per their plan of care. This affected one (Resident #21) of three residents reviewed for falls. The facility census was 40.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents with post-traumatic stress disorder (PTSD) were provided with trauma-informed care. This affected one (#12) of one resident reviewed for PTSD. The facility census was 40.

Inspectors wroteBased on interview and medical record review the facility failed to address pharmacy recommendations timely for Resident #2 and Resident #9. This effected two (Resident #2 and Resident #9) of five residents reviewed for unnecessary medications. The facility census was 40.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed within the 14 day allotted time period following the assessment reference date (ARD). This affected seven residents (#6, #7, #10, #13, #19, #22, #32) of 25 sampled residents. The facility census was 35. Findings Include: 1. Review of the medical record for Resident #10 revealed an initial admission date of 01/16/20 with the latest readmission of 12/18/20 with diagnoses including diabetes mellitus, major depressive disorder, anxiety disorder, hypertension, morbid obesity, obstructive sleep apnea, hyperlipidemia, osteoarthritis, chronic pain and congestive heart failure. Review of the resident's MDS list revealed a quarterly MDS assessment with the ARD date of 07/24/23 still in progress and incomplete. [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure one resident's quarterly Minimum Data Set (MDS) assessment was transmitted to the required state agency. This affected one resident (#17) of 25 sampled residents. The facility census was 35. Findings Include: Review of the medical record for Resident #17 revealed an initial admission date of 04/20/22 with the diagnoses including hyperlipidemia, anemia, pain, gastro-esophageal reflux disease and [NAME] cell carcinoma. Review of the resident's MDS list revealed a quarterly MDS assessment with the ARD date of 07/14/23 not transmitted to the required state agency. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not transmitted to the state agency as required. [...]

Inspectors wroteBased on record review, pharmacy recommendation review, interview, and facility policy review, the facility failed to ensure two residents (#5, #18) pharmacy recommendations were addressed by the physician. This affected two of five residents reviewed for unnecessary medications. The facility census was 35.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure one resident's (#5) antihypertensive medications were held when the resident's pulse was below the physician ordered parameter. This affected one of five residents reviewed for unnecessary medications. The facility census was 35. Findings Include: Review of the medical record for Resident #5 revealed an initial admission date of 10/04/22 with the latest readmission of 04/10/23 with the diagnoses including COVID-19, hypertension, pneumonia, major depressive disorder, major depressive disorder, suicidal ideations, traumatic subdural hemorrhage, frontal lobe and executive function deficit following cerebral infarction, seizures, atrial fibrillation, hyperlipidemia, benign prostatic hyperplasia, gastro-esophageal reflux disease and arthritis. [...]

Inspectors wroteBased on record review and interview the facility failed to provide an appropriate diagnosis for the use of an antipsychotic medication. This affected one resident (#3) of five residents reviewed for unnecessary medications. The facility census was 35.

Inspectors wroteBased on interview and record review the facility failed to provide a resident with timely dental care and services. This affected one resident (#27) of one resident reviewed for dental services. The facility census was 35.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #10. Actual harm occurred on 10/07/21 when Resident #10, who was severely cognitively impaired was identified to have a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer to the ball of his left foot. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer and to promote healing once the ulcer was identified. [...]

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to provide adequate and necessary care and services to prevent the development of hand contractures for two residents (#5 and #25). Actual harm occurred when Resident #25 who was severely cognitively impaired was not provided range of motion services or the application of splint/ orthotic devices resulting in the development of bilateral hand contractures. Actual Harm also occurred for Resident #5 when the facility failed to provide range of motion and/or hand roll/splinting care for the resident's left hand to prevent a decline in range of motion and development of a contracture to the hand. This affected two residents (#5 and #25) of three residents reviewed for positioning/ mobility.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure appropriate personal protective equipment (PPE) was worn by nursing staff when providing direct care to Resident #340, who was on droplet precautions for a 14 day quarantine period for COVID-19 following a recent admission. They also failed to ensure nursing staff properly disinfected their face shields when leaving the resident's room before moving on to provide care to other residents to prevent the potential spread of COVID-19. This had the potential to affect all 37 residents residing in the facility.

Inspectors wroteBased on record review, review of a facility self reported incident (SRI) , facility policy and procedure review and interview the facility failed to prevent the misappropriation of narcotic pain medication. This affected 13 residents (#3, #5, #9, #11, #12, #20, #24, #26, #244, #246, #247, #248 and #250) of 18 residents identified to receive narcotic medications.

Inspectors wroteBased on record review, review of Food and Drug Administration (FDA) information, review of a HealthDay News Study and interview the facility failed to provide adequate justification for the use of antibiotics for those residents who tested positive for the COVID-19 virus. This affected 21 residents (#6, #7, #8, #17, #23, #26, #28, #29, #30, #32, #39, #41, #35, #39, #40, #241, #242, #243, #244, #245, #249) of 27 residents prescribed antibiotics. The facility census was 37.

Inspectors wroteBased on record review, review of a facility self reported incident (SRI) and interview the facility failed to ensure Resident #19 was free from an incident of verbal abuse when staff identified a nursing assistant (NA #600) speaking inappropriately to the resident while using derogatory/explicit language. This affected one resident (#19) of 16 residents reviewed for abuse.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) was completed Resident #6, who had a mental illness diagnosis added after his initial PASARR was completed. This affected one resident (#6) of one resident reviewed for PASARR.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #23 was positioned properly and safely to consume his meal. This affected one resident (Resident #23) randomly observed during the initial dining observation. The facility census was 37.

Inspectors wroteBased on observation, record review and interview the facility failed to provide ensure Resident #5, who was totally dependent on staff for personal hygiene/bathing was provided timely and adequate nail care. Resident #5's fingernails were observed to be long and jagged. The jagged edges of the nails were observed cutting into the resident's skin due to a contracture of the left hand. This affected one resident (#5) of 19 residents observed for activities of daily living.

Inspectors wroteBased on record review and interview the facility failed to have ensure psychoactive medications were justified and administered to residents only with an acceptable clinical indication for use. This affected two residents (#36 and #19) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure laboratory testing was obtained as ordered for Resident #12. This affected one resident (#12) of five residents reviewed for unnecessary medication use.