Holden Manor Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Holden Manor Health & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 2, 2024

  Based on observation and interview, the facility failed to remove a buildup of dust and food debris from under the reach-in refrigerator; failed to label items that were not easily identifiable in the containers those items were in; failed to ensure employees washed hands after handling non-food items then going back to handling food items; failed to prevent the buildup of debris in the window unit air conditioner; failed to check the temperature of food items before placing those items on the steam table; failed to ensure the pot holder was free from damage that could allow fibers to contaminate food; failed to ensure dietary employees handled containers used or serving residents, without contaminating those containers; failed to use a three-step (wash, rinse and sanitize) process to wash… […]

• No harm, potential for more than minimal, widespreadF880Aug 2, 2024

  Based on observation, interview, and record review, the facility failed to perform adequate hand hygiene during medication pass for three supplemental residents (Resident's #11, #27, and #10) out of nine supplemental residents and failed to create and implement a Tubercolosis (TB, a potentially serious infectious bacterial lung disease) program when staff failed to complete two-step Mantoux skin tests (a test to show potential TB infection) for two sampled residents (Resident #141 and #241). […]

• No harm, potential for more than minimal, widespreadF812Jan 13, 2023

  Based on observation and interview, the facility failed to store dishes in a manner to prevent contamination; to ensure two ceiling vents were free from a buildup of dust; to label four containers with the contents of what was in those containers; to maintain the gasket (a piece of rubber or some other material that is used to make a tight seal between two parts that are joined together) one of the reach-in refrigerators; to maintain the blade portion of a spatula in an easily condition; and to maintain the stovetop free of a heavy buildup of food debris and grease. This practice potentially affected all residents. The facility census was 41 residents. 1. Observations on 1/9/23 from 9:22 A.M. […]

• No harm, potential for more than minimal, widespreadF880Jan 13, 2023

  Based on observation, interview, and record review, the facility failed to ensure its Water Management Plan outlined plans for implementing testing protocols and plans for corrective actions that the facility would implement as a result of changes in municipal or facility water quality; and to ensure proper hand hygiene was performed during a medication pass. The facility census was 41 residents. 1. Record review of the guidance outlined in the Centers for Disease Control and Prevention (CDC) Legionella Environmental Assessment Form, dated June 2015, showed: -On page three, obtain a written copy of the program policy. […]

• No harm, potential for more than minimal, patternF568Aug 2, 2024

  Based on interview and record review, the facility failed to maintain evidence (via receipts or signatures) for monetary transactions in the resident trust fund accounts for two sampled residents (Resident #2 and #3) out of four sampled residents; and failed to maintain a proper accounting of the end of month petty cash (the amount of cash that is accessible for residents with resident trust that residents can request funds from) amounts from July 2023 through April 2024. This practice potentially affected 22 residents with resident trust. The facility census was 46 residents. 1. […]