Holden Rehabilitation & Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF760Dec 15, 2023

  Based on observation, record review, and interview, the facility failed to ensure that one Resident (#161) out of a total sample of 14 residents was free from significant medication errors. Specifically, the facility failed to administer Hydromorphone (Opioid: medication used to treat severe pain) Hydrochloride (HCl: common salt used in some medications to make them more water soluble) on an as needed (PRN) basis, according to the facility standards of practice and the prescribing Practitioner's orders. Findings include: Review of the facility's policy, titled Administering Medications, dated 2001 and revised April 2019, indicated the following: - Medications are administered in accordance with Prescriber orders . […]

• No harm, potential for more than minimal, patternF761Dec 15, 2023

  Based on observation, interview, record and policy review, the facility failed to store drugs and biologicals in accordance with professional standards and facility policy for three Residents (#19, #66, and #35) out of a total sample of 24 residents and on two out of four medication carts. Specifically, the facility failed to adhere to medication storage requirements when: 1. Medications were observed stored on Resident #19's night stand. 2. Medications were observed stored inside a disposable plastic cup on Resident #66's rolling bedside table. 3. Medications were observed on a medication cart on the Laurel Unit with no Nurse present at the cart. 4. Medications were observed stored in a medicine cup on Resident #35's breakfast tray. 5. […]

• No harm, potential for more than minimal, patternF694May 16, 2022

  Based on observation, interview and record review, the facility failed to ensure staff: 1. implemented physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. to measure the external catheter length, for one Resident (#99) out of two applicable sampled residents. Findings include: Resident #99 was admitted to the facility in April 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/11/22 at 10:14 A.M., the surveyor observed Resident #99 seated in a wheelchair in his/her room with an IV pole and empty bag of IV [MEDICATION(S)] (antibiotic). Resident #99 said he/she had an infection and that's why he/she was receiving the IV antibiotic. 1. […]

• No harm, potential for more than minimal, patternF880May 16, 2022

  Based on observation, interview and record review, the facility failed to: 1. ensure staff followed infection control practices related to personal protective equipment (PPE) use for residents on isolation/droplet precautions related to COVID-19 on one of three units and, 2. ensure oxygen tubing was changed regularly and bilevel positive airway pressure ([CONDITION(S)]- type of ventilator used to treat sleep apnea and other conditions in which a person is still able to breath on their own but assistance is needed) equipment was stored in a sanitary manner for one Resident (#57) out of 21 sampled residents. 1. […]

• No harm, potential for more than minimal, patternF880Jan 5, 2021

  Based on interview, policy review, and observation, the facility failed to ensure staff properly used and cared for Personal Protective Equipment (PPE) and performed hand hygiene after removing PPE, related to COVID-19, on two out of three units. Findings include: During an interview on 1/5/21 at 8:25 A.M., the Assistant Director of Nurses said the facility was in an active COVID-19 outbreak, the most recent positive case was a staff member on 1/4/21. Review of the facility policy for COVID-19 Infection Precautions and PPE Equipment guidance, dated 9/15/20, indicated the following: -Purpose: To implement Infection Precaution protocols based on Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services, and Department of Public Health (DPH) guidance to minimize… […]