Holiday Operator, LLC DBA Holiday Rehabilitation a

In the surveyor’s words

From the most serious findings on record at Holiday Operator, LLC DBA Holiday Rehabilitation a, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Jul 22, 2022

  Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to informing the resident's physician immediately when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 resident reviewed, Resident ID #1. Findings are as follows: Record review of an anonymous community reported complaint sent to the Rhode Island Department of Health on [DATE] revealed that on [DATE], Resident ID #1 had been screaming in pain since 6:00 AM. The nurse on the unit had indicated to the staff and the resident's spouse that she was waiting for the resident to have a bowel movement. […]

• Immediate jeopardy, isolatedF684Jul 22, 2022

  Based on record review and staff interview, it has been determined that the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences for 1 of 6 residents reviewed for pain management, Resident ID #1. Findings are as follows: Record review of an anonymous community reported complaint sent to the Rhode Island Department of Health on [DATE] revealed that on [DATE], Resident ID #1 had been screaming in pain since 6:00 AM. The unit nurse caring for the resident had indicated to staff and the resident's spouse that she was waiting for the resident to have a bowel movement. […]

• Actual harm, isolatedF689Jun 10, 2026

  Based on clinical record review, and staff and resident interview, the facility failed ensure that Resident ID #2's environment remained free of accident hazards, as possible, relative to the resident's assessed transfer needs and facility policy. Specifically, the facility failed to implement the Physical Therapist's recommendation for the use of a mechanical lift following the resident's identified decline in strength and mobility on 5/11/2026 and failed to ensure staff utilized a gait belt during manual transfers. As a result, Resident ID #2 was subjected to unsafe transfer practices including, being lifted under the arm and elbow area, which resulted in swelling, extensive bruising, and increased pain to the resident's left upper extremity. […]

• Actual harm, isolatedF697May 8, 2026

  Based on surveyor observation, record review, and staff interview, the facility failed to ensure that a resident receives timely and appropriate pain and symptom management consistent with professional standards of practice, for end-of life-care including the prompt administration of physician-ordered medications for pain and anxiety, for 1 of 2 residents reviewed who were receiving hospice services, Resident ID #1. This failure resulted in the resident experiencing unmanaged pain, terminal agitation, and psychosocial distress during his/her final hours of life.Findings are as follows:According to the American Nurses Association (2018) Position Statement titled, The Ethical Responsibility to Manage Pain and the Suffering It Causes, nurses have an ethical responsibility to relieve pain and… […]

• Actual harm, isolatedF687Aug 22, 2024

  Based on record review and staff interview it has been determined that the facility failed to ensure that residents receive foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) relative to peripheral vascular disease for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review revealed that the resident was readmitted to the facility in August of 2024 with diagnoses including, but not limited to, cellulitis (a bacterial infection of the skin and the soft tissues underneath) and peripheral vascular disease (a condition where narrowed arteries reduce blood flow to the arms or legs). […]