Inspection Reports for Holiday Retirement Home Inc

The facility remains not in compliance with all regulations surveyed. Specifically, the Emergency Power Supply System (EPSS) generator maintenance and testing did not meet required standards, including failure to document load calculations and confirm minimum load requirements during monthly tests.

The facility was found to be not in compliance with all regulations surveyed. Specifically, the Emergency Power Supply System (EPSS) generator maintenance and testing standards were not met, as the facility failed to document load calculations and provide evidence of meeting minimum load requirements.

Deficiencies were identified related to professional standards of care, quality of care, infection prevention and control, antibiotic stewardship, immunizations, and life safety code compliance. The facility failed to meet requirements in areas including comprehensive care plans, notification of physician for changes in condition, infection control practices, and maintenance of fire safety systems.

The facility failed to ensure residents received care according to physician orders, including incorrect air mattress settings, improper oxygen administration, failure to notify physicians of significant weight changes, inadequate infection control practices, incomplete antibiotic stewardship, missing pneumococcal vaccination documentation, and maintenance issues in the kitchen area.

The complaint was substantiated based on findings that Resident ID #1 had multiple wounds with maggots that were not identified by facility staff during skin assessments, and the facility lacked competency-based training for nursing staff on skin assessments.

The facility failed to provide appropriate foot care and treatment to Resident ID #1, resulting in wounds with maggot infestation that were not identified during skin assessments. Additionally, the facility lacked sufficient nursing staff competencies for skin assessments and failed to maintain complete and accurate medical records related to skin assessments. These deficiencies placed Resident ID #1 and other residents at risk for serious harm.

Deficiencies were cited related to failure to meet professional standards of quality in comprehensive care plans, significant medication errors, and multiple Life Safety Code violations including emergency lighting, fire alarm system maintenance, sprinkler system installation, fire drills, and electrical equipment safety.

The complaint investigation found substantiated deficiencies related to failure to follow physician's orders for a Freestyle Libre sensor and medication errors involving insulin dosing for Resident ID #2.

The facility failed to follow physician's orders regarding the use and documentation of a Freestyle Libre sensor for Resident ID #2, lacking physician orders and documentation for sensor changes. Additionally, the facility administered incorrect insulin doses to the same resident on multiple occasions despite physician orders specifying dosage adjustments based on blood sugar levels.

The complaint was substantiated based on multiple witness statements and staff interviews confirming the abusive incident involving Staff A and Resident ID #1. The facility was also found to have hired Staff A despite disqualifying criminal background information and failed to report the incident promptly.

The facility failed to keep Resident ID #1 free from physical abuse when a staff member forcefully pushed the resident into a wheelchair against their will. Multiple witness statements and staff interviews confirmed the abusive behavior. Additionally, the staff member involved was hired despite having disqualifying information on a criminal background check, and the facility failed to report the incident promptly.

The visit was complaint-related due to allegations of inappropriate behaviors by Resident ID #1. The complaint was substantiated by findings of incomplete 15-minute checks and documentation discrepancies.

The facility failed to ensure that 15-minute checks for Resident ID #1 were consistently completed and properly documented across multiple dates from September through November 2023. Staff interviews confirmed incomplete documentation and lack of verification of these checks.

The visit included a complaint investigation related to supervision to prevent elopement and medication administration issues, specifically involving Narcan use and opioid medication management.

Deficiencies were cited related to free of accident hazards/supervision/devices, drug regimen free from unnecessary drugs, infection prevention and control, life safety code violations including doors with self-closing devices, stairways and smokeproof enclosures, portable fire extinguishers, fire drills, electrical systems, and emergency power supply system maintenance.

The facility was found deficient in ensuring adequate supervision to prevent resident elopements, maintaining a drug regimen free from unnecessary drugs, implementing an effective infection prevention and control program including contact precautions for residents with MDROs, and establishing a comprehensive water management program as required by CDC guidelines.

The facility was determined not to be in compliance with these requirements and deficiencies were identified related to abuse reporting, medication administration, skin integrity, nutrition, respiratory care, dialysis, behavioral health services, drug regimen review, and dental services. Plans of correction were provided for each deficiency.