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Deficiency Records for Holden Manor Health and Rehabilitation
A list of the most recent deficiencies for Holden Manor Health and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Holden Manor Health and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-08-02 | 2024-09-15 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-08-02 | 2024-09-15 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-08-02 | 2024-09-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-08-02 | 2024-09-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-08-02 | 2024-09-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-08-02 | 2024-09-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-08-02 | 2024-09-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-02 | 2024-09-15 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-08-02 | 2024-09-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-08-02 | 2024-09-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-08-02 | 2024-09-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-08-02 | 2024-09-15 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-08-02 | 2024-09-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-02 | 2024-09-15 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-08-02 | 2024-09-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-02 | 2024-09-15 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-08-02 | 2024-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-02 | 2024-09-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-08-02 | 2024-09-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-08-02 | 2024-09-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-08-02 | 2024-09-15 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-08-02 | 2024-09-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-08-02 | 2024-09-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-08-02 | 2024-09-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-08-02 | 2024-09-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-08-02 | 2024-09-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-13 | 2023-03-31 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-01-13 | 2023-02-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-13 | 2023-02-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-13 | 2023-02-21 | N |
| Respond appropriately to all alleged violations. | Health | 2023-01-13 | 2023-02-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-13 | 2023-02-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-13 | 2023-02-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-13 | 2023-02-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-13 | 2023-02-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-13 | 2023-02-21 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-13 | 2023-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-13 | 2023-02-21 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-01-13 | 2023-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-13 | 2023-02-21 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Use approved construction type or materials. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-01-13 | 2023-02-21 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2020-11-13 | 2020-12-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-11-13 | 2020-12-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-11-13 | 2020-12-11 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2020-11-13 | 2020-12-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-11-13 | 2020-12-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-11-13 | 2020-11-18 | N |
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